A MOTHER who fought to expose ‘endemic’ care failures that caused her son’s death said she had done him proud as her five-year campaign for justice achieved a milestone victory.
Sara Ryan finally saw Southern Health NHS Foundation Trust admit ‘wholehearted responsibility’ as it was fined more than £1m for the death of her son Connor Sparrowhawk, after he drowned while staying at one of its care homes.
The Headington teenager, who had a learning disability, epilepsy and autism, tragically died at Slade House in Oxford on July 4, 2013, after having an epileptic fit while left unsupervised in the bath.
A judge at Oxford Crown Court today slapped Southern Health with a total of £2m in fines for health and safety breaches that led to the deaths of Connor and Teresa Colvin, a 45-year-old patient who also died under the trust’s care.
Speaking outside the court, Dr Ryan said: “No one should die a preventable death in the care of the state.
“Families should not have to fight for answers and accountability.
“The #JusticeforLB campaign has shone a light on systemic failings in the care of learning disabled people.
“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’.
She described Connor as her ‘beautiful boy’ and said she appreciated a ‘heartfelt apology’ made by Southern Health’s chief executive Nick Broughton, who replaced Katrina Percy last year.
Connor's grieving family has pushed to hold the trust to account under the banner JusticeforLB (laughing boy, Connor’s nickname), breaking through the barrier of denial that the trust deployed in the initial aftermath.
At the end of a sentencing hearing today, Mr Justice Jeremy Stuart-Smith said behind each death was ‘the story of unnecessary human tragedy’.
He told the court: “It took a time-consuming and punishing campaign on behalf of Connor's parents and Teresa's husband to uncover serious and systemic problems with the trust.
“Their lives have been dominated by deep, catastrophic and unspeakable pain of sadness and loss.
“They have sat through these proceedings, watching their personal tragedy being examined in the cold light of health and safety legislation.”
He branded both deaths ‘entirely preventable’ and the result of ‘deep-rooted and endemic’ failures that he acknowledged had since been eradicated within the trust.
Southern Health admitted two counts of failing to discharge its duty relating to their care, and Mr Justice Stuart-Smith handed a fine of £1.05m for Connor and £950,000 for Mrs Colvin, who died at a Southampton mental health unit.
The judge said the penalty, thought to be the biggest fine of an NHS trust following prosecution by the Health and Safety Executive, was justified by the 'terrible consequences' of care failures.
As Dr Ryan exited the packed courtroom following the sentencing, friends were heard congratulating her: “You did it.”
Mr Justice Stuart-Smith said Dr Ryan had endured 'utterly unjustifiable criticism' from some Southern Health staff members during her campaign, and her victim statement ‘made for almost unbearable reading’.
Speaking after the sentencing, Dr Ryan accused the trust of 'arming itself with a range of legal weapons and dirty tricks' to dodge responsibility.
In 2014 an inquest ruled neglect had played a part in Connor’s death, and an independent report later criticised the trust for failures, leading to the health and safety charges.
In February Valerie Murphy, who was responsible for Connor’s care at Slade House, was suspended from the medical profession for 12 months after a tribunal found her guilty of failures including inadequate risk assessments.
Mr Justice Stuart-Smith listed 16 key failures accepted by the trust in Connor's case, including lack of effective monitoring.
He added: "It is of very grave concern the endemic failures disclosed following these avoidable deaths that were allowed to rise at all and persist for so long, heightened by the failure to learn any lessons between April 2012 [when Mrs Colvin died] and July 2013 [when Connor died].
“There appears to be no excuse."
He did note the trust had since 'substantially overhauled and strengthened' health and safety operations.
During a two-day hearing last week, the trust's representative warned that any fine would hit cash-strapped public services hard.
The judge said he had considered this but there was no evidence a fine would impact any particular service.
One of Southern Health’s legal representatives told the court the trust ‘wholeheartedly accepts responsibility for profound failures'.
Nick Broughton, chief executive of Southern Health, added: "I feel deeply saddened and truly sorry that we let them down with such devastating consequences.
"Their deaths were avoidable and entirely preventable.
"Words can do little to ease the enormity of the families' losses and pain."
He insisted the deaths had been 'genuine catalysts for change'.
The trust will have two months to pay.
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