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Connor Sparrowhawk inquest: Care unit death 'contributed to by neglect' Connor Sparrowhawk inquest: Care unit death 'contributed to by neglect'
(35 minutes later)
Neglect contributed to the death of an Oxford teenager who drowned in a bath at an NHS care unit, a jury inquest has ruled.Neglect contributed to the death of an Oxford teenager who drowned in a bath at an NHS care unit, a jury inquest has ruled.
Connor Sparrowhawk, 18, drowned after an epileptic seizure at Slade House, in Headington, Oxfordshire, in July 2013.Connor Sparrowhawk, 18, drowned after an epileptic seizure at Slade House, in Headington, Oxfordshire, in July 2013.
The learning disability unit, run by Southern Health NHS Foundation Trust, has since been closed.The learning disability unit, run by Southern Health NHS Foundation Trust, has since been closed.
The jury also concluded there were "serious failings" by the trust, including his bathing arrangements.The jury also concluded there were "serious failings" by the trust, including his bathing arrangements.
On 4 July 2013, Connor was discovered submerged and unresponsive in a bath at the unit.On 4 July 2013, Connor was discovered submerged and unresponsive in a bath at the unit.
Jurors at Oxford Coroners' Court heard staff had been told he should be checked every 15 minutes while in the bath, but there was no formal place to log this observation.Jurors at Oxford Coroners' Court heard staff had been told he should be checked every 15 minutes while in the bath, but there was no formal place to log this observation.
A post-mortem examination concluded he drowned after an epileptic seizure.A post-mortem examination concluded he drowned after an epileptic seizure.
The jury ruled his death had been "contributed to by neglect" and said there had been inadequate communication with Connor's family, as well as inadequate training and supervision.The jury ruled his death had been "contributed to by neglect" and said there had been inadequate communication with Connor's family, as well as inadequate training and supervision.
'Poor assessment' 'Failed in most tragic way'
Katrina Percy, the trust's chief executive, said: "It is absolutely clear that Connor should not have been in a bath without observation."Katrina Percy, the trust's chief executive, said: "It is absolutely clear that Connor should not have been in a bath without observation."
She described it as "an absolutely tragic failure".She described it as "an absolutely tragic failure".
She said evidence from the inquest and the trust's own investigations had shown the unit had a "real lack of team-working", "poor assessment" around Connor's epilepsy care, and a "lack of clarity about who was in charge".She said evidence from the inquest and the trust's own investigations had shown the unit had a "real lack of team-working", "poor assessment" around Connor's epilepsy care, and a "lack of clarity about who was in charge".
As well as members of the frontline team, Ms Percy said senior managers and clinicians had been disciplined.As well as members of the frontline team, Ms Percy said senior managers and clinicians had been disciplined.
"I am deeply, deeply sorry to Connor's family - his parents, his siblings, his wider family - we failed Connor in the most tragic way," she said."I am deeply, deeply sorry to Connor's family - his parents, his siblings, his wider family - we failed Connor in the most tragic way," she said.
Ms Percy said the trust had since made "many changes" to the way it provides services for people with learning disabilities, including implementing mandatory comprehensive epilepsy training for all staff caring for people with learning disabilities.Ms Percy said the trust had since made "many changes" to the way it provides services for people with learning disabilities, including implementing mandatory comprehensive epilepsy training for all staff caring for people with learning disabilities.
She added the experiences of Connor's family had "brought into sharp focus the need to engage more effectively with patients, their families and carers" and "involving them in every decision concerning care".She added the experiences of Connor's family had "brought into sharp focus the need to engage more effectively with patients, their families and carers" and "involving them in every decision concerning care".
'Harrowing accounts'
On behalf of the family, lawyer Charlotte Haworth Hird said: "Connor's death was fully preventable.
"Over the past two weeks, we've heard some harrowing accounts of the care provided to Connor.
"We have also heard some heartfelt apologies and some staff taking responsibility for their actions, for which we are grateful.
She added: "Since Connor's death, Southern Health NHS 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 to us."
She described it as a "long and tortuous battle", adding: "Families should not have to fight for justice and accountability from the NHS."
Connor, who had learning disabilities as well as epilepsy, was admitted to Slade House in March 2013 after his behaviour became aggressive.Connor, who had learning disabilities as well as epilepsy, was admitted to Slade House in March 2013 after his behaviour became aggressive.
Six weeks before his death, Connor's mother Dr Sara Ryan emailed staff to say she thought he had experienced a seizure and bitten his tongue, the inquest heard.Six weeks before his death, Connor's mother Dr Sara Ryan emailed staff to say she thought he had experienced a seizure and bitten his tongue, the inquest heard.
However, a decision was made to reduce observations of him from every 10 minutes to once an hour.However, a decision was made to reduce observations of him from every 10 minutes to once an hour.
An independent report into his death, commissioned by the trust, said this was a "missed opportunity".An independent report into his death, commissioned by the trust, said this was a "missed opportunity".
After Connor died Care Quality Commission inspectors entered the unit and concluded "care and treatment was not consistently planned and delivered" and "the provider did not have an effective system in place to identify and manage risks to health, safety and welfare".After Connor died Care Quality Commission inspectors entered the unit and concluded "care and treatment was not consistently planned and delivered" and "the provider did not have an effective system in place to identify and manage risks to health, safety and welfare".