Poor practice, not management failure, key factor in Connor Sparrowhawk’s death, finds report

Failures in the care of a teenager who died in a learning disability unit were due to ‘poor practice’, not failings in management or commissioning, an NHS England-commissioned review has concluded.

Connor Sparrowhawk, who had learning disabilities and epilepsy, died on 4 July 2013. He drowned in the bath following an epileptic seizure while an inpatient at Slade House, an Oxfordshire assessment and treatment unit run by Southern Health NHS Foundation Trust. The unit has since closed down.

A jury inquest concluded last week that Connor’s death was “contributed to by neglect”, with a lack of adequate training and guidance for staff identified as a contributing factor. The jury also identified “very serious failings” in Connor’s care, including his bathing arrangements.

An independent report by consulting firm Verita, published in February 2014, found that Connor’s death was preventable.

Today’s report, also by Verita, focused on whether the commissioning and management of Oxfordshire’s learning disability services contributed to Connor’s death.

Takeover process

Southern Health took on the contract to run the Oxfordshire services, including Slade House, from Ridgeway partnership in November 2012. Investigators found a series of “deficiencies” in the way the acquisition process was handled. Problems included:

• Southern Health was “slow to respond” to the departure of two learning disability leaders, which had left the service in a “vulnerable position”.
• By February 2013 – three months after the takeover – commissioners complained of insufficient contact from Southern’s divisional directors overseeing the services.
• The trust’s reliance on its existing quality assurance processes to monitor the acquired services was “flawed” as reviews carried out before or around the time of the acquisition had flagged concerns over Ridgeway services. Concerns raised by the reviews included poor governance arrangements and “inadequate completion of risk assessments” at some services.
• The trust’s approach to communication and engagement with Ridgeway staff after the acquisition was “inadequate” and failed to ensure that employees’ concerns surrounding the takeover were properly addressed.

‘Poor practice was key issue’

If Southern Health had handled the acquisition process “more effectively”, problems with the way staff at Slade House were working may have been identified, the review said. However, investigators said they had not seen evidence to allow them to conclude that this would have prevented poor decisions around Connor’s care.

“In our first report we took the view that the key issue in Connor’s care was poor practice by clinical staff. We have not seen anything during our work on this second investigation to change that,” the report said.

It added: “The failures in care during Connor’s inpatient admission were not caused by Southern Health managers or commissioners. The clinical staff failed to carry out procedures and processes that were their responsibility and within the competence and knowledge expected of registered health professionals.”

Katrina Percy, Southern Health’s chief executive said some of the report’s findings “make challenging reading for the trust and the wider NHS”.

“Southern Health will consider this report’s findings with the wider health and social care system and work together to improve the safety and quality of care for all patients and everyone who relies on our services,” she said.

“Nothing is more important to us that the safety of the people in our care. Connor’s death was preventable. He needed our support and we failed to keep him safe, and I am truly sorry for that.”

Dispute over conclusion

However, today’s Verita report has sparked controversy after it emerged that the only two lay members appointed to the investigation disagreed with its overall conclusion.

Dr George Julian, Connor’s family’s lay representative, said: “Having been involved with this process from the beginning I am unable to accept and support the conclusions drawn by the investigators. I consider that the evidence collected and the findings presented in the report clearly indicate that Southern Health had information available to them, that they failed to act upon.”

Meanwhile, Bill Love, the investigation’s second lay representative, has written to Verita supporting some of the report’s findings but disagreeing with the conclusion.

The Verita review also examined how staff applied legal frameworks to Connor’s care. He remained on Slade House as an informal patient after initially being admitted under section 2 of the Mental Health Act. During Connor’s time on the unit, one application was made for a Deprivation of Liberty Safeguards (Dols) order but this was refused after a best interests assessor concluded Connor was not deprived of his liberty.

Investigators found that the use of the Dols and the Mental Health Act was “consistent with professional practice at the time” but recommended that Southern Health update its Dols policies to provide clearer guidance to staff on several matters.

The review also recommended that Oxfordshire’s health and social care commissioners ensure that service user views are taken into account in commissioning decisions. Interviews carried out as part of Verita’s investigation found that families felt engagement and partnership working with them was “not always at the heart of Oxfordshire learning disability services”.

“Although there were some examples of good practice these were largely reported within the context of services that were constrained by poor information, inadequate budgets, poor leadership and coordination and at times an unwillingness to listen or involve families,” the report said.