A mental health trust has been fined £1.5 million over its failure to “prevent suicide”.
Essex Partnership University NHS Foundation Trust (EPUT) was sentenced at Chelmsford Crown Court on Wednesday after pleading guilty in November to an offence under the Health and Safety at Work Act 1974.
The Health and Safety Executive (HSE) brought the prosecution against the trust following an investigation that identified 11 deaths where a “point of ligature was used within the ward environment of the trust’s premises”.
Judge Mr Justice Cavanagh said a “litany” of “systematic failures” were found to have taken place over a prolonged period, describing the trust’s actions to protect its patients at the time as “woefully inadequate”.
Prosecutor Shauna Ritchie said: “This offence arose following concerns received about failings by the trust to prevent suicide.”
The HSE probe covered the period from October 1 2004 to March 31 2015, during which a number of deaths through hanging occurred on the trust’s wards, including that of Ben Morris in 2008, David King in 2009, Steve Oxton in 2012, Matthew Leahy also in 2012, and Iris Scott in 2014.
Others who died were either not identified during the court case or were done so only by their initials at the request of their families.
Judge Cavanagh agreed with the prosecution that there were “repeated” failings to address the risk of ligature points before and after the deaths of patients, with recommended action not put into practice in some cases for a number of years afterwards.
He added: “There’s no doubt the failures to remove ligature points were a significant cause in the deaths of 11 people who died during the relevant time period, and of a 12th person who died just after and a number of near misses.
“Time and time again opportunities to put measures in place were lost.”
The grief-stricken family members of those who died were given the opportunity to read out victim impact statements in court.
Lisa Anne-Morris, mother of Ben Morris who was 20 years old when he died, described the moment she was told the news, saying “a part of me died with him”.
“Every day is a nightmare I can’t wake up from,” she added, saying her son’s death had also had a profound impact on her own mental health.
In a statement read out by family friend Sally King, the parents of David King began by thanking the court for giving them “a voice”.
Recounting the day they were told their son had died, they wrote: “I invited the policeman and the man from the mental health authority in and he asked us to sit down. I, as David’s mother, instinctively knew something terrible was wrong. That’s when they informed me he was dead.
“I knew I would have to tell his little boy what had happened. George was six years old. It had happened five days before Christmas.
“It was the most difficult thing I have ever done, telling a little boy his daddy was dead. I can’t describe to you the pain that was on his face. This memory never goes away.
“I promised George then that those responsible for his daddy’s death would be brought to court.”
They added: “David tried to ring us on December 20 but it went to answerphone. He had tried to get change for a £10 but staff wouldn’t help him. He said he loved us and would try and call again. But he never did.”
Bernard Thorogood, representing the trust, said: “I would like to make a public expression of apology for these identified series of failures accepted by the trust, and an expression by the trust through me of regret, remorse and sympathy.”
He said the new chief executive of the trust, Paul Scott, was at the hearing and had already implemented significant changes, met with families and was committed to continuing to improve the wards.
Mr Thorogood asked that the trust’s financial situation be taken into account during the sentencing.
The trust will be required to pay the fine over a five-year period, and pay legal costs totalling £86,222.23.
In a statement after the hearing, Priya Singh, a solicitor at Hodge Jones & Allen, which represents families of those who died, said: “Today’s fine of £1.5 million handed to EPUT following the HSE investigation simply highlights the failings of mental health care in Essex.
“While the fine is welcome news, the families are still left with many unanswered questions, and this fine does not represent justice.
“It only scratches the surface of what is going so badly wrong in Essex.
“The only way to establish the truth of the gross failings in care across Essex Mental Health Services is through holding a full statutory public inquiry.”
Paul Scott, EPUT chief executive, said: “I would like to personally express my deepest sympathies and apologies to the families and friends of those who lost their lives. I am fully committed to ensuring that every lesson is learnt.
“Since joining EPUT as chief executive last October, I have put safety at the forefront of everything we do.
“I am grateful to the families who have shared their experiences in court today, and also with me privately. Their experiences have had a deep impact on our staff and will help the trust to drive continuous improvements to safety on our wards.”
Mr Scott said improvements have already been made to services including an addition £10 million spent on ward safety last year.
He added: “We are committed to doing everything we can to ensure EPUT provides the safest possible care so that our patients and our local community have confidence in the services we provide.”