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£2m fine for Southern Health after wholly avoidable deaths

The Health and Safety Executive (HSE) has fined Southern Health NHS Foundation Trust a total of £2m after continued failings led to the deaths of two vulnerable patients.

In April 2012, Teresa Colvin (45) died after being found slumped and unconscious at a telephone kiosk at Woodhaven Adult Mental Health Hospital in Southampton.

Teresa, affectionately known as TJ, had been admitted only 48 hours before she was found hanged by a telephone cord.

Despite the history of patients at Woodhaven, and other sites, using phone cords as ligatures, no action had been taken by the Trust.

The coroner, Kevin Wiseman ruled that he could find no “systematic failure” in Teresa’s care, but that the risk of the telephone in the unit had been “underestimated”.

The Trust has since shortened all telephone cords on all its sites.

However, it was the death of 18 year-old Connor Sparrowhawk the following year that sparked the investigation into the Trust.

On 4 July, Connor was found dead in the bath, having drowned after an epileptic seizure, while he was a patient at Slade House, a specialist unit in Oxford. His mother, Dr Sarah Ryan disputed claims that her son had died of natural causes and launched an extensive campaign, believing that the Trust had failed her son.

Investigations led to the discovery that the Trust had failed to investigate the deaths of over 1,000 patients in just a four-year period.

There had been a series of management failings, including a failure to control risks and a failure in planning.

Following the trial at Oxford Crown Court, HSE executives paid tribute to Dr Ryan for her “continued campaigning on these tragic issues”.

Tim Galloway, deputy director of field operations added: “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.”

John McQuater, head of litigation at Atherton Godfrey, commented: “Our thoughts, first and foremost, are with the families of Connor Sparrowhawk and Teresa Colvin. Not only have both families been left devastated by the tragic and needless deaths, they have also been subject to protracted investigations.

The Trust failed to act on warning signs and risk assessments. Had they done so, both deaths could have been avoided.”

Author: Gail Harris

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Trust admits guilt over teenage patient’s death

Southern Health NHS Foundation Trust has admitted their guilt over the death of a teenage patient.

The Trust provides mental health and learning disability services to patients in Hampshire and Oxfordshire.

Connor Sparrowhawk, who was aged just 18 years old, died in July 2013 whilst a patient of the Trust at Slade House, a specialist treatment and assessment unit, in Oxfordshire.

Connor, who was known to suffer from epilepsy, drowned in the bath after suffering an epileptic seizure, whilst he was an in-patient at the unit.

A medical tribunal in August 2017 found that Connor’s epilepsy had not been properly assessed or managed and there had been failures on the part of the doctors employed by the Trust to carry out proper risk assessments for Connor, which resulted in no adequate supervision during bath times.

This, tragically, led to Connor’s avoidable and preventable death.

The Trust pleaded guilty to breaching health and safety law and face an unlimited fine when sentenced at Oxford Crown Court early next year.

Slade House closed in 2014, following Connor’s death.

Julia Dawes, the Trust’s Interim Chief Executive, described Connor’s death as entirely preventable in a statement following the hearing, and apologised for not keeping Connor safe whilst he was a patient at the Trust. Ms Dawes also confirmed that Connor’s death had led to significant changes and improvements at the Trust, which will hopefully prevent such a tragedy happening again.

Any death is devastating for the family and friends of the deceased, but it is particularly so when the death was avoidable and occurred as a result of a lack of care on the part of medical professions who are entrusted to look after our loved ones.

If you have any concerns about care provided to you or a family member in any clinical setting, and would like advice about the possibility of making a claim then please contact our experienced medical negligence team on 01302 320621 or email

Author: Laura Armstrong



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Raising maternal mental health awareness

Author: Clare Middleton

This week (1-7 May) is National Maternal Health Awareness Week.

Pregnancy and the birth of a child is such a happy and joyful time. But for some women, it can be a time of high anxiety, low mood, trauma and depression.

National Maternal Mental Health Awareness Week has been developed to help women access support and to increase awareness of maternal mental health.

Only in its second year, it is hoped that by raising awareness, more resources will be invested in women’s mental health around pregnancy and childbirth.

Did you know that suicide is the leading cause of direct maternal deaths occurring up to 1 year after the end of pregnancy?

According to the Birth Trauma Association, around 10,000 women a year develop PTSD following childbirth, but as many as 200,000 more women feel traumatised by childbirth. This trauma can have long term consequences on the mother in all aspects of her life.

Many hospitals across the UK now offer a ‘debriefing’ after childbirth, where parents are able to sit down with a midwife, look at the medical records and discuss what happened during the birth. Too often, during childbirth, the opportunity to fully understand what is happening is lost, whether due to pain, medication or the speed at which events happen. The ‘debrief’ is a chance to ask the questions that you were not able to ask at the time.

At Atherton Godfrey, our medical negligence team have helped many women find the answers they need. If you have concerns about any aspect of your treatment in labour, or the antenatal or postnatal period, then our specialist team may be able to help.