An NHS trust has been fined for one of the most serious breaches of health and safety regulations after a psychiatric nurse was bludgeoned to death by a mentally ill patient.

An NHS trust has been fined for one of the most serious breaches of health and safety regulations after a psychiatric nurse was bludgeoned to death by a mentally ill patient.

An Old Bailey judge heavily censured the South West London and St George's Mental Health Trust for a series of failures which led to the killing.

It is the first case brought by the Health and Safety Executive against the NHS in which an NHS employee has died. The case was considered so serious by City of London magistrates that they referred it to the Crown Court last month.

Eshan Chattun, a nurse at Springfield mental hospital, part of the trust, had been left alone on 17 June 2003 to supervise Joseph Cann, an aggressive and potentially violent patient, who had been detained under the Mental Health Act earlier in the day. Mr Chattun, 43, had no walkie-talkie or personal alarm and the wall alarm was broken. Cann was being held in a locked lobby area where he was being kept under observation.

Although he had been told not to enter the lobby, Mr Chattun did so for reasons that remained unexplained, the court heard. Cann, who had been agitated and very upset, attacked him and the nurse died in a pool of blood from multiple injuries. Part of his ear was severed during the assault.

The trust admitted neglect which contributed to the death. It pleaded guilty to breaching Section 2 of the Health and Safety at Work Act, which stipulates that every employer has a duty "to ensure, as far as is reasonably practicable, the health, safety and welfare of all his employees". Judge Gerald Gordon fined the trust £28,000 and ordered it to pay £14,000 costs.

He said: "Bad practices grew up and nobody thought about them or put them right. That was seriously unacceptable and incompetent, in my judgement. The trust's conduct fell significantly below standards to ensure safety.

"If the case serves no other purpose, I hope it will encourage those in charge of other establishments - if they have not already done so - to urge a review of proceedings and keep them under review."

Simon Antrobus, prosecuting on behalf of the HSE over the killing of Mr Chattun, said it was a tragedy waiting to happen. All staff supervising potentially violent patients should have received special training, but Mr Chattun was understood to have had his training deferred. Other staff had received no training and there was no system to check, Mr Antrobus said.

Only some staff used personal alarms and a culture had grown up where they were often not worn because they were regarded as cumbersome. Mr Chattun had not been issued with an alarm although some were available in an upstairs office.

The trust is already the subject of an inquiry into the killing of Denis Finnegan, a former banker who was stabbed while cycling in Richmond Park by a patient, John Barrett, who had walked out of Springfield hospital 24 hours earlier.

Cann, 22, was ordered to be detained indefinitely at Broadmoor top-security psychiatric hospital after he was convicted in January of Mr Chattun's manslaughter.

Outside the court, Mr Chattun's widow Famide, who is suing the trust, said: "We believe this prosecution was very important to make sure that no other NHS worker is put at risk in the way that Eshan was. Nothing can bring Eshan back but it will help us to know that it will not happen again."

Dr Nigel Fisher, chief executive of the hospital trust, said: "This was an exceptional incident. I believe that we have done all we reasonably can to prevent such an event ever happening again."

Brian Etheridge, regional director of the HSE, said: "Health and safety is not an unnecessary extra and should not put a burden on businesses. All we ask for is a simple assessment of risks."

Danger in the line of duty

* Peter Bryan, 35, below, battered his friend Brian Cherry, 43, to death with a hammer in east London in February 2004, then cooked his brain and ate it. He was sent to Broadmoor in April 2004 where, within days, he killed a patient, Richard Loudwell, 59. He was jailed for life in March.

* Daniel Williams, 27, was convicted of manslaughter and jailed for life after he stabbed a fellow mental patient to death at Fieldhead Hospital in Wakefield, West Yorkshire, in 1998. He pleaded guilty to killing 22-year-old Andrew Pawson after an argument. An independent inquiry said Williams was obsessed with Nazism and had a history of drug abuse and violence. Hospital staff had assessed him as low risk.

* John Rous stabbed to death Jonathan Newby, 22, a care worker in an Oxford centre for the homeless in October 1993. Rous, 49, a schizophrenic, telephoned police and said they would have a "dead corpse" on their hands, but they ignored him. He was sent to Broadmoor hospital after being convicted of manslaughter.

* Andrew Robinson, a schizophrenic with a 15-year history of violence, stabbed to death Georgina Robinson, 26, an occupational therapist, at a centre for acute psychiatric care in Torquay in September 1993. He had planned to murder John Major.

* Anthony Joseph, 27, a paranoid schizophrenic who claimed to be the son of God, stabbed a social worker to death at a hostel after she told him he needed to return to a psychiatric hospital. Jenny Morrison, 51, above, was stabbed more than 100 times at the halfway house in Balham, south London, in November 1998. Joseph was sent to Broadmoor indefinitely.