Hospital faces up to patient death

By Anna Lindsay
BBC News, Southampton

Sean Phillips pictured with an injured knee, days before he died

Sean Phillips had never been into hospital before.

But on a trip to London in June 2000 he leap-frogged a bollard and tore the tendon in his knee.

Within days, the 31-year-old was booked into Southampton General Hospital for a routine operation.

Four days after being admitted to the trauma and orthopaedic department of the hospital, he was dead.

A long police inquiry then began - after a member of hospital staff, unhappy at the way Mr Phillips was treated, tipped off the Southampton coroner in an anonymous phone call in the days after his death.

Sean was a fun-loving, caring, emotional... he was my soul mate, he was my other half. And we've been robbed of that Annabel Grant

Nearly six years later, the Southampton University Hospitals NHS Trust (SUHT) has been fined £100,000 for admitting it did not adequately supervise junior doctors in the trauma and orthopaedic department in June 2000.

Two of them - Dr Amit Misra and Dr Rajeev Srivastava - were convicted of Mr Phillips' manslaughter due to gross negligence in April 2003 - and given 18 month suspended sentences.

In fact, a review team for the government's then Commission for Health Improvement (CHI) which, by coincidence, was working in the hospital's trauma and orthopaedic department at the time of Sean Phillips' death, was highly critical of the department's systems.

Sean Phillips' partner Annabel Grant said the hospital should be fined

Its findings, published in November 2000, said: "At the time of the review, CHI had serious concerns about the quality of care given to trauma and orthopaedic patients.

"Management of clinical staff on the wards was deficient, junior doctors lacked direction and supervision from consultants and nurses were under constant pressure."

This was not all. BBC News has learned that whereas nurses in the department had a formal system of handovers, the junior doctors did not.

Blood tests taken from Sean Phillips the day he started showing signs of an illness were not checked for 24 hours, by which time it was too late to save him.

The prosecution also said that if the hospital had organised daily ward round visits by a specialist registrar the chances of Mr Phillips' condition being missed would have been lessened.

For the family of Sean Phillips, what they can take away today is comfort, is the fact that we've put things right Mark Hackett, chief executive of Southampton University Hospitals NHS Trust

There were also issues regarding why nurses treating Sean Phillips did not contact senior medical staff.

The trust's defence team said nurses always could contact more senior staff but added they now had the mobile phone numbers of consultants - to make them "empowered - no more do they feel, due to some perceived hierarchy, that they cannot go to more senior staff".

And BBC News has learned that the hospital trust never checked the previous employment reference of Dr Misra.

Professor Allan Skirving, of the Royal Perth Hospital in Western Australia, said: "They [SUHT] never made any contact... we would not have given him a good reference.

Sean went into hospital for a routine operation after hurting his knee

"It became apparent within a brief period that he was not able to do anything independently."

The hospital's conviction comes three years after Dr Misra and Dr Srivastava were found guilty of gross negligence manslaughter for failing to act to save Mr Phillips - as his blood pressure, temperature and pulse rate showed alarming abnormalities.

He was developing a rare condition known as toxic shock syndrome.

Hundreds of patients at risk

The charge to which the hospital pleaded guilty - under section 3 (1) of the Health and Safety at Work Act 1974 - arose out of Mr Phillips' death.

But it also relates to the trauma and orthopaedic department during all of June 2000 - meaning hundreds of other patients were also put at risk.

Mr Justice Cresswell, the High Court judge sentencing SUHT at Winchester Crown Court on Tuesday, said the trust's fine "marks the criminality and disgrace of [the trust's] breach of duty".

"They were duty bound to look after Sean, as a trust, as a whole"

In its defence, the trust said its systems in June 2000 were typical of the NHS at the time but that they had since greatly changed.

Mark Hackett, chief executive of the trust, said: "For the family of Sean Phillips, what they can take away today is comfort, is the fact that we've put things right."

But the fine is little consolation to Mr Phillips' partner, Annabel Grant, with whom he had a son, Mitchell, now aged eight.

She told the BBC News website: "Sean was a fun-loving, caring, emotional... he was my soul mate, he was my other half. And we've been robbed of that.

"They were duty bound to look after Sean, as a trust, as a whole. You go into hospital, you put your lives in their hands.

"They're there to look after you. So, yes, I do believe they should be fined and should have to pay for what they've done."