Neglect contributed to the death of a teenager who drowned in the bath while in the care of Southern Health Foundation Trust, an inquest has found.

  • Jury inquest finds death of Connor Sparrowhawk contributed to by neglect
  • Mr Sparrowhawk, who had epilepsy, drowned in a bath following a seizure while in the care of Southern Health Foundation Trust
  • Trust chief executive apologises “unreservedly” for “preventable death”

Connor Sparrowhawk, 18, died at Southern’s short term assessment and treatment unit in Oxfordshire in July 2013.

The jury inquest found today that Mr Sparrowhawk, who had autism and epilepsy, died as a result of drowning following a seizure, and that his death was contributed to by neglect.

The jury found: “Connor’s death was contributed to by very serious failings, both in terms of systems in place to ensure adequate assessment, care and risk management of epilepsy in patients with learning disability at STATT and in terms of errors and omissions in relation to Connor’s care at STATT.”

The findings go on: “Contributing factors include: a lack of clinical leadership on the unit; a lack of adequate training and the provision of guidance for nursing staff in the assessment, care and risk management of epilepsy.

“In relation to Connor’s specific epilepsy care, a very serious failing was made in relation to Connor’s bathing arrangements.

“Other failures included the failure to complete an adequate history of Connor’s epilepsy and complete an adequate epilepsy risk assessment soon after admission… Evidence also exists of inadequate communication with Connor’s family and between staff regarding Connor’s epilepsy care, needs and risks.”

The STATT unit was closed by the trust at the end of 2013 following a poor Care Quality Commission inspection.

In a statement today Mr Sparrowhawk’s mother, Sarah Ryan, and stepfather, Richard Huggins, said: “The care Connor received in the STATT unit was of an unacceptable standard. The introduction of new medication led to increasing seizure activity on the unit, a fact denied by the consultant psychiatrist for reasons only known to her. Connor was allowed to bathe unsupervised and drowned, 107 days later.”

The statement added: “Since Connor’s death, Southern Health Foundation Trust have consistently tried to duck responsibility, focusing more on their reputation than the intense pain and distress they caused (and continue to cause us). It has been a long and tortuous battle to get this far and even during the inquest, the trust continued to disclose new information, including the death of another patient in the same bath in 2006. Families should not have to fight for justice and accountability from the NHS.”

Katrina Percy, chief executive of Southern Health, apologised “unreservedly” for Mr Sparrowhawk’s “preventable death”.

“Connor needed our support. We did not keep him safe and his death was preventable”.

She added: “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.”

Ms Percy said the trust had also “strengthened its clinical leadership” in learning disability services and introduced mandatory epilepsy training for staff.