An NHS Trust has been fined £2m for the deaths of two vulnerable patients in its care after admitting errors were ‘avoidable and entirely preventable’.
Southern Health NHS Foundation Trust was sentenced yesterday following the deaths of 45-year-old Teresa Colvin and 18-year-old Connor Sparrowhawk.
At Oxford Crown Court, HSE told of a series of management failings leading up to both deaths including the failure to control risks, and failures in planning.
The court heard how, on 26 April 2012, Teresa Colvin was found slumped and unconscious at a telephone kiosk at Woodhaven Adult Mental Health Hospital in Southampton. She died a short time later following treatment.
There had been a history of patients across the Trust, including those at Woodhaven, using phone cords as a ligature.
But the Trust had failed to act on assessments showing how it could better control the risks associated with the use of phones with cords.
HSE’s deputy director of field operations Tim Galloway said: “The known risk of patients across the Trust using phone cords as ligature was never sufficiently addressed. This ultimately led to the death of this vulnerable patient.”
The court was told of the second incident, on 4 July 2013, when 18-year-old Connor Sparrowhawk died after suffering an epileptic seizure in the bath at Slade House in Oxford.
HSE found that despite Mr Sparrowhawk’s previous suspected seizures, he was allowed to use the bath alone with checks from staff taking place every 15 minutes.
“Southern Health was aware of the patient’s condition and there had been a number of warning signs prior to the incident taking place. Allowing Connor to use the bath unsupervised was an obvious risk and a serious management failing,” said Mr Galloway.
Commenting in a statement issued on Southern Health’s website, chief executive Dr Nick Broughton, said: “Since I joined the Trust in November I have looked closely at what happened to Teresa and Connor and the events that followed. I feel deeply saddened and am truly sorry that we let them down with such devastating consequences. Their deaths were avoidable, entirely preventable and should never have occurred.
“Personally, and on behalf of the trust board, I apologise unreservedly.”
Southern Health NHS Foundation Trust, pleaded guilty to two breaches of Section 3(1) of the Health and Safety at Work Act 1974. For the breach relating to Teresa Colvin, the sentence was a £950,000 fine. For the breach relating to Connor Sparrowhawk’s death, the sentence was a fine of £1,050.000.
Liberal Democrat Norman Lamb MP, formerly health minister, commented that he was "horrified" at the time to learn that the HSE had decided not to investigate Connor Sparrowhawk's death. "After urging them to reconsider, I was pleased that they eventually investigated and decided to prosecute the trust," he said.
"Almost five years after Connor's death, however, this process has taken far too long. His family have had to suffer unimaginable distress at the inordinate delay, and have been treated terribly throughout the process.
"No fine will deliver true justice to the families of Connor Sparrowhawk and Teresa Colvin. However, I welcome the very clear signal to Southern Health – and other organisations – that the rights of people with learning disabilities and complex mental health conditions are paramount, and that there can be no second class citizens in our NHS," he added.
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