After a patient fell on the hospital grounds and suffered fatal injuries, a health board was fined PS850,000. The victim had wandered from an unlocked ward.
Lyn Thomas, age 74, passed away in November 2019, while Lyn was at Maesteg Hospital recovering from a brain surgery.
Andrew, her son, said that it was beyond belief that she had been allowed out on various occasions.
Cwm Taf Morgannwg's health board admitted to violating the health and safety of work act.
In a statement to Cardiff magistrates Mr Thomas said that his mother was the "loving, kind heart of our family".
Lyn Thomas was in Maesteg Hospital's Llynfi Ward, which provides care for the elderly and dementia patients to recover from surgery at the University Hospital of Wales (UHW), Cardiff.
The court heard that a Depravation of Liberty Safeguarding Order (DOLS), had been placed in hospital in Cardiff due to her confusion after the operation and her risk of wandering.
However, at Maesteg's hospital, there was no DOLS order and no risk assessment.
The court was told that patients could not leave the Llynfi ward at Maesteg because there was no lock on it. After Mrs Thomas was admitted to the ward she was found on her knees outside at a bus stop nearby.
A DOLS urgent order was issued. However, Mrs Thomas was still found wandering around the grounds the next day.
On the 13th of November 2019, Mrs Thomas was last seen leaving the ward just before 8pm.
She left the hospital at the front door. She was found unconscious near the gateposts about 20 minutes later.
She had crossed the zebra crossing, and she was now going down external stairs. It was dark, wet, and snowy.
The court was informed that Mrs Thomas's health had rapidly deteriorated and she died.
Andrew Thomas, her son, stated that Maesteg staff weren't as involved or caring with them as at UHW.
It was "bad enough," he said, that his mother managed to escape the city within one day of her arrival in Maesteg. He stated that it was "beyond belief", that it occurred on two additional occasions.
In addition, the court heard that the HSE had later inspected the board and served an improvement notice to the board in October 2020. Also, the board admitted that improvements were not completed within the required timeframe.
Cwm Taf Morgannwg's barrister Nigel Fryer stated to the court that the board had apologised "wholeheartedly, profoundly to [the Thomas family]".
He stated that the board was "horrified" by what had occurred and that there had been failures.
In the meantime, the Llynfi Ward remains closed.
According to the court, there have been instances of patients leaving the ward in the past. Mr Fryer stated that the lock was obvious and it would be foolish to accept any other.
According to the court, a lock was placed on the ward's door within 24 hours after Mrs Thomas's death.
BBC Wales was told by Helen Turner, HSE inspector that there were no safeguards to prevent vulnerable patients leaving, and that the health board had "felt very far short" what it needed.
She stated that the case was about accountability, and responsibility.
Ms Turner said, "It's about managers recognising risks and taking action to address them within their control."
She stated that the health board was trying to change the culture, and she hoped the prosecution would send a clear message to all health boards in Wales.
Paul Mears, chief executive of Cwm Tf Morgannwg, stated: "As health boards, we fully accept these charges and take this opportunity for Mrs Thomas' family and all those in our wider community to be reassured that we have made critical improvements to stop such a tragic incident from happening again.
"Cwm Taf Morgannwg is committed to making things right and providing the best healthcare services for our communities.
"We have learned from Mrs Thomas's tragic passing and I am confident in the solid risk assessments, policies, and procedures that are in place in all our inpatient areas."
