There were ‘deficiencies’ in Southern Health Foundation Trust’s takeover of a learning disability service in the care of which a vulnerable teenager later died, an independent review has concluded.

  • “Deficiencies” in Southern Health FT’s takeover of Ridgeway Partnership, which operated facility where Connor Sparrowhawk died
  • Independent report concludes its approach “made it less likely that poor practice would have been known about or checked”
  • Review did not find evidence of “direct or indirect” connection to failures that led to his preventable death

However, the report said there was no evidence the deficiencies contributed to the preventable death of 18-year-old Connor Sparrowhawk.

Mr Sparrowhawk, who had autism and epilepsy, drowned in the bath at Southern Health’s short term assessment and treatment unit in Oxfordshire in July 2013.

Last week a jury concluded that he drowned following a seizure, and that his death was contributed to by neglect.

Southern Health commissioned the consultancy Verita to undertake an independent investigation into Mr Sparrowhawk’s death, which concluded in February last year that his death was preventable.

Katrina Percy

The report made for ‘challenging reading for the trust and wider NHS’, Katrina Percy said

However, the Oxfordshire Safeguarding Adults Board and NHS England had ongoing concerns about Southern Health’s learning disability services, and therefore asked Verita to conduct a further investigation into whether wider issues in the local health system had contributed to the death.

Verita’s report, published this week, concludes there were “deficiencies” in Southern Health’s “post-acquisition actions” following its takeover of Ridgeway Partnership, which operated the unit in which Mr Sparrowhawk later died.

Southern Health had relied on a “business as usual” approach to the acquisition, which Verita said was “not appropriate”. Processes should have been in place to ensure “any deterioration in the quality of services could be identified quickly”.

Two key employees experienced in learning disability moved out of management roles, and the trust did not put in place actions to address “the cultural change required of an established learning disability service joining a large mental health and community trust with a small learning disability service”.

However, while Southern Health’s approach had “made it less likely that poor practice would have been known about or checked”, Verita concluded there was “not a direct or indirect connection to the failures that led to Connor’s death”.

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

She added: “There are clearly areas for improvement in relation to acquisitions by NHS provider organisations, and also in relation to the consistent provision of high quality services for people with learning disabilities.”

However, in a statement posted online, Mr Sparrowhawk’s family said they disagreed with the report’s conclusions.

“We believe that the poor attention to detail in post-acquisition phase, poor communication, poor epilepsy policies and guidance and the absence of any meaningful leadership must have directly contributed to Connor’s ‘care’ and ultimately his death,” the statement said.