The Roman Catholic Diocese of Dunkeld has been fined for health and safety failings which led to the death of a vulnerable care home resident at a property in Dundee.

Dundee Sheriff Court was told that in the early hours of 30 May 2017, a 94-year-old man fell nearly 30 feet from a second-floor window of the Wellburn Care Home.

The investigation

An investigation by the HSE and Police Scotland identified that the bedroom window from which the man fell was unrestricted.

Health & Safety Executive officers found that many of the windows at the care home had not been fitted with restrictors which prevent windows being opened to an extent that a person could fall from the window.

In court

The Diocese pled guilty to contraventions of Section 3(1) and Section 33(1)(a) of the Health and Safety at Work Act 1974 at Dundee Sheriff Court on 14 October 2020. They were fined £40,000 on 27 October 2020.

Alistair Duncan, Head of the Health and Safety Investigation Unit, Crown Office, said: “This tragic incident could easily have been prevented had suitable and sufficient measures been put in place. A window restrictor would have prevented this from being able to happen.

“Hopefully, this prosecution and the sentence will remind other organisations that failure to fulfil their obligations can have tragic consequences and that they will be held to account for their failings.”

Types of fall and at-risk categories

Serious injuries and fatalities have occurred when people have fallen from or through windows in health and social care premises.

There are three broad categories of falls. These are:

• Accidental – these are a minority but occur where people unintentionally fall through or from windows. This can happen where people are able to sit on and fall from sills, or where windows are positioned such that people could easily fall through them.
• Falls arising out of a confused mental state – a significant number of reports refer to the mental state of individuals. In particular, senility, dementia, reduced mental capacity, mental disorder and the effect of drink and drugs (both prescribed and illegal) can all cause anxiety and confusion. In these cases, people have often tried to escape or used a window, believing it to be an exit.
• Deliberate self-harm or suicide – a recognised risk for people with certain health conditions, particularly those with a history of self-harm or mental disorder.

Required standards

Tragic incidents such as this can easily be prevented by implementing suitable and sufficient measures.

Where vulnerable people have access to windows large enough to allow them to fall out and be harmed, those windows should be restrained sufficiently to prevent such falls.

• Window restrictors should restrict the window opening to 100 mm or less (4 inches)
• Be suitably robust to withstand foreseeable forces applied by an individual determined to open the window further
• Be sufficiently robust to withstand damage (either deliberate or from general wear)
• Be robustly secured using tamper-proof fittings so they cannot be removed or disengaged using readily accessible implements such as cutlery and
• Require a special tool or key to bypass or override the safety device