Mansoor Elahi was an inpatient at Birch Hill Hospital who suffered from mental health problems including schizophrenia who was participating in a pre-arranged rafted canoeing activity provided by Link4Life in partnership with Pennine Care NHS Foundation Trust at Hollingworth Lake in Rochdale. During the activity he removed his buoyancy aid and jumped into the water in an attempt to end his own life.
An investigation by the Health and Safety Executive found that Pennine Care NHS Foundation Trust had failed to carry out a risk assessment for the activity or to adequately assess Mr Elahi’s suitability to attend. At the inquest, the representative for Link4Life indicated that it was his understanding was that only low risk patients would be permitted to participate in the sailing activity. In addition, it transpired that Mr Elahi had been rescued from the lake previously by his brother a few weeks earlier after entering it and attempting to swim. Surprisingly, his Consultant Psychologist was not informed of the decision to let him go which was made by two other members of staff. On the day, there were two mental health workers on duty to help supervise the activity, however one member of staff stayed on the shore with another patient who felt too unwell to participate. At this stage the HSE submitted, the risks associated with the activity and the staffing ratios should have be reassessed demonstrating another missed opportunity and indicating the need for staff to continually reassess matters.
The Trust pleaded guilty at Manchester Crown Court to breaches of Regulation 3(1) of the Management of Health and Safety at Work Regulation 1999 and Section 3(1) of the Health and Safety at Work etc. Act 1974. On 29 July 2016 they were fined £30,000 and ordered to pay costs of £51,223.88. Given the seriousness of the breach and the new sentencing guidelines, a much more significant fine could have been imposed, however in its mitigation, the Trust made clear it was facing unprecedented financial pressure and any fine would have a significant impact on services.
After the conclusion of the case, the HSE stated that "The Trust failed to adequately assess Mr Elahi’s suitability to attend the rafted canoeing activity. Mr Elahi’s actions were entirely foreseeable as he had tried to enter the lake on a previous occasion. Had the Trust carried out a suitable assessment they would not have allowed a vulnerable person the opportunity to end his life.”
As NHS Trusts and private health and social care providers look to provide activity programmes for patients and residents, this case serves to highlight the importance of undertaking proper and thorough risk assessments. This is particularly pertinent where people are new to the care provider and/or have a condition that can cause a variation in their ability to adequately safeguard themselves. Often, there is a perception that risk assessments are time consuming and prohibitive. The HSE guidance in this area stipulates that the process is not about creating huge amounts of paperwork, but identifying sensible measures to control workplace risks. This includes identifying hazards, deciding who might be harmed and how, evaluating the risks and deciding on precautions, recording significant findings and reviewing/updating the assessment if necessary. The simple steps in the case above should have identified that Mr Elahi was not suitable under the Trust's own policies to be undertaking activities of this nature. The medical director for Pennine Care stated that the Trust “deeply regrets” the circumstances that led to Mr Elahi’s death and apologised once more to his family and highlighted the Trust has taken all necessary action to ensure there could not be a repetition of this tragedy.