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'We’ve done you proud' — Families speak after NHS Trust fined £2million over patient deaths

Today Southern Health was fined £2m over the “entirely preventable” deaths of 18-year-old Connor Sparrowhawk and Teresa Colvin, aged 45.

Sara Ryan speaking in Oxford on 26 March 2018, after Southern Health was fined £2million (image #JusticeforLB)

Clare Sambrook writes:

Today at Oxford Crown Court, Southern Health NHS Foundation Trust was fined £2m for allowing the “entirely preventable” deaths of 18-year-old Connor Sparrowhawk and Teresa Colvin, who was 45. Passing sentence, Mr Justice Stuart-Smith spoke of their families’ “deep, catastrophic and unspeakable pain, sadness and loss”. 

Teresa Colvin’s husband Roger, speaking outside court today, said Teresa, who was affectionately known as TJ, had been “a vivacious, beautiful, and loving woman” who was dearly loved. In a statement he read to the court Roger Colvin spoke of life’s “what-ifs” and how every day something would trigger a memory, accentuating his terrible loss. TJ’s sister Wendy Andrade spoke of anger and hurt that was still very raw for the family and the massive void that TJ’s death had left. 

Teresa Colvin was found hanged by a phone cord at Woodhaven Adult Mental Health Hospital, Southampton on 22 April 2012. She died four days later.

The court heard that Southern Health had failed to act upon warnings about ligature risks from health and safety expert Mike Holder. He resigned in protest at the Trust’s inaction eight weeks before Teresa Colvin’s death.

Between 2007 and 2011 more than 1,700 “ligature incidents” had occurred across the Trust. The very phone cord that TJ would later use had been identified as a risk to patients. The cost of eliminating the risk would have been £53. Nothing was done about it.

 

Connor Sparrowhawk, a funny, quirky and beloved young man, was just 18 when he died on 4 July 2013 whilst a patient at Slade House, a Short Term Treatment and Assessment Centre at Headington in Oxford.

Connor had autism, learning difficulties and epilepsy, but it was the Trust’s neglect that caused his death.

His mother, Sara Ryan, had warned staff — in writing — that Connor had an injury to his tongue that suggested a recent seizure. Yet he was allowed to bathe unsupervised and behind a locked door, and he drowned in the bath.

 

Mr Justice Stuart-Smith said each death was an “unnecessary human tragedy”, and it was a “regrettable fact” that Sara Ryan and Roger Colvin had had to campaign for justice. 

Connor’s family and friends campaigned under the banner #JusticeforLB — his nickname was Laughing Boy because he laughed so much. Their work provoked the exposure of the Trust’s failure to investigate hundreds of unexpected deaths. 

Connor Sparrowhawk (#JusticeforLB)

While failing to watch over Connor, Southern Health had spent months monitoring his mother’s blog. The morning after his death executives turned their attention to reputation management. Through years of lies and obfuscation Southern Health attacked bereaved families and persistently tried to shift blame for Connor’s death from itself to Sara Ryan. One Trust employee left a message on her voicemail calling her “a vindictive cow”. 

The judge paid tribute to Sara Ryan today: “It is clear on the evidence that Dr Ryan in particular faced not merely resistance but entirely unjustified criticism as she pursued her Justice for LB campaign.”

He noted Southern Health’s admission: 

“The Trust fully acknowledges that Dr Sara Ryan has conducted herself and the Justice for LB campaign in a dignified, fair and reasonable way. To the extent that there have been comments to the contrary by Trust staff and family members of staff, these do not represent the view of the Trust and are expressly disavowed.”

The judge said that victim impact statements from Sara Ryan and from Connor’s step-father Richard Huggins “make for almost unbearable reading”.

He said: “Dr Ryan describes how the light went out of her life on 4 July 2013. And in dignified and restrained terms she lays bare how the assertion by the Trust in the early days that Connor had died of natural causes compounded her grief. As did Mr Colvin when referring to the loss of TJ, Dr Huggins refers to their grief being raw. Their lives have become dominated by a deep, catastrophic and unspeakable pain, sadness and loss.”

 

Over years we have published work by Sara Ryan, by Connor’s brother Tom, and disclosure stories about Southern Health’s failure to take action to remedy known problems.

Today we pay tribute to bereaved families who fight for truth and accountability, who work to make public services safer for everyone. We thank George Julian, whose reporting of inquests and tribunals through live-tweeting has shone a light on Connor’s and other state-related deaths.

Mr Justice Stuart-Smiths judgement can be found here. Connor’s family’s statement in response to today’s sentencing follows below.

 

Family statement on the Health & Safety Executive (HSE) prosecution of Southern Health #JusticeforLB

Sara Ryan writes:

Five years ago this month we took our beautiful boy to what we thought was a specialist NHS unit. He drowned in the bath 107 days later.

No one should die a preventable death in the care of the state. Learning disabled people should not die on average twenty years before their non-disabled peers. Families should not have to fight for answers and accountability. They should not have to raise funds for legal representation at a time of unspeakable grief and pain.

Southern Health dug deep into publicly funded pockets and armed itself with a range of legal weaponry and dirty tricks.

The #JusticeforLB campaign has shone a light on systemic failings in the care of learning disabled people. We have collectively and effectively revealed weaknesses in regulatory practices, a disregard for the lives and deaths of certain people and the limitations of work by large established charities in this area.

We appreciate Dr Nick Broughton’s recognition and acknowledgement of the failings that spread across five years under Katrina Percy’s leadership, and his heartfelt apology for these. [Broughton has been Southern Health chief executive since November 2017].

We thank the HSE for their meticulous and sensitive investigation and everyone who has stood alongside us fighting for what is right and just.

I’m left thinking if Connor was here now, in the shadow of Oxford Crown Court and the St Aldates police station, he would repeatedly ask ‘why mum?

I’d reply ‘I don’t know matey but we’ve done you proud’.

Bus, by Connor Sparrowhawk (#JusticeforLB)


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