NHS trust fined £100,000 for poor supervision

Prosecutions and Claims |
01.05.2006

An NHS hospital has been fined £100,000  for failing to have adequate systems to spot mistakes made by its junior doctors. Southampton University Hospitals NHS Trust was prosecuted under the Health and Safety at Work Act  after it failed to monitor doctors properly.

At Winchester Crown Court, the trust admitted failing to supervise house officers Amit Misra and Rajeev Srivastava when a man died at Southampton General Hospital following a routine knee operation six years ago.

Despite a high temperature, high pulse rate and low blood pressure, the two doctors failed to recognise that 31-year-old Sean Phillips had developed toxic shock syndrome, and failed to seek help and advice from senior doctors.

Both men were convicted of manslaughter by gross negligence in April 2003 and sentenced to 18 months in prison, suspended for two years. Last year, the General Medical Council banned Misra from working for one year and Srivastava for six months.

The Crown Prosecution Service also decided to prosecute the trust under health and safety legislation. On 11 January, the trust pleaded guilty to breaching Section 3(1) of the Health and Safety at Work Act 1974 for failing to ensure patients' health and safety by not adequately supervising doctors in the trauma and orthopaedic department during June 2000. Sentencing on 11 April, Mr Justice Cresswell fined it £100,000 and ordered it to pay £10,000 costs.

At the sentencing hearing, the court heard that a proper system of supervision and evaluation of junior staff at the hospital could have saved Mr Phillips's life. Prosecuting, Hywel Jenkins said if the hospital had organised daily visits by a specialist registrar for all patients "the chances of it [the condition] being missed would have been lessened".

Richard Lissack QC, in mitigation, stressed that the trust was not responsible for Mr Phillips's death and that it had admitted guilt in relation to one aspect of care in one department during a short period in June 2000. He said it had since set up an automated early warning system to monitor patients' vital signs and trigger an automatic response involving a senior doctor where there is a problem.

Speaking on BBC Radio 4, medical negligence specialist Muiris Lyons, of Alexander Harris Solicitors, said the judge was "effectively criticising the management responsible for the systemic errors. NHS Trusts need to ensure they are providing back-up for staff, and that when individuals make mistakes, there is a system in place to catch those mistakes and prevent patient harm or at the very least mitigate that harm."