A private healthcare company was ordered today to pay out nearly £130,000 after the elderly father of a BBC health correspondent died due to hospital management neglecting their duties.
Michael Walsh, 85, fell 15ft from a balcony at the BMI Shelburne Hospital in High Wycombe, Buckinghamshire, after being left on his own despite suffering from confusion following an operation.
On Valentine's Day 2009, Mr Walsh walked on to the balcony through unlocked doors in his room and fell off the balcony, Aylesbury Crown Court heard.
He died of pneumonia resulting from his injuries the following day.
The court heard that there were no keys available to staff to lock the doors and even once they were made available, the sliding doors could not be fully locked.
The fatal flaw was not recognised until after Mr Walsh's death as BMI Healthcare did not carry out an adequate risk assessment, the court heard.
BMI was today fined £100,000, ordered to pay £29,446.95 in costs and a £15 victim surcharge after previously pleading guilty to a failure to discharge a duty under the Health and Safety at Work Act 1974.
Judge Joanna Cutts said: "In every sense this is a tragic case. It is clear that Mr Walsh was a loved man and in his later years took an active life.
"It appeared that even with locks, one side of the sliding doors could not be locked. A properly conducted risk assessment should have revealed that the doors could not be locked and recognised the implications of that.
"The company fell significantly short of applicable standards.
"The sad death of Mr Walsh is clearly a serious aggravating factor in this case.
"In every sense Mr Walsh was an honourable person.
"I cannot ignore that this company could and should have done more to ensure the safety of patients and a man has died as a result."
Mr Walsh's son and health correspondent for the BBC, Fergus Walsh, said: "We are very relieved it is over and the crucial thing is that it never happens to anybody again, whether it is in an NHS hospital, a private hospital or a nursing home.
"Any sliding door that can open is the same risk as a window."
The broadcaster continued: "Michael Walsh went into hospital for a routine operation, which was successfully completed, but just days later died in terrible pain.
"It seems impossible to imagine that rooms would be fitted with patio doors that could not be locked, particularly when post-operative confusion is known to affect patients of all ages. And it is surely basic common sense that vulnerable and confused people are not left unattended in an environment where they could injure themselves.
"We sincerely hope that a tragedy like this does not happen again and that a clear message is sent to all hospitals and care homes to check the safety of their premises."
Mr Walsh, an active man from Beaconsfield, Buckinghamshire, had not suffered from confusion prior to his routine prostate operation, and was left with a fractured spine after the fall on February 14 2009. He was transferred to an NHS hospital but died the following day after developing pneumonia.
The court, sitting in Amersham, heard that Mr Walsh had become confused in the days after his operation on February 10, shouting at staff and at one point throwing a fire extinguisher down a corridor.
He was monitored by nurses and doctors and it was only when the day staff were handing over to the night staff that Mr Walsh was left alone to walk out on to the balcony.
The judge recognised that there was no failure in terms of staff or staffing levels, but that the failure was not realising the built-in risk of the doors that could not be locked.
BMI has now rectified the problem, the court heard.
The company is the country's largest private healthcare provider, with 69 hospitals across the country.
The firm handles more than 250,000 inpatient and one million outpatient visits each year and had not been convicted of a health and safety breach prior to this case, a significant mitigating factor, according to the judge.
After the hearing, Health and Safety Executive inspector Robert Meardon said: "This case graphically illustrates that hospitals need to ensure that vulnerable patients in their care are not allowed to be put at unnecessary risk. This patient's accident was entirely avoidable.
"The hospital had not assessed the risk of someone falling off their balcony in private rooms, and had no system in place to ensure that the risks of a fall were adequately controlled. A possible control would have been to have locks on the balcony doors, with keys under the supervision of medical staff.
"However Mr Walsh was left alone, and he was able to get on to the balcony and fall several metres to the ground below.
"There is a well-known accident history in the care sector of vulnerable people falling from window openings and balconies, which is why there is no excuse for duty holders to fail to manage these risks. It is essential that effective assessment of the risks are undertaken in order to ensure the necessary preventive measures are put in place."
After an inquest into Mr Walsh's death in 2010, his son revealed that his father had been a firm believer in private healthcare.
He said: "My father had great faith in private medicine. He was suspicious of the NHS. It is an irony that he paid a lot of money, as he had private insurance for 50 years, and in the end it sadly let him down."