Healthcare provider fined over death in its care

NHS Ayrshire and Arran has been fined £67,000 over its failure to follow its own procedures relating to the care of a patient with a history of depression.

Gary Niven was able to hang himself in a room at the AE department of Crosshouse Hospital on 31 August 2010. Although he was resuscitated, Gary had suffered hypoxic brain damage and died on 3 September 2010.

The Crown Office and Procurator Fiscal Service asked the Health and Safety Executive to examine the circumstances in November 2012.

HSE found that the risk of psychiatric patients being left alone – and by implication self-harming – was identified by NHS Ayrshire and Arran (also known as Ayrshire and Arran Health Board). It had procedures for staff to follow, to reduce the risks, but these were not followed for Gary.

Kilmarnock Sheriff’s Court heard that Gary, 42, had called for an ambulance saying he was feeling suicidal and had already attempted to hang himself. He had a history of depression and intractable cluster headaches.

On arrival at the hospital in Kilmarnock, he was taken to a room beside the main staff base, where he could be observed in-between assessments, as the doors were always left open. Just over an hour after his arrival, the charge nurse noticed the door was closed. Gary was found unresponsive inside, having been able to construct a ligature from the arm of his jumper.

NHS Ayrshire and Arran pleaded guilty to breaching its Sections 3 and 33(1)(a) duties under the Health and Safety at Work Act 1974. It was fined £100,000, reduced to £67,000 on the basis of its early guilty plea.

It was noted in court that NHS Ayrshire and Arran had made significant changes to its policies and procedures since the incident.

HSE Inspector Mark Carroll said after the hearing: “Having identified the risks and implemented a policy, NHS Ayrshire and Arran should have ensured these were followed. It didn’t, which has led to the death of a much-loved son, brother and father in Gary Niven, whose family are absolutely devastated.”

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:
  3. HSE news releases are available at
  4. In Scotland the Crown Office and Procurator Fiscal Service has sole responsibility for the raising of criminal proceedings for breaches of health and safety legislation.

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