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