Intended for healthcare professionals


Southern Health is fined £2m over deaths of two patients

BMJ 2018; 360 doi: (Published 27 March 2018) Cite this as: BMJ 2018;360:k1411
  1. Ingrid Torjesen
  1. London

An NHS trust has been fined £2m (€2.28m; $2.83m) after admitting “systemic failures” regarding the deaths of two vulnerable patients.

Connor Sparrowhawk, 18, drowned in a bath after an epileptic seizure at Slade House in Oxford in 2013, while under the care of Southern Health NHS Foundation Trust. Teresa Colvin, 45, died after being found unconscious in 2012 at Woodhaven Adult Mental Health Hospital, also run by the trust. In 2017 Southern Health admitted having breached health and safety laws.

The trust was fined £1 050 000 over the death of Sparrowhawk and £950 000 over the death of Colvin. During sentencing at Oxford Crown Court on 26 March Mr Justice Stuart-Smith described the deaths as an “unnecessary human tragedy.”

He said it was “regrettable” that victims’ relatives had had to campaign “to uncover the serious systemic problems with the trust’s health and safety management arrangements that underpin this prosecution,” which existed for years before and after their deaths and are “now fully acknowledged by the trust.”

The judge said that the trust, in its submission to the court, had “recognised the seriousness of the failings” disclosed by the investigations into the two deaths. The trust admitted that the deaths were “both preventable and should not have occurred,” that it had not ensured appropriate care for the two patients, and that it had ineffective policies and procedures and poor leadership.

An investigation by the Care Quality Commission prompted by Sparrowhawk’s death led to the discovery that Southern Health had not properly investigated the unexpected deaths of more than 1000 patients with learning disabilities or mental health problems from 2011 to 2015.1

In its statement to the court the trust said, “It is a matter of significant regret that between April 2011 and spring 2016 the trust did not adequately address the quality and safety, governance and assurance challenges it faced in a timely and robust way.”

The trust now has an entirely new board and has significantly strengthened management within the trust, and “substantial evidence has been put before the court to the effect that the trust has now addressed the deficiencies in its health and safety management systems,” the judge said.

He added that the level of the penalty was “a just and proportionate outcome that marks the seriousness of the trust’s offending, the terrible consequences of that offending, and the other material factors that I have indicated.”


View Abstract