The death of a teenager with learning disabilities and epilepsy who drowned in the bath at an NHS unit after a seizure was “contributed to by neglect”, an inquest jury has concluded.
Connor Sparrowhawk, 18, died on 4 July 2013 while an inpatient at Slade House, an Oxfordshire learning disability unit that was run by Southern Health NHS Foundation Trust. The unit has since closed down.
A unanimous jury concluded that a series of “very serious failings” had contributed to Connor’s death. These included errors in his bathing arrangements, inadequate epilepsy training and guidance for staff, and a lack of clinical leadership on the unit. Inadequate communication with Connor’s family after previous suspected seizures had also led to “missed opportunities”, the jury found.
Following the conclusion, Southern Health’s CEO apologised “unreservedly” to Connor’s family for his death and said the trust would “reflect” on the issues raised by the jury.
Apology from Southern Health
Asked about the apology, Connor’s mother, Dr Sara Ryan, and stepfather Richard Huggins, said it had come “too late”.
Speaking outside Oxfordshire county hall, Huggins said: “What would really be an apology now is if they started to treat people in their care properly.”
He added: “This is not simply a learning disability or disability issue. This is about basic human rights…Competent healthcare is a right that belongs to every single citizen, irrespective of their disability, their cognitive impairment. We want some honesty and some candour. We don’t want games played after two and a half years.”
A ‘quirky, loving boy’
At the beginning of the two-week long inquest, the jury heard how Connor, who was nicknamed Laughing Boy or ‘LB’, was a “quirky”, “loving” boy who loved sunshine, Eddie Stobart lorries and buses.
He was admitted to Slade House in March 2013 after his behaviour became aggressive. On the morning of 4 July, 107 days after his admission to the unit, he took a bath ahead of a day trip to tour a local bus company. Staff discovered Connor submerged in the bath and unresponsive.
A post-mortem examination later concluded Connor drowned after an epileptic seizure.
Observation and communication failings
The inquest heard how staff had been told Connor should be checked every 15 minutes when bathing but there was no place to formally record these observations.
Jurors at also heard about an incident six weeks before Connor’s death where he had bitten his tongue. At the time, Connor’s mother had emailed staff to say she felt the bite could indicate a seizure. However, two weeks later Connor’s care team reduced his observations from every 10 minutes to once an hour.
The jury concluded that Connor’s bathing arrangements were a “very serious failing” and checks should have been undertaken on a “sight and sound basis”. An adequate risk assessment should also have been carried out within a week of Connor’s admission to the unit, it added. Inadequate communication with Connor’s family after suspected seizures was identified by the jury as an error.
On the issue of staff training, the jury concluded that too few staff on the unit were trained in managing epilepsy and a change of shift patterns at had also reduced opportunities for them to undertake training. The guidance available to the unit’s staff was also “inadequate” as they were not given an epilepsy toolkit that was used elsewhere in Southern Health at the time of Connor’s death.
‘A long and tortuous battle’
In a statement, Connor’s family said they had faced a “long and tortuous battle to get this far” and felt that Southern Health had “consistently tried to duck responsibility” over Connor’s death.
“Families should not have to fight for justice and accountability from the NHS,” the statement said.
“We would like to thank everyone who has supported the campaign for Justice for LB, and hope that the spotlight that has been shone onto the careless and inhumane treatment of learning disabled people leads to actual (and not just relentlessly talked about) change. It is too late for our beautiful boy but the treatment of learning disabled people more widely should be a matter of national concern.”
In a statement, Katrina Percy, chief executive of Southern Health, said: “I am deeply sorry that Connor died whilst in our care. Connor needed our support. We did not keep him safe and his death was preventable.
“We have thoroughly investigated the circumstances surrounding Connor’s death and continue to work hard to help ensure that this doesn’t happen again. In the two years since he died we have made many changes to the way we provide services for people with learning disabilities.
“It has always been our intention to support people with Learning Disabilities in the community where appropriate. We now have an Intensive Support Team across all of our Learning Disability services, enabling us to support more people to be cared for at home with their families or carers instead of in hospital.
“We decided to close the Short Term Assessment and Treatment unit where Connor died at the end of 2013 following a poor CQC inspection. As a result of the improvements made in community services since then, the closure is now permanent.
“Among other steps taken, the Trust has strengthened its clinical leadership in Learning Disability services. We have also implemented mandatory comprehensive epilepsy training for all our staff caring for people with learning disabilities.
“The experiences of Connor’s family have brought into sharp focus the need to engage more effectively with patients, their families and carers, learning from their experience and expertise and involving them in every decision concerning care.
“We will reflect on the narrative conclusion of the jury.
“As we await publication of the Coroner’s Preventing Future Deaths report we will continue to work with others who want to improve services for people with learning disabilities and to challenge the way resources and attitudes are focused in the NHS and wider society.
“We will carefully consider evidence heard during the inquest and the jury’s conclusion and act swiftly upon any need for further changes identified as a result.
“I again apologise unreservedly to Connor’s family for his preventable death.”