Oxfordshire treatment unit could have prevented death of man with epilepsy

The results of an independent inquiry into the death of a patient with a learning disability have been published, concluding the death was preventable.

18-year-old Connor Sparrowhawk, who had a learning disability and epilepsy, was found submerged in a bath at Slade House, a specialist NHS Assessment and Treatment Unit run by Southern Health NHS Care, after an epileptic seizure.

Published by Verita, the inquiry has been pursued by Connor’s family after his death was originally recorded as being due to natural causes, with support from charity Mencap and The Challenging Behaviour Foundation.

Mencap

Jan Tregelles, chief executive of Mencap, and Vivien Cooper, chief executive of The Challenging Behaviour Foundation, released this joint statement:

“Since Winterbourne View, a spotlight has been shone on assessment and treatment units, placing an urgent need to radically transform care and support for people with a learning disability and behaviour that challenges. It is shocking that a preventable death has happened in these circumstances.

“Sadly we know that Connor’s death is not the only tragedy. We are currently working with families in similar, dreadful situations. Our fight for justice will not stop until every person with a learning disability and behaviour that challenges receives high quality care in their local community.”

The inquiry found Slade House to have ‘failed significantly’ in its duties, having failed to gain a complete picture of Connor’s care and support needs, most notably through a lack of collaboration with his family.

Commenting on the report, Connor's mother, Sara Ryan, said: “We are pleased that the report is fair and balanced, and that it has been made public. We encourage people to read it, and to remember that Southern Health were quick to write Connor's death off as natural causes and that all due processes were followed. He 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 NHS Foundation Trust

Expressing a “deep regret and sincere apologies” to the family of Connor, Southern Health NHS Foundation Trust chief executive, Katrina Percy, issued the following comment and assured the public that a number of key actions are being carried out:

“Connor was a young man with learning disabilities who was admitted to one of our in-patient units last year. He was found submerged in the bath on the unit on 4 July 2013 and tragically died in hospital shortly afterwards. Post-mortem findings showed that he died as a result of drowning, likely to have been caused by an epileptic seizure.

“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. We are wholly committed to learning from this tragedy in order to prevent it from happening again and I would like to apologise unreservedly to Connor’s family.”

External investigation

Ms Percy continues: “Following Connor’s death we commissioned an external company, Verita, to investigate the circumstances in which Connor died. The investigation reviewed all the facts relating to the event and the care provided to Connor. Clinical records were reviewed, staff and family members interviewed and Connor’s family were given the opportunity to comment on a draft version of the report. The final report has now been completed by Verita and received by Connor’s family and ourselves. This has provided us with a set of key findings and recommendations.

“A couple of months after Connor’s death, the unit was also inspected by the Care Quality Commission and was found to be non-compliant with a number of standards. We were most concerned to learn of the issues highlighted through their inspection and immediately closed the unit to new admissions. We undertook an investigation into what had led to these failings and why it was that our governance processes had not allowed us to pick up on them sooner. HR investigations in this regard are ongoing.

“The unit remains closed to admissions whilst we work with our commissioners to design a new model of care for Learning Disability patients in the Oxfordshire, Buckinghamshire and Swindon areas which will better meet their needs. This has been our intention since the acquisition of the former Ridgeway Trust in November 2012 in order that services in these areas be brought in line with the model of service delivery that the Trust has provided with good results in Southampton and Hampshire.”