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Neglect contributed to teenager's death at NHS unit, inquest finds Neglect contributed to teenager's death at NHS unit, inquest finds
(35 minutes later)
Neglect contributed to the death of a vulnerable teenager who drowned at an NHS unit after suffering a seizure as he took a bath, an inquest jury has ruled.Neglect contributed to the death of a vulnerable teenager who drowned at an NHS unit after suffering a seizure as he took a bath, an inquest jury has ruled.
There was lack of training and leadership at the unit in Oxfordshire and poor communication between staff and the family of 18-year-old Connor Sparrowhawk, the jury said.There was lack of training and leadership at the unit in Oxfordshire and poor communication between staff and the family of 18-year-old Connor Sparrowhawk, the jury said.
After the inquest, Southern Health NHS foundation trust, which ran the unit, accepted it had not kept the patient safe and admitted his death had been preventable.After the inquest, Southern Health NHS foundation trust, which ran the unit, accepted it had not kept the patient safe and admitted his death had been preventable.
Sparrowhawk’s family paid tribute to a “gentle, quirky, hilarious and beyond loved son, brother, grandson, nephew, cousin.” They described the accounts of care provided to him as “harrowing”. Sparrowhawk’s family paid tribute to a “gentle, quirky, hilarious and beyond loved son, brother, grandson, nephew, cousin”. They described the accounts of care provided to him as “harrowing”.
The inquest at Oxford coroner’s court was told how Sparrowhawk, who who had a learning disability and epilepsy, was admitted to the Statt (short-term assessment and treatment team) unit at Slade House after becoming prone to violent outbursts. The inquest at Oxford coroner’s court was told how Sparrowhawk, who had a learning disability and epilepsy, was admitted to the Statt (short-term assessment and treatment team) unit at Slade House after becoming prone to violent outbursts.
A plan was drawn up that included observations of him carried out every 10 minutes because of his epilepsy. But a month before Sparrowhawk died, a decision was made at a care plan hearing to cut observations to once an hour, even though he had recently bitten his tongue, which could have indicated a seizure.A plan was drawn up that included observations of him carried out every 10 minutes because of his epilepsy. But a month before Sparrowhawk died, a decision was made at a care plan hearing to cut observations to once an hour, even though he had recently bitten his tongue, which could have indicated a seizure.
The inquest was told that Sparrowhawk loved to take baths and would lie in the tub for as long as three hours. On the day he died – 4 July 2013 – a nurse said he popped his head around the bathroom door to check on him around 10 minutes after the bath had been run. The two did not speak but the teenager seemed fine, he said.The inquest was told that Sparrowhawk loved to take baths and would lie in the tub for as long as three hours. On the day he died – 4 July 2013 – a nurse said he popped his head around the bathroom door to check on him around 10 minutes after the bath had been run. The two did not speak but the teenager seemed fine, he said.
About 20 minutes later, a fellow staff member told him that Sparrowhawk was submerged, his face blue. He was pronounced dead in hospital later.About 20 minutes later, a fellow staff member told him that Sparrowhawk was submerged, his face blue. He was pronounced dead in hospital later.
Sparrowhawk’s mother, Sara Ryan, told the jury that she had only found out during the inquest that the door was habitually closed when he had a bath, and she would have objected had she known.Sparrowhawk’s mother, Sara Ryan, told the jury that she had only found out during the inquest that the door was habitually closed when he had a bath, and she would have objected had she known.
Asked why she had not mentioned the need to observe her son in the bath, she said it had not occurred to her to raise it with expert staff. She said it would have been like asking a schoolteacher taking children on a trip not to “let them loose on a motorway”.Asked why she had not mentioned the need to observe her son in the bath, she said it had not occurred to her to raise it with expert staff. She said it would have been like asking a schoolteacher taking children on a trip not to “let them loose on a motorway”.
Sparrowhawk’s stepfather, Richard Huggins, told the inquest he had found the unit “bleak” and staff had made them feel they were an “inconvenience”. But he said: “At no point did we think our son would die in a National Health Service specialist unit.”Sparrowhawk’s stepfather, Richard Huggins, told the inquest he had found the unit “bleak” and staff had made them feel they were an “inconvenience”. But he said: “At no point did we think our son would die in a National Health Service specialist unit.”
As part of a narrative conclusion, the jury noted failures in his care, including: As part of a narrative conclusion, the jury noted failures in Sparrowhawk’s care, including:
Sparrowhawk’s family said: “The care Connor received in the Statt unit was of an unacceptable standard. Connor’s death was fully preventable. Over the past two weeks we have heard some harrowing accounts of the care provided. We have also heard some heartfelt apologies and some staff taking responsibility for their actions, for which we are grateful.Sparrowhawk’s family said: “The care Connor received in the Statt unit was of an unacceptable standard. Connor’s death was fully preventable. Over the past two weeks we have heard some harrowing accounts of the care provided. We have also heard some heartfelt apologies and some staff taking responsibility for their actions, for which we are grateful.
“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.“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.
“We hope that the spotlight that has been shone on to the careless and inhumane treatment of learning disabled people leads to actual (and not just relentlessly talked about) change. It is too late for our beautiful boy but the treatment of learning disabled people more widely should be a matter of national concern.”“We hope that the spotlight that has been shone on to the careless and inhumane treatment of learning disabled people leads to actual (and not just relentlessly talked about) change. It is too late for our beautiful boy but the treatment of learning disabled people more widely should be a matter of national concern.”
Mark Atkinson, chief executive at the disability charity Scope, said: “This is an utterly tragic case that never should have happened. It highlights serious failures in care, leadership and management. Too many disabled people are still being admitted to hospitals and institutions and kept there too long – a shocking average of five years.Mark Atkinson, chief executive at the disability charity Scope, said: “This is an utterly tragic case that never should have happened. It highlights serious failures in care, leadership and management. Too many disabled people are still being admitted to hospitals and institutions and kept there too long – a shocking average of five years.
“To avoid future tragedies like this we need to invest in first-rate social care that ensures people have the right personalised support to live full and fulfilled lives within their local community. The government must prioritise sustainable social care funding in the upcoming comprehensive spending review.”“To avoid future tragedies like this we need to invest in first-rate social care that ensures people have the right personalised support to live full and fulfilled lives within their local community. The government must prioritise sustainable social care funding in the upcoming comprehensive spending review.”
Katrina Percy, the chief executive of Southern Health NHS foundation trust, said: “I am deeply sorry that Connor died whilst in our care. Connor needed our support. We did not keep him safe and his death was preventable.”Katrina Percy, the chief executive of Southern Health NHS foundation trust, said: “I am deeply sorry that Connor died whilst in our care. Connor needed our support. We did not keep him safe and his death was preventable.”
She said the Statt unit been closed and many changes had been made to the service since Sparrowhawk died. Percy added: “We will reflect on the narrative conclusion of the jury.”She said the Statt unit been closed and many changes had been made to the service since Sparrowhawk died. Percy added: “We will reflect on the narrative conclusion of the jury.”