Southern Health fined £2m over ‘entirely preventable’ deaths of patients

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Southern Health
Teresa Colvin (45) died at the Woodhaven unit at Tatchbury Mount, Calmore, in 2012

AN NHS trust has been fined £2m for breaching health and safety laws over the deaths of two patients in its care, including that of a 45-year-old woman from Lyndhurst.

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The punishment was handed down to Southern Health NHS Foundation trust, which is based near Totton, by a judge at Oxford Crown Court who described the fatalities as tragedies that were “entirely preventable”.

Southern Health pleaded guilty to two charges brought by the Health and Safety Executive (HSE) – one relating to the death at the Woodhaven unit at Tatchbury Mount in 2012 of Teresa Colvin.

Known as TJ, the Emery Down resident had a history of depression and self-harm. She died in hospital following a ligature incident that was partly due to “systematic failures” from the trust management botching risk control.

Her case was raised by Labour leader Jeremy Corbyn at Prime Minister’s Questions on Wednesday when he accused the government of underfunding mental health services.

Outside court on Monday, her husband Roger said: “For me, there was no goodbye to my wife, who was beautiful in so many ways. I was robbed of that opportunity because of the actions of the trust.

“TJ and I believed the hospital was a place of safety but Southern Health collectively failed her in several ways, with dire and irreversible consequences. It is so tragic and very, very sad. Her death should not have happened.

“My wife was caring, bubbly and full of fun. I don’t want TJ to be just another statistic, nor do I want the same happening to anyone else.”

Hampshire mental health services
Woodhaven hospital, at Tatchubury Mount, closed in 2012 

Southern Health provides mental health and community services for five counties including Hampshire and Dorset, and manages hospitals such as Lymington, Hythe and Fordingbridge.

The second case was of Connor Sparrowhawk, who drowned aged just 18 after suffering an epileptic fit in a bath at a unit in Oxford in 2013.

Campaigning by his mother, Dr Sara Ryan, eventually led to an official investigation which in 2015 revealed how the trust’s management was failing patients.

As reported in the A&T, the then chief executive Katrina Percy was forced to resign in 2016 after repeated criticism of her governance. In court, Mr Justice Stuart-Smith attacked the previous “intransigence” of senior executives towards the families.

There is now a completely new management team, and although the trust is still rated as “requires improvement” by the Care Quality Commission, last year it was said by inspectors to have “turned the corner”.

Dr Nick Broughton, the current chief executive, said: “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.

“I know that words can do little to ease the enormity of the respective families’ losses and pain. But Teresa and Connor’s deaths have been genuine catalysts for change, and I sincerely hope our actions to improve care as a direct result provide some comfort, however small.”

He said the trust’s approaches had been overhauled, including a dedicated health and safety team and guardians at all levels, as well as more involvement of families.

The result was welcomed by Barton woman Maureen Rickman whose sister, Joanna Deering (52), committed suicide in 2011 which was linked by the coroner to her discharge from hospital by Southern Health.

But she wanted Mrs Percy – who received a £190,000 pay-off – and former medical director Dr Lesley Stevens to have been at court to hear the sentence, and described their absence as a “travesty of justice and governance”.

The £2m penalty sent a “very clear warning” to other NHS trusts, Dr Rickman said, but it was also a “rough kind of justice” that would divert money away from vulnerable patients.
Southern Health was fined £950,000 over the case of Mrs Colvin and £1.05m for Mr Sparrowhawk.

Mr Justice Stuart-Smith said he reduced the combined penalty from a potentially higher figure because of the “significant financial pressure” currently facing the trust and the efforts made more recently to make it safer for patients.

He described the fine as a “just and proportionate outcome that marks the seriousness of the trust’s offending, the terrible consequences of that offending”.

HSE’s deputy director of field operations, Tim Galloway, said afterwards: “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.”

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