Deaths Crisis: HSE: Hospital fined after safety failings led to dementia patient’s death

Norfolk and Suffolk NHS Foundation Trust has been fined £366,000 after the death of a patient on a specialist dementia ward.

Norwich Crown Court heard how Mrs Joan Darnell, age 78, had been admitted as a patient to the Julian Hospital, on 28 September 2014 on the Blicking Ward, a specialist ward for patients suffering with dementia. On the 16 October Mrs Darnell was reported missing and was found face-down in a bath full of water in one of the bathrooms on the ward.

An investigation from the Health and Safety Executive found that the Trust did not have sufficient policies or procedures in place for managing the safety of patients. They had failed to complete an appropriate risk assessment for Mrs Darnell and take steps to prevent vulnerable patients having unsupervised access to bathrooms.  At the time of the incident the Trust did not have adequate systems and arrangements in place to ensure that patients under their care on the ward were effectively monitored. .

Norfolk and Suffolk NHS Foundation pleaded guilty to breaching Section 3 (1) of the Health and Safety at Work etc. Act 1974 and fined £366,000 and ordered to pay costs of £12,888.48.

HSE Anthony Brookes, said “This was a tragic and preventable death. Had the trust put in place the correct procedures for the staff to manage the risks to vulnerable patients Mrs Darnell may still be alive. It is vital that patients’ needs are taking into consideration and Hospital Trust’s carry out appropriate risk assessments. They need to make sure the correct work systems are put in place to ensure they are managed but also appropriately monitored.”

Notes to Editors:


  1. The Health and Safety Executive (HSE) is Britain’s national regulator for workplace health and safety. It aims to reduce work-related death, injury and ill health. It does so through research, information and advice, promoting training; new or revised regulations and codes of practice, and working with local authority partners by inspection, investigation and enforcement.
  2. More about the legislation referred to in this case can be found at: link to external website
  3. HSE news releases are available at

You can read about what led to Mrs Darnell’s tragic death here.

The original press release from the HSE can be found by clicking on the image below:

5 thoughts on “Deaths Crisis: HSE: Hospital fined after safety failings led to dementia patient’s death”

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