British hospital fined over patient's death after routine knee surgery

Apr 12 2006

A British hospital has been fined £100,000 for failing to supervise doctors after a man died following routine knee surgery.

The hospital trust was also ordered to pay £10,000 in costs.

Southampton University Hospitals NHS Trust was charged under health and safety legislation following the death of 31 year old Sean Phillips, at Southampton General Hospital in June 2000 after suffering from toxic shock syndrome.

Mr Phillips was admitted to Southampton General Hospital on June 23 2000 to repair torn knee ligaments.

The operation went well and he was expected to leave the next day, but an infection set in which Mr Phillips was unable to deal with and toxins started to build up in his body in a rare reaction.

Despite obvious signs doctors Amit Misra and Rajeev Srivastava failed to diagnose the condition or seek help and advice from senior doctors even though they visited Mr Phillips on a number of occasions over the two days.

Prior to the death concerns had been voiced about the competence of senior house officers in the trauma and orthopaedic department where Mr Phillips was being treated.

Senior nurse Liz Onslow had alerted the senior consultant Simon Latham of her concerns about senior house officers in trauma and orthopaedic in general and Amit Misra in particular.

Mr Latham has admitted serious problems existed and there was a lack of supervision by senior doctors.

Misra's consultant David Warwick also admitted that he had very little direct contact with house doctors and left it to senior registrars and nurses to deal with any problems.

The trust pleaded guilty to failing to supervise the doctors.

Misra and Srivastava were both convicted of manslaughter by gross negligence in 2003 and sentenced to 18 months in prison.

The General Medical Council have suspended Misra from working for a year and Srivastava for six months.

Mark Hackett, chief executive of Southampton University Hospitals NHS Trust, says the hospital has now improved supervision and its early warning system.

Since Mr Phillips' death the trust has set up an automated early warning system that monitors patients' vital signs and when there is a problem it triggers an automatic response and a senior doctor becomes involved.

There has also been a change in the training of senior house officers nationally since August 2002 and internally at the trust there were now better mechanisms for improved staff relationships and liaison which includes thorough and consistent ward rounds or advice seven days a week by senior doctors.

The court was told that the trust had an excellent reputation and had never been convicted of a health and safety matter before.

The hearing was also told that the fine would come out of the general budget for the trust and so would be taken from money used for patient care, the trust has apparently overspent by £6m in the last financial year.