An NHS Trust has been fined £300,000 after a mental health patient fell to his death from a hospital chimney tower.

Adam Withers, 20, died at Epsom Hospital in May 2014.

Surrey and Borders Partnership NHS Foundation Trust (SABP) had admitted a serious health and safety charge at Guildford Crown Court in January.

The Trust was yesterday ordered to pay a fine of £300,000 by September 21, as well as £16,769 in prosecution costs, and a victim surcharge of £120.

From January 2016: Mother tells inquest of moment son Adam Withers fell to his death from Epsom Hospital chimney

Mr Withers, from Orchard Gardens, Epsom, had been diagnosed with acute and transient psychosis in April 2014.

He had climbed onto a conservatory roof and up a ladder attached to a chimney while his mother and twin sister Carla were visiting, an inquest was told last year.

In January 2016, his mother, Michelle Withers, told Woking Coroners Court that she had pleaded with him to climb down.

He had become agitated after they arrived late for their scheduled visit on May 9, 2014, and used a flower pot to climb onto a conservatory roof in the courtyard of the hospital’s Elgar Ward before his fatal fall.

Mrs Withers also told the court there were no doctors or nurses present at the time.

They looked away as Adam fell to his death, Carla told the BBC after the sentencing.

“All of a sudden there these gasps – these horrible, horrible gasps,” she told the Victoria Derbyshire Show.

“And then people just started screaming, and these nurses came round the corner and they were as pale as sheets. You just knew they had seen something horrific.”

She added: “That is how we found out that he had died. That is not how you should find out someone has died.”

On January 22, 2016, a jury concluded that Adam Withers climbed to the top of a 130-foot chimney and fell from it unintentionally while suffering an acute psychotic illness.

The jury also concluded that his death was “caused or more than minimally contributed to by” multiple failures of Surrey and Borders Partnership NHS Foundation Trust (SABP) and Epsom and St Helier university Hospitals NHS Trust.

These included:

  • A failure by SABP to take effective steps to address the known risk of detained patients absconding from the Elgar Ward courtyard via its flat roof;
  • A failure by SABP to reassess Adam’s risk levels after a comment in relation to climbing the ladder on the chimney;
  • A failure by SABP to take effective steps to prevent Adam from absconding from Elgar Ward pending reassessment of his risk levels after his comment in relation to climbing the ladder on the chimney;
  • A failure by both Trusts to effectively communicate changes to the environment and take remedial action to address identified risks.

From December 2014: Raft of security measures after patient fell to his death from Epsom Hospital chimney

From June 2015: Mental health patients barred from hospital courtyard after 20-year-old climbed and fell from chimney

SABP is responsible for mental helath provision at Epsom Hospital.

The Trust introduced a raft of extra security measures – including making drainpipes and ledges harder to climb, and making the courtyard off-bounds for mental health patients – at the hospital after Mr Withers’ death.

After Thursday’s sentencing, Fiona Edwards, SABP chief executive said: “We fully accept the judge’s decision and the fine imposed on us.

“I am deeply sorry for Adam’s death and continue to offer my most sincere condolences to his family and friends for the devastating impact this has had on them.

“This was a tragic accident and we accept responsibility for our contribution to his death. Sadly the loss of his life has helped drive, and contributed to, all of our safety work and service improvements.

“We have cooperated fully with the Health and Safety Executive to identify our failings and made significant changes to improve safety following this incident."

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