Staff ‘distressed’ by NHS Trust’s response to death of man with learning disabilities

Staff at Southern Health tell CQC the trust has not been ‘as open as honest as it could have been’ in handling of Connor Sparrowhawk’s death

18-year-old Connor Sparrowhawk died in July 2013 at a Southern Health unit

The way an NHS Trust responded to the preventable death of a man being cared for at one of its learning disability units has caused distress to its own staff and people using services, according to the Care Quality Commission.

Staff at Southern Health told CQC inspectors that the trust had not been ‘as open and honest as it could have been’ and had acted ‘outside its own values’ in the way it handled the death of 18-year-old Connor Sparrowhawk, a report published today shows. The situation was ‘impacting signifcantly’ on the welfare of staff, carers and patients, inspectors found.

The CQC gave the trust, which provides mental health, community health and learning disability services, an overall rating of ‘requiring improvement’. The trust’s inpatient learning disability services were deemed to need improvements. Its community learning disability provision was rated as ‘good’. The inspection was carried out in October last year.

Connor’s death

Connor, who had autism, a learning disability and epilepsy, was found unconscious in the bath on 4 July 2013 following an epileptic seizure at Slade House, an Oxfordshire learning disability unit run by Southern Health. He died the same day in hospital. Slade House’s inpatient unit was closed after the CQC published a damning report on the service in November 2013 and Southern Health has since reconfigured its services in Oxfordshire.

An independent review, published in February last year, found that Connor’s death was preventable. A second external review into the commissioning of Oxfordshire learning disability services is ongoing and today’s CQC report said the uncertainty among staff over whether Southern Health would continue to deliver the services had also damaged morale.

“A previous external review had found that [Connor’s] death was preventable. Staff and service users were concerned about how the trust was handling the situation as they felt the trust had not been as open and honest as it could have been. This was clearly causing distress and affecting staff morale and unrest with people using services and their families. They felt the trust had failed to communicate effectively and was acting outside of its own values,” the CQC report said.


Connor’s mother, Sara Ryan, has documented her interactions with Southern Health since her son’s death via her ‘mydaftlife’ blog. A grassroots movement, the Justice for LB campaign (LB refers to ‘Laughing Boy’ – Connor’s nickname), has also raised awareness of developments via social media. Ryan told Community Care that she wasn’t surprised that Southern Health staff had raised concerns with the CQC.

“I think when something like what happened to Connor happens then often people don’t really get to know about it. I don’t think the staff within the same organisation would necessarily know about it, or other patients or their families,” she said.

“I think because we’ve been very openly documenting Southern’s actions since Connor died and before, it’s seemed apparent to me that they are not demonstrating the candour they should be and they’ve continued to not do so for some 20 months now. It’s unacceptable.”

In response to the CQC’s findings on staff distress, a Southern Health spokesperson said: “We absolutely acknowledge the concerns raised by staff and we accept that the situation could have been handled differently. There has been progress made since that time, which has been recognised as part of the CQC inspection.

“Significant changes in management have strengthened our leadership team for the division, and we have introduced many methods to work more closely with our staff to more opportunities for open communication. It’s not right that any member of staff should still feel this way, and so we will continue in these efforts to continue making improvements, so that our staff feel they have been heard, and their concerns acted upon.”

Other CQC findings

Overall the CQC found that the trust’s staff were caring and passionate and it identified some areas of good practice, such as a peer review system the trust had in place. But the watchdog raised concerns over staffing shortages in mental health and community health services. There were also concerns that potential ligature points at a secure hospital operated by the trust put patient safety at risk and staff and patients warned of problems accessing mental health crisis services, particularly out-of-hours. The trust said it was working to address the areas of improvement highlighted by CQC.

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