Death of 18-year-old in failing NHS learning disability unit was preventable, finds inquiry

Connor Sparrowhawk died in bath at unit run by Southern Health NHS Trust following significant failures in his care

Picture credit: RunPhoto/Getty Images

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.

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3 Responses to Death of 18-year-old in failing NHS learning disability unit was preventable, finds inquiry

  1. liz jones February 25, 2014 at 12:13 pm #

    When will the punishment for abuse be proportionate to the crime? Lessons learned or further training is simply not good enough and staff protected by large organisations like Southern Health are free to continue to practice.Complacency and arrogance kills as post Winterbourne View investigations highlighted.The fact remains the NHS model for people with Learning disabilities has and has always been a second rate service, one could say experimental . Mencaps Death by indifference yet another paper Tiger binned by the practitioners who think they know better? Investigation into services for people with learning disabilities at Cornwall Partnership NHS Trust in 2006 and others over the years can only put the fear of God into any parent or Carer who are advised that the people we care for ‘need’ to be placed in these units for their own ‘best interest’ I cannot even begin to comprehend the torment, grief and loss Connor’s family are experiencing in amidst the duplicitous engagement with Southern Health Trust..Apologies by Katerina Percy are inadequate and don’t reflect what a horrific way the poor lad died I hope she resigns how else will she sleep at night?

  2. Beth Gregson February 26, 2014 at 8:46 am #

    I am not well versed in the jargon and world of learning disability, but the story of LB and the figt of his family to get justice for their much loved son, grandson, brother, cousin and friend has moved me to blog, tweet and get involved. From an outsiders view, im stunned by the indifference, buck passing and antagonistic “professionalism” displayed by the staff on the the unit.

    It is often said there is not enough money and support in the community is poor due to lack of funds, but it cost £3500 to have connor in the unit for the 15 weeks he was there it cost £52,500 shows its not really about money, its being spent in the wrong place.

    I have spent days reading other blogs and it seems to me (from personal experience) that young people with Aitism in particular really struggle in their mid to late teens and end up in these Units die to lack of support. the MHA seems to be used. This isnt just the scandal of one family, its a scandalbeing played out up and down the country, sadly as its Learning disabled people – few seem to care.

  3. Shaun Webster February 26, 2014 at 10:56 am #

    At CHANGE we feel really sad and angry. We have heard about the report into the death last July of of 18 year old Connor Sparrowhawk. It says that his death was preventable. This means that he should not have died. Connor was living in failing NHS unit for people with learning disabilities. He was died in the bath, following an epileptic fit. He was not cared for properly.
    The report says that there should have been an epilepsy care plan. Instead, his care plan only said to check him every 15 minutes. This was sadly far from being often enough.
    Shaun, worker with learning disabilities says “I think this was a criminal offence. Staff should have been there for Connor. He should have had the support when he needed it – not 15 minutes later, when it was too late. This feels like we are back in the 19th Century again.
    I am a man with learning disabilities, but I get support to live independent. I wish everyone got the support they needed and could live their lives in the community. This is what I want.
    At CHANGE, I do work to help get institutions closed across Eastern Europe. I do training of professionals, I act as a role model to young people who want to live their lives independently. I think training by people with learning disabilities who are employed to do this can make a real difference to how professionals think. It makes them stop and think about what we want. We have so much to do here in the UK before people with learning disabilities have their rights respected. What is more important – care or money? – Connor’s life was worth more than this.
    I want to say to Connor’s mum, Sara that I am so sorry for your loss. I wish it had never happened. I feel very sad. It makes me want to work harder so that this never, ever happens again to anyone else.”