A north-east health board has been fined almost £65,000 after a patient took his own life at an Aberdeen hospital.
Vincent Mulsant – a popular musician who played in several local bands – was a psychiatric patient at Royal Cornhill Hospital when he died in 2020.
NHS Grampian referred the tragedy to the Health and Safety Executive (HSE) after it emerged the 40-year-old – who was known to friends as Vinnie – had managed to obtain clinical tape and a bin bag while at the hospital.
The HSE then passed the file to the Crown, which charged NHS Grampian with failing to ensure the health and safety of non-employees.
The health board pled guilty to the charge at Aberdeen Sheriff Court and said the tragedy had resulted in procedural changes at hospitals across Scotland.
It is the first time in the board’s 20-year history that it has been convicted of a crime.
Fiscal depute Catherine Fraser said that Mr Mulsant – whose family hails from France – had been on Huntly Ward at Cornhill at various stages since December 2019.
The ward is for people aged 18 to 65 with acute mental health needs.
Ms Fraser said that, in late February 2020, Mr Mulsant had left the hospital and returned to his Aberdeen home, where he self-harmed twice.
When he returned to Cornhill, staff encouraged him to clean his own wounds so he would have agency in his care.
However, this allowed him to obtain and stash clinical tape and a bin bag, the court heard.
Ms Fraser told the court that several psychiatric assessments of Mr Mulsant in February and March 2020 concluded he had a high risk of suicide.
On March 26, Mr Mulsant was admitted to Aberdeen Royal Infirmary after taking an overdose of pills and was taken back to Cornhill after receiving treatment.
Two days later, a member of staff went to see Mr Mulsant in his bedroom, but couldn’t find him.
He waited 10 minutes and, when Mr Mulsant didn’t return, made further enquiries.
‘My beautiful son’
Mr Mulsant was then found unconscious in a bathroom.
Staff tried CPR and called paramedics to help but, sadly, Mr Mulsant was pronounced dead at the scene, due to asphyxiation.
At time of his death, Mr Mulsant’s mother Brigitte wrote a moving tribute to him.
She called him her “beautiful son” and thanked her family in France for their support.
Brigitte added: “I also wish to thank Vincent’s many friends and my friends for all their love, support and kind words.”
His friend, Wilson Noble, of Fraserburgh, wrote: “Vinnie was a lovely guy and will be sadly missed.
“Back in 2006 from when we played in a band together in Aberdeen, doing one of the things he loved best.
“Take care pal, thank you for being my friend.”
The family’s heartache was made worse by the fact Mr Mulsant died at the very start of the pandemic so could not hold an open funeral and loved ones could not travel from France.
Yesterday’s court case examined the reasons behind his death.
‘There was no policy in place preventing bag usage’
Ms Fraser said: “Although his death involved a clinical waste bag as opposed to bag lining the bin in the bathroom, there would have been an equal opportunity for him to have made use of that in any case.”
Scotland had no policy at the time of the incident preventing or monitoring bin bag and clinical waste bag usage, though England did.
It was up to Health Facilities Scotland to advise NHS boards about it, and it did not.
The court heard how NHS Grampian didn’t prohibit the use of bin bags because it had never been the cause of anyone taking their own life previously.
However, in the wake of Mr Mulsant’s death, there was a review and the policy was changed.
Since July 2020, safer bins have been used, processes are in place to ensure clinical tape is collected, with monthly audits, and visitors are banned from bringing in bin bags.
The board’s representative told the court that two of its staff were involved in the decision to introduce these new measures across Scotland.
Under health and safety laws, the only punishment that Sheriff Morag McLaughlin could impose was a fine.
‘NHS Grampian is in a perilous financial situation’
She gave the board credit for its guilty plea, for making changes after Mr Mulsant’s death and for upholding patient welfare standards.
Sheriff McLaughlin said she acknowledged NHS Grampian was “in a perilous financial state” and any fine would mean funds taken away from patient care.
She added: “That said, there must be some punishment.
“I appreciate there must be a balance between NHS staff carrying out checks for the presence of certain objects which might pose a danger, and patient autonomy – and this balance is far from an exact science.
“However, the failing here is that the danger posed by the clinical waste bag to Mr Mulsant was not appreciated and there were no guidelines to that effect.
“Those measures clearly proved inadequate.”
‘His family out to have been reassured he was safe’
Sheriff McLaughlin fined the board £64,500 to be paid within two months.
She added: “Whatever is said here in court today can not in full compensate Mr Mulsant’s family for their loss and I want to extend my deepest sympathies to them.
“They ought to have been reassured that he was safe at the hospital.
“It is difficult for us to understand the devastation they must feel.”
Two NHS Grampian bosses were in attendance at court and expressed their sympathy with Mr Mulsant’s loved ones after the hearing.
Mum: ‘A mixture overwhelming relief and deep sadness’
After the hearing, Brigitte Mulsant told the P&J: “I waited four years to hear that NHS Grampian has pleaded guilty to the charge.
“That guilty plea is not going to bring my son back but at least the board has finally admitted responsibility for his death.
“I was very emotional when I learned of the guilty plea. It was a mixture overwhelming relief and deep sadness.
“This brings me closure because it has been an ordeal.
“To me, the fine is irrelevant. As long as they got punished and admitted responsibility – that’s the important thing.”
Following the hearing, an NHS Grampian spokeswoman said: “We apologise unreservedly for the failings which led to this tragic incident.
“Lessons have been learned and significant improvements made as a result.
“However, we remain deeply sorry to the family of Mr Mulsant for their loss.”