Yesterday, Southern Health NHS Foundation Trust was fined £2 million at Oxford Crown Court for two offences under Section 3(1) of the Health and Safety at Work Act 1974. The charges arose from the deaths of two vulnerable patients. The fine is the highest financial penalty imposed against an NHS Trust for offences of this type.

Southern Health: The background

Southern Health pleaded guilty to the offences in 2017 and admitted ‘systemic failures’ that breached health and safety laws and led to the deaths of Connor Sparrowhawk and Teresa Colvin.

Teresa Colvin, 45, died at Southampton General Hospital after she was found unconscious at Woodhaven Adult Mental Health Hospital on 26 April 2012.

Connor Sparrowhawk, 18, drowned in a bath after an epileptic seizure at Oxford unit, Slade House. A Coroner concluded that his death was contributed to by neglect.

The sentence marks the end of a six year period in which the Trust has been subject to intense scrutiny from Coroners, the GMC, the NMC, the CQC, the police and the Health and Safety Executive (HSE) into the deaths of Mr Sparrowhawk and Mrs Colvin.

Mazars report

The independent Mazars report published in December 2016 concluded that Southern Health had failed to properly investigate the deaths of more than 1,000 patients with learning disabilities or mental health problems over four years.

Sentencing of Southern Health

In his sentencing comments, Mr Justice Stuart-Smith remarked that the deaths were an ‘unnecessary human tragedy’. He described the sentence as a ‘just and proportionate outcome that marks the seriousness of the trust’s offending [and] the terrible consequences of that offending.’

In imposing the sentence, the Court adopted revised sentencing guidelines introduced in February 2016. The Court found that the Trust’s culpability for the offences was high and that the harm caused was also high. The Court did, however, apply the highest permissible reduction in sentence, one third, to reflect credit for the Trust’s prompt guilty pleas.

The revised sentencing guidelines have seen penalties increase significantly. Fines collected by the HSE during the first year of the new sentencing guideline increased by 74%, to £61.6m from £35.5m.

The Court’s unprecedented sentence underlines the challenges faced by Trusts and other healthcare providers in both providing care to vulnerable persons and in properly investigating circumstances where that care falls short. The Court found as an aggravating feature in this case that the Trust had failed to properly investigate and learn from previous incidents and concerns raised by staff, service users and their families.