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Southern Health NHS Foundation Trust fined £2 million after ‘wholly avoidable’ deaths of two patients

Posted: 09/04/2018


Following the deaths of two mental health patients under its care, Southern Health NHS Foundation Trust, which provides community health, mental health, learning disability and social care services across the south of England from its headquarters in Southampton, has been subject to a prosecution by the Health & Safety Executive (HSE). The outcome of the prosecution has been heard at Oxford Crown Court where the trust pleaded guilty to the charges made against it and has had a £2 million fine imposed due to the failings identified by the HSE.

The first death, which was investigated and contributed to the subsequent prosecution, was that of 18 year old Connor Sparrowhawk. In July 2013 Connor died after suffering an epileptic seizure in the bath at the trust’s specialist unit, Slade House in Oxford. The HSE investigation found that despite Mr Sparrowhawk’s known vulnerability and previous suspected seizures, he was allowed to use the bath alone with checks from staff taking place only every 15 minutes. The HSE concluded that allowing him to bath unsupervised for any length of time was an ‘obvious risk’ and criticised the trust for failing to have systems in place to manage Connor properly and safely.

After Connor’s death, NHS England published an independent Mazars report in December 2015 into the deaths of people with learning disabilities or mental health problems under the care of Southern Health NHS Foundation Trust. As part of the investigation, the HSE looked at this report and concluded that one of the deaths met the criteria for a full HSE investigation, which was subsequently instigated.

This was the death of 45 year old Teresa Colvin in April 2012. She was found slumped and unconscious at a telephone kiosk at Woodhaven Adult Mental Health Hospital in Southampton and died shortly afterwards, despite medical treatment. Teresa had used the telephone cord as a ligature on herself. The HSE was concerned that even though the trust had already, based on past incidents, looked at the risks associated with the use of corded phones, it had not taken sufficient steps to manage and avoid / reduce this risk. It was the HSE’s view that had the risk been managed properly across the trust’s facilities, Teresa Colvin would not have died in this way.

The court heard that the HSE investigations found a series of management failings which it concluded led to both deaths, including a failure to control risks, and failures in planning. The trust was prosecuted for breaches of Section 3(1) of the Health and Safety at Work Act 1974, and pleaded guilty to both charges. This section of legislation places general duties on employers and the self-employed towards people other than their employees to protect them from the risk of injury – in this case the relevance of the section was the obligation to patients under the trust’s care. The court imposed a fine for each breach leading to death, together totalling £2 million.

Following the outcome of the prosecution, the deputy director of field operations for the HSE, Tim Galloway, said: “These tragic incidents could have wholly been avoided with better supervision and planning. Instead two families are left utterly devastated and let down by those who had a duty of care for their loved ones….The trust was responsible for caring for those suffering with mental health issues and for those with learning difficulties. On these two occasions it failed these two patients and their families.”

Philippa Luscombe, partner in the personal injury and clinical negligence team at Penningtons Manches LLP, comments: “From the information available, the circumstances leading to these two untimely deaths were both avoidable. The whole point of the UK’s health and safety legislation is to ensure that employers and others running any form of organisation consider the safety of their employees and those affected by their day-to-day activities or those who are under their care. In the case of these two patients, there were obvious risks which should have been identified and managed. Connor’s condition put him at risk without supervision of certain activities and the trust should have appreciated and managed that risk. In Teresa’s case, the issue of patients with mental health difficulties accessing phone cords and using them to self harm was a problem which the trust and indeed that specific facility had encountered, but despite their awareness, no steps were taken to reduce or manage that risk.

“Whether the obligations were those of basic health and safety risk assessment and management (as looked at by the HSE), or of a duty of care in medical management of these two patients, the trust failed both the patients and their families. We hope that the thorough investigation by the HSE and the significant fine imposed because of the tragic outcomes will result in a real shake up at the trust and a proper focus on managing the safety of patients who are at risk.”


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