The chief executive of an NHS trust responsible for the care of a teenager who drowned in a bath after an epileptic seizure has said she is “truly sorry” the organisation failed to keep him safe.
Southern Health NHS Foundation Trust pleaded guilty to breaching health and safety law at Banbury magistrates’ court yesterday (18 September), following a criminal prosecution by the Health and Safety Executive (HSE) relating to Connor Sparrowhawk’s death in 2013.
In a statement provided later on Monday, Julie Dawes, the interim chief executive of the trust, acknowledged the “devastating impact” that the 18-year-old’s death, at Slade House learning disability unit in Oxford, had had on his family.
“The effect of Connor’s death has been far reaching and whilst it in no way compensates for the loss his family has suffered, it has led to significant changes and improvements in the Trust,” Dawes said. “There have been times when our actions unintentionally added to the distress of Connor’s family.”
In blog posts written on the two days before the hearing, Connor’s mother Sara Ryan welcomed the trust’s recognition of her family’s pain, but criticised the time it had taken the organisation to take full responsibility.
“It’s really time to start walking up hills if you mean business around changing practice,” Ryan wrote. “Demonstrate the ‘impact’ a patient’s death has had on your organisation with actions. Not talk.”
‘Very serious failings’
An inquiry carried out in the wake of Connor’s death found that it was preventable and followed significant failings in his care. A unanimous jury at an inquest in 2015 concluded that a series of “very serious failings” – included errors in his bathing arrangements, inadequate epilepsy training and a lack of clinical leadership – had contributed to Connor’s death.
And last month, a medical tribunal established that a psychiatrist responsible for treating Connor had failed to carry out risk assessments. Dr Valerie Murphy admitted that she had not taken into account the implications of allowing him to bathe alone.
Last year the Care Quality Commission (CQC) identified ongoing “serious concerns” about the safety of mental health and learning disability patients at Southern Health NHS Trust. In an inspection report, the regulator said that the trust’s leadership was “ineffective” in handling risks to patients.
A report by auditing firm Mazars, commissioned by NHS England and published in December 2015, found Southern Health had investigated “too few” deaths of mental health and learning disability patients, and blamed a “failure of leadership”.
Following the trust’s guilty plea, sentencing will take place at Oxford crown court on 12 October. The organisation faces a potential unlimited fine.