A judge today imposed a "lenient" £50,000 fine on a hospital's governing trust after a court heard how health and safety failings were a "significant cause" of the death of a severely disabled patient.
Basildon University Hospital in Basildon, Essex acknowledged that 20-year-old Kyle Flack died following failures in its "systems and procedures" during a hearing at Basildon Crown Court.
Judge Christopher Mitchell - who also ordered the hospital to pay £40,000 prosecution costs - listed a series of failings but said he was wary of depriving the hospital of cash to spend on health care.
Basildon & Thurrock University Hospitals NHS Foundation Trust admitted breaching health and safety law by failing to ensure patients were not exposed to risk after being prosecuted by the Health and Safety Executive (HSE) as a result of Mr Flack's death nearly four years ago.
Prosecutor Pascal Bates had told the court that Mr Flack, a quadriplegic who had cerebral palsy, suffocated at the hospital in October 2006 after getting his head trapped next to bed bars.
Mr Bates said the hospital had failed to properly supervise Mr Flack, failed to properly pass on information, failed to properly train staff, failed to properly assess risk and had not headed warnings.
He said the offences amounted to a "serious" breach of duty and the hospital had fallen "markedly short" of the required standard.
The judge said he was satisfied that the hospital had thoroughly investigated Mr Flack's death and made improvements in care procedures.
But Mr Flack's mother, Gill, of Stanford-le-Hope, Essex, said after the hearing that she was not convinced that lessons had been learned.