• Southern Health fined £2m for management failings that led to two patient deaths
  • Trust admitted two breaches of health and safety law last year in connection to the deaths of Connor Sparrowhawk and Teresa Colvin
  • Fined £950,000 in relation to Ms Colvin’s death and £1,050,000 in relation to Mr Sparrowhawk’s
  • Trust chief executive says the deaths were a “catalyst for change” at Southern Health

A trust has been fined £2m for “serious systematic” management failings that led to the deaths of two vulnerable and disadvantaged patients.

Southern Health admitted two breaches of health and safety law in relation to the deaths of 18 year old Connor Sparrowhawk and Teresa Colvin, 45.

It pleaded guilty to breaching section 3(1) of the Health and Safety at Work Act 1974 in relation to Mr Sparrowhawk in September and to Ms Colvin in November.

In sentencing at Oxford Crown Court today, judge Sir Jeremy Stuart-Smith gave the trust a fine of £950,000 in relation to Ms Colvin’s death and another fine of £1,050,000 in connection to Mr Sparrowhawk’s.

Mr Sparrowhawk drowned in a bath following an epileptic fit at the trust’s Slade House specialist unit in Oxford in July 2013.

Ms Colvin died after being found unconscious at Woodhaven Adult Mental Health Hospital, near Southampton, in April 2012.

Judge Stuart-Smith said it was regrettable that it took a “time consuming and punishing campaign” by the patients’ families to uncover the “serious systematic problems” at the trust.

He added: “Those systemic problems lasted for years from well before the death of [Ms Colvin] until well after the death of Connor. The existence of those problems is now fully acknowledged by the trust.

“The trust has also made it completely clear that it does not attempt to shift or deflect responsibility for what went wrong onto individuals in its employment.

“What went wrong went far deeper than that: this case is concerned with deep rooted systemic failings directly affecting the safety of vulnerable and disadvantaged patients.

“They were patients who were in the trust’s care and who needed, above all else, the trust to protect them.”

The prosecution was brought by the Health and Safety Executive, which told the court its investigation had found a series of management failings leading up to both deaths, including a failure to control risks, and failures in planning.

In a statement today, HSE deputy director of field operations Tim Galloway said the two deaths were “wholly avoidable” with better supervision and planning.

He added: “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 caring for those with learning difficulties. On these two occasions it failed these two patients and their families.”

Today’s fines follow the trust being fined £125,000 after a Care Quality Commission prosecution in October over safety warnings repeatedly ignored by the trust.

Southern Health chief executive Nick Broughton said his trust fully accepted the failings and the deaths were “avoidable, entirely preventable and should never have occurred”.

He added: “I feel deeply saddened and am truly sorry that we let them down with such devastating consequences.

“Personally, and on behalf of the trust board, I apologise unreservedly.”

Dr Broughton said the two deaths had been “genuine catalysts for change” that have led to the trust’s services becoming safer through overhauling approaches to managing ligature and supporting patients with epilepsy.

He added: “I know that words can do little to ease the enormity of the respective families’ losses and pain. 

“Crucial to these and other improvements is the contribution from many families and individuals dedicated to bringing about change. Whether working alongside us, or indeed as campaigning activists, their courage, dignity and insight is making a difference and deserves recognition.

“The job of improving safety and quality is never complete and it remains the single highest priority for me and my colleagues.”