Betsi Cadwaladr University Health Board (BCUHB) has been fined £250,000 following failures relating to patient falls in hospitals.

Three patients fell in 2022 and 2023 and died. The cause of death of two of them was a direct result of falling.

Richard Hughes, 84 and Gwilym Williams, 74, fell at Ysybty Gwynedd, Bangor in January and June 2022 respectively. Nancy Read, 93, fell at Wrexham Maelor Hospital in January 2023.

BCUHB was initially investigated by the Health and Safety Executive (HSE) following two other patient falls in 2020, one of which resulted in death.

HSE took enforcement action against BCUHB that required it to implement an effective patient fall management system, including ensuring patients had appropriate falls risk assessments (with clear risk controls detailed), that the risk assessments were reviewed and updated accordingly in the event of a patient’s health deteriorating, and staff received training on patient falls.

The action also required BCUHB to review patient falls policy and to ensure the entire system worked effectively. A follow-on inspection in November 2021 identified BCUHB was still not managing patient falls and this resulted in further action.

Over the next two years, the three patients died; BCUHB had not implemented a system to identify and manage patient falls quickly, or provide staff with updated training.

(BCUHB) pleaded guilty to breaching Section 3 (1) of the Health and Safety at work Act 1974 and have been fined £250,000 and ordered to pay costs of £11,766.

HSE inspector Sarah Baldwin-Jones said: “This is the second time this health board has been prosecuted in less than 18 months.

“These incidents could so easily have been avoided had BCUHB followed their own adult falls policy.”

BCUHB chief executive Carol Shillabeer’s court statement said: ”The standard of care provided wasn’t of an acceptable level.”