Patient safety

Southern Health fined £125,000 by regulator

The troubled Southern Health trust has been handed a £125,000 fine after it admitted that it failed to provide safe care and treatment to a patient who was injured falling from a hospital roof.

The CQC brought an investigation following an incident at Melbury Lodge, a psychiatric unit in Winchester which cares for people who need to be admitted to hospital as a result of serious mental health problems.

The controversial trust pleaded guilty to the charge in June but sentencing was adjourned until this week when Basingstoke Magistrates’ Court handed out the fine.

Paul Greaney QC, prosecuting, told the court that since March 2010, a number of patients who had been detained under the Mental Health Act had climbed onto the lodge’s roof from a courtyard area in an attempt to abscond.

A security review completed by the trust itself had recommended safety measures including blocking up gaps in a fence and fitting anti-climb guttering, but these improvements had not been made.

The injured patient had previously been at the centre in 2012 and had tried to climb out over the roof on that occasion before being restrained and brought down.

Three years later the same patient was readmitted to the unit with deteriorating health and, despite warnings from family to staff, was able to climb back up to the roof.

Unfortunately, despite attempts by staff to talk the man down, he fell from the roof and sustained serious neck injuries.

Despite this incident and multiple recommendations that the roof should be closed off, the trust took no action. In fact, three more patients were able to access the roof in February 2016, one of them was also injured.

In addition to the £125,000 fine that Southern Health received, the CQC has also ordered payments of £36,000 in prosecution and a £170 victim surcharge.

“There can be no excuse for this failure by Southern Health to protect their patients from harm,” said Ted Baker, chief inspector of hospitals. “Unfortunately, this was not an isolated incident – but part of a wider failure to deal with concerns over safety as they arose.

“The trust had failed to make basic improvements to protect the people in its care, despite having been aware of the dangers for years. There had been at least seven incidents before this - yet they ignored clear evidence from their own reports on safety and did little to prevent this dreadful accident.

“Even after this event, the trust was slow to take action. It was a false economy which has now cost the trust dearly – and with awful consequences for one man.

“In the circumstances, we had no choice but to prosecute in the criminal courts. I hope this case will serve as a warning to any other provider that imagines they can cut corners on safety at the expense of their patients."

In reply to the CQC judgement, Julie Dawes, interim chief executive issued an apology: “Southern Health pleaded guilty to the charges from the Care Quality Commission and we fully accept the fine imposed today by the court.

“We should have taken action earlier to make sure that no-one being cared for at Melbury Lodge could access the roof and was not at risk of harm. We deeply regret that a patient was seriously injured by falling from the roof in 2015. The impact on this individual and their family has been enduring and for this we are truly sorry. 

“Significant improvements have been made to Melbury Lodge since 2015, both in response to safety concerns raised by the Care Quality Commission and to make it as welcoming and homely as possible.

“The safety and wellbeing of patients is our top priority, and we are continuing a number of programmes of improvement work to ensure that we can deliver safe and quality care across all Southern Health services.”

This is one of a number of incidents that the trust has been involved in, including the tragic death of teenager Connor Sparrowhawk.

The patient, who was epileptic and had autism as well as other learning difficulties, drowned in a bath tub in an incident the trust agreed was “entirely preventable”.

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