NHS Trust admits guilt over Connor Sparrowhawk's 'entirely preventable' death

Southern Health NHS Foundation Trust has pleaded guilty to health and safety breaches over the death of a teenager who drowned in a bath while receiving its care.

Eighteen-year-old Connor Sparrowhawk, who had a learning disability, was left unattended in a bath and drowned after an epileptic seizure at Slade House, run by the Trust.

At the time of the teenager’s death in 2013, his family was told he had died of natural causes, however an investigation in 2014 found his death was entirely preventable and neglect had contributed to his death at the specialist learning disability unit.

The NHS Trust, which offers specialist mental health and learning disability services to patients in Hampshire and Oxfordshire, pleaded guilty on 18 September at Banbury Magistrates’ Court to breaching health and safety law in a prosecution brought by the Health and Safety Executive (HSE).

Following the hearing, the Trust's interim chief executive, Julie Dawes, described his death as "entirely preventable".

Julie Dawes said: "Connor's loss continues to have a devastating impact on his family and we are truly sorry that we didn't keep him safe. "There have been times when our actions unintentionally added to the distress of Connor's family."

Ms Dawes said his death had led to "significant changes and improvements" at the Trust and added she hoped all families and service users "will now experience a more compassionate approach from Southern Health".

Mr Sparrowhawk, known as the 'Laughing Boy', had epilepsy, autism and learning difficulties and was admitted to Slade House, on 19 March 2013. He was found unresponsive in the bath only four months later on 4 July.

'I miss him so bloody much'

Connor Sparrowhawk's mother Sara Ryan attended the hearing. Dr Ryan, an academic researcher of autism and learning difficulties who led a four-year campaign for those responsible to be brought to account, has regularly revealed her thoughts about her son's death in her blog mydaftlife. On 17 September, the day before the Trust's guilty plea was entered in court, Dr Ryan posted: 'I hope some respect will be shown to our beautiful boy who died in the cross hairs of a greedy, arrogant and failing Trust.''

In a previous post, she tweeted: 'I just miss him. I miss him so bloody much.'

The Trust’s guilty plea, follows a separate medical tribunal on 19 August, which found a doctor had not conducted risk assessments for Mr Sparrowhawk.

An England-wide review of how NHS trusts investigate the deaths of patients was carried out in 2016, sparked by a review of all mental health and learning disability deaths at the Trust from April 2011 to March 2015, after Connor Sparrowhawk’s death. The investigation revealed the Trust only held a review into one per cent of all the deaths of people with learning disabilities during a four-year period.

In the report, Professor Sir Mike Richards, chief inspector of hospitals, said: “We found that the level of acceptance and sense of inevitability when people with a learning disability or mental illness die early is too common.”

Slade House was shut in 2014. The NHS Trust's former boss Katrina Percy resigned in October 2016. Last March, all non-executive directors resigned from the Trust. On 12 September, the Trust announced Dr Nick Broughton, leader of Somerset Partnership NHS Foundation Trust, will start work as Southern Health's chief executive in November.

MP Norman Lamb, who was Care Minister at the time of Mr Sparrowhawk’s death, said earlier this year, the HSE’s move to prosecute the Trust over the death of the teenager had “taken far too long” but was “better late than never”.

The HSE is prosecuting Southern Health NHS Foundation Trust under Section 3 of the Health and Safety Work etc Act 1974. Sentencing is due to take place on 12 October at Oxford Crown Court.