• This fine is the highest penalty imposed against an NHS Trust for offences of this type.  The Trust pleaded guilty to the offences in 2011 and admitted systemic failures.

    TC died at Southampton General Hospital after she was found unconscious at Woodhaven Adult Mental Health Hospital on 26.04.12.

    CS drowned in the bath after an epileptic seizure at the Oxford Unity Slade House.  The Coroner had concluded that his death was contributed to by neglect.

    In sentencing, Mr Justice Stuart-Smith remarked the deaths were unnecessary human tragedies and the sentence was a just and proportionate outcome to mark the seriousness of the offending and terrible consequences of that offending.

    Despite applying the highest permissible reduction in sentence of 1/3 to reflect the Trust’s prompt guilty pleas, the penalties reflect the new revised sentencing guidelines.  One aggravating feature present in this case was that the Trust had failed to properly investigate and learn from previous incidents and concerns raised by staff, service users and families.

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