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“The human cost of institutional failings” – what you need to know about the NHS Trust fined £2m over preventable deaths


    On 26 March 2018, Southern Health NHS Trust was fined £2 million over the death of two vulnerable patients in its care, which the Trust admitted were “both preventable and should not have occurred”. We take a look at the history to the case as well as the regulatory investigations that led to a prosecution of the NHS Trust in the criminal court and a significant fine being imposed.

    By Ali Cloak

The tragic death of Teresa Colvin in 2012 and Connor Sparrowhawk in 2013 has led to five years of campaigning, investigations and (finally) a prosecution in the criminal court. Their cases have a long history and the investigations have been brought about mainly due to the persistent and powerful campaigning of Connor’s mother, Dr Ryan, and Teresa’s husband, Roger Colvin.

Teresa Colvin died after being found unconscious at Woodhaven Adult Mental Health Hospital in Hampshire and Connor Sparrowhawk drowned in a bath following an epileptic seizure at Slade House in Oxfordshire – both facilities were run by Southern Health NHS Trust.

Following the death of Connor, an investigation into all mental health and learning disability deaths at Southern Health NHS Trust between April 2011 and March 2015 was completed. The investigation found that only 272 of the 722 deaths in the Trust during that time had been properly investigated. This led to the regulatory body – the Health and Safety Executive – undertaking its own investigation into 91 of the cases. Their investigation highlighted that in Teresa and Connor’s cases there were substantial breaches of health and safety legislation and they brought a prosecution under criminal law.

Due to the specific problems at Southern Health Trust, the Health Secretary ordered a wider review into how NHS Trusts in England investigate deaths in NHS care which was published in December 2016 by the Care Quality Commission, titled ‘Learning, Candour and Accountability’.

The prosecution of Southern Health

Southern Health was prosecuted in the criminal court for breaching sections of the Health and Safety at Work Act.

The NHS Trust pleaded guilty and admitted there were ‘systemic failures’ in the deaths of Connor and Teresa, including that it:

  • Had ineffective policies and procedures
  • Failed to analyse risks
  • Failed to respond to warnings
  • Failed to properly supervise patients, and
  • Provided care to the two patients that was not appropriate.

As a result of this admission, the Trust was fined £2 million, broken down into £950,000 for Teresa Colvin’s death and £1,050,000 for the death of Connor Sparrowhawk. The judge noted that the fine was “a just and proportionate outcome that marks the seriousness of the Trust’s offending”.

Southern Health was prosecuted by the Health and Safety Executive, which was the regulatory body at the time in charge of enforcing breaches of health and safety legislation. This job is now carried out by the Care Quality Commission (CQC). A prosecution under health and safety legislation is only one possible means of redress when a loved one suffers an avoidable death or injury under the care of the state – other redress can be sought through a claim in negligence and complaints can also be made to the NHS Trust, or if appropriate, against an individual doctor or nurse to their regulatory bodies.

Has anything changed?

Since the production of the 2015 report focusing on Southern Health and the 2016 report that looked at the issue nationally, Southern Health have tried to show how they are improving their systems and policies.

The Trust put evidence before the court to show how it has already, and continues to, improve its health and safety management systems. In fact, one of the reasons that the judge did not give a higher fine to the Trust was that it could see that investments had been made and were being implemented to improve patient safety and minimise risks.

This is an encouraging sign that when significant concerns are raised, things will change. However, it is tragic that so many deaths went without investigation for so long for this to happen.

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