NHS Foundation Trust Fined After Deaths of Two Patients

Monday, 26th March 2018

An NHS Foundation Trust has been fined £2m after a series of management failings led to the deaths of two vulnerable patients at different facilities owned by the Trust.

The Health and Safety Executive (HSE) prosecution follows the deaths of 45-year-old Patient A at a Mental Health Hospital and the death of 18-year-old Patient B at a specialist unit in Oxford. Both centres were under the management of the same NHS Foundation Trust.

Oxford Crown Court heard both HSE investigations found a series of management failings leading up to both deaths including a failure to control risks, and failures in planning.

The NHS Foundation Trust, pleaded guilty to two breaches of Section 3(1) of the Health and Safety at Work etc. Act 1974. For the breach relating to Patient A, the sentence was a £950,000 fine. For the breach relating to Patient B’s death, the sentence was a fine of £1,050.000.

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

“The Trust was responsible for caring for those suffering with mental health issues and caring for those with learning difficulties. On these two occasions it failed these two patients and their families.

“Our thoughts remain with these patient’s families as they continue to come to terms with these avoidable tragedies.

Background of Case

Death of Patient B

On 4 July 2013, an 18-year-old patient died after suffering an epileptic seizure in the bath at the Trust’s specialist unit in Oxford.

An investigation by the Health and Safety Executive (HSE) found that despite the patient’s vulnerability and previous suspected seizures, he was allowed to use the bath alone with checks from staff taking place every 15 minutes.

Tim Galloway added: “The Trust was aware of the patient’s condition and there had been a number of warning signs prior to the incident taking place. Allowing this patient to use the bath unsupervised was an obvious risk and a serious management failing.”

Death of Patient A

Following Patient B’s death, NHS England published the independent Mazars report in December 2015 into the deaths of people with a learning disability or mental health problem at this NHS Foundation Trust

In response to the report and following an assessment of all the deaths that occurred on the Trust’s premises from April 2011, HSE concluded that one death met the criteria for a full HSE investigation.

On 26 April 2012, Patient A was found slumped and unconscious at a telephone kiosk at an Adult Mental Health Hospital in Southampton. She died a short time later following treatment.

It became clear during HSE’s investigation that the Trust failed to act on the findings of assessments that it could better control the risks associated with the use of phones with cords. There had been a history of patients across the Trust, including those at this particular Hospital, using phone cords as a ligature.

Tim Galloway added: “The known risk of patients across the Trust using phone cords as ligature was never sufficiently addressed. This ultimately led to the death of this vulnerable patient.”