In the first criminal trial to be brought over a patient's death, a hospital trust was yesterday fined ?100,000 for failing to supervise two junior doctors. Southampton University Hospitals Trust was convicted after a health and safety prosecution prompted by the death of a young father who had been admitted for a routine knee operation.
The trust, which has a ?6m deficit, was also ordered to pay ?10,000 in costs. It pleaded guilty to failing to supervise the two doctors during a brief period but, in a statement, denied any responsibility for the death.
Sean Phillips, 31, died at Southampton general hospital in June 2000 after two senior house officers (SHOs) attending him in the trauma and orthopaedics department failed to realise he had contracted toxic shock syndrome.
Amit Misra and Rajeev Srivastava were convicted of manslaughter by gross negligence in 2003, given an 18-month suspended sentence, and, last year, temporarily struck off by the GMC. But, in an unprecedented move, the Crown Prosecution Service also decided to prosecute the trust, under the Health and Safety at Work Act.
Winchester crown court heard that there was a lack of supervision by consultants, no formal system of daily visits by registrars which should have picked up Mr Phillips' condition, and only half the required number of junior doctors.
Concerns had been raised about staffing levels and the competence of doctors in the trauma and orthopaedics department. On the day of Mr Phillip's death, a senior nurse, Liz Onslow, warned that SHOs were not providing "appropriate and timely follow-up care."
Sitting at Winchester crown court, Mr Justice Cresswell said the trust was guilty of an "extremely serious offence" and that the medical care of patients was a "solemn duty. Common sense dictates that a reasonable standard of care must pertain seven days a week, 52 weeks a year."
Mr Phillips, who was admitted to repair torn knee ligaments and whose operation had gone well, had had a "tragic death". "A fine healthy and much-loved person has died unnecessarily."
After the hearing, the trust's chief executive, Mark Hackett, stressed that a new monitoring system, introduced in June 2000 but not rolled out to the orthopaedics ward until the November, now meant nurses could go straight to consultants if they had concerns about a patient's deterioration. "The warning signs that were there in the past, today they would have been acted on. A patient today with those warning signs would have been referred to a senior person, who would have acted on them very quickly," he said. The fine would have to be paid out of money from the hospital's budget.
Mr Phillips' father, Myles, said: "Saying the lack of supervision had nothing to do with my son's death is an utter insult and a terrible thing to say."