North Wales health board fined £200,000 after death of woman in its care

Her family described Dawn Owen's death as "wholly avoidable" and "completely unnecessary". Credit: Wales News

One of the largest health boards in Wales has been fined £200,000 after a woman died in its care.

Dawn Owen, 46, was found unconscious at the Hergest Unit - a secure mental health unit - at Ysbyty Gwynedd in Bangor on 20 April 2021.

Betsi Cadwaladr University Health Board pleaded guilty to breaching the Health and Safety at Work Act and was fined £200,000 over Dawn's death.

The health board was also ordered to pay costs of more than £13,000 to the court.

Dawn's family described her death as "wholly avoidable" and "completely unnecessary" as they called on the health board to act on the findings of a Health and Safety Executive (HSE) investigation.

The family said: “Staff complacency at all levels contributed in this case, as well as numerous policy breaches and issues between staff and management."

They added: “We have been tragically let down by the Hergest Unit, who we believed were providing a safe place for Dawn and the care that she urgently needed.”

Llandudno Magistrates' Court heard there were several missed opportunities, including the fact no risk assessment was carried out when she was admitted and there was no review of her care when she expressed a desire to self-harm.

Dawn's family paid tribute to her, describing her as “a bright, happy person who always had a positive attitude".

They said: "She had a heart of gold and would always help others in need - she would give away her last penny to do so."

However, they added: "Dawn was a highly vulnerable person and had been battling her demons and addictions for many years."

Speaking after the case, HSE inspector Sarah Baldwin-Jones said: “This incident could so easily have been avoided had a thorough risk assessment been carried out on admission, identifying in this case, the change in Dawn’s condition and risk of self-harm.

“Where a patient presents with a risk of self-harm, there is a requirement upon a health board to manage the patient’s safety, to avoid incidents like this."

She added: “Health Boards and Trusts should be aware that HSE will not hesitate to take appropriate enforcement action against those that fall below the required standards. Our thoughts remain with Dawn’s family and friends.”

Carol Shillabeer, Chief Executive at Betsi Cadwaladr University Health Board, said: “My heart goes out to the family and loved ones of Dawn Louise Owen for their tragic loss. On behalf of the Board I wish to reiterate how sorry I am for the failings in her care.

“We are determined to keep improving the safety and experience of the service that we provide, and although the vast majority of patients receive safe and effective care, we will ensure that, where we fall short, that this drives long lasting change.”

Darren Millar MS, the Welsh Conservative Shadow Minister for North Wales, called for an independent enquiry "so confidence can be restored" in the health board.

Mr Millar said: “My heart goes out to the family and loved ones of Dawn Owen. Her death should not have happened and was entirely preventable.

“The Betsi Cadwaladr University Health Board has been in special measures and targeted intervention due to failings in mental health services since June 2015. It is a disgrace that, more than eight years later, mental health patients in North Wales are still coming to harm and needlessly dying in our hospitals.

“The public in North Wales are fed up with excuses and apologies, they want to see a Health Board that learns lessons and implements change when things go wrong, but that has not been happening."

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