The death of an 18-year-old man in a failing NHS learning disability unit was preventable and followed significant failings in his care, an inquiry has found.
Connor Sparrowhawk died last July after being found submerged in a bath following an epileptic seizure at the short-term assessment and treatment team (Statt) unit in Slade House, a service in Oxford run by Southern Health NHS Foundation Trust.
The report, by investigations specialists Verita, found that had a safe observation process been in place for when Connor was in the bath he would not have died. However, despite being told he had had a seizure two months before his admission in March 2013, Connor had no specific epilepsy care plan, other than a section in his main care plan that said he should be observed every 15 minutes in the bath.
The report said this was “unsafe” for someone with active epilepsy, and found that no risk assessments were conducted in relation to his epilepsy or his bathing arrangements. Staff missed an opportunity to increase monitoring of Connor after he had a suspected seizure in May 2013. The inquiry also found that just three of the 17 staff on the unit had had training in epileptic care from October 2010-August 2013.
The report also identified a lack of clinical leadership at the Statt, which operated a team-based approach in which no one individual held responsibility for ensuring Connor’s care was appropriate
Damning CQC inspection
Two months after Connor’s death, the Care Quality Commission (CQC) inspected Slade House and its subsequent report, published in November, failed the service on all 10 standards it was inspected against and issued six warning notices requiring the trust to improve it. Slade House, which also includes a longer-term assessment and treatment unit, John Sharich House, was closed to new admissions and remaining patients were moved out of the Statt. Though three of the CQC’s warning notices were lifted following an inspection last December, these relate to environmental standards, not patient care; the Statt remains closed and the main commissioner, Oxfordshire council, has refused to rule out never placing anyone there again.
Connor’s death has caused widespread outrage on social media, particularly among followers of his mother, Sara Ryan, whose blog, my daft life, had chronicled the family’s experience of services before focusing on their grief and anger at his death and the trust’s response to it.
‘A long and distressing fight’
Following the publication of the report, Sara Ryan said: “[Connor] should never have died and the appalling inadequacy of the care he received should not be possible in the NHS. It has been a long and distressing fight to reach this point and get the facts surrounding his death out in the open. He was a remarkable young man who was failed by those who should have kept him safe. We miss him beyond words.”
Southern Health’s chief executive, Katrina Percy, apologised “unreservedly” to Connor’s family, adding: “I am deeply sorry that Connor died whilst in our care and that we failed to undertake the necessary actions required to keep him safe.”
She said “HR investigations are ongoing” into the care failings at Slade House. The trust has reviewed staff training in relation to care planning and risk assessments for epilepsy, and that its learning disability would now undergo mandatory enhanced training in these areas. Also, a specialist epilepsy nurse has audited all care plans for inpatients with learning disabilities and made amendments where necessary.
Percy said that the trust was working with commissioners to redesign learning disability services in Oxfordshire, Buckinghamshire and Swindon so that they better met patients’ needs. Southern acquired these from the former Oxfordshire Learning Disability NHS Trust in November 2012.