clipboard The death of 18-year-old Connor Sparrowhawk, who had autism, a learning disability and epilepsy, last year could have been prevented and followed a catalogue of failings in his care, an independent report has confirmed.

Connor was found unconscious in the bath on the Short Term Assessment and Treatment Team Unit (STATT unit) at Slade House in Headington, Oxfordshire, run by Southern Health NHS Foundation Trust, on July 4, 2013 and died that day.

The report, completed by the independent organisation Verita, investigated Connor’s death and found the following:

That Connor’s death was preventable

That there were significant failings in his care and treatment

That the failure of staff to respond to and appropriately risk assess Connor’s epilepsy led to a series of poor decisions around his care

That the level of observations in place at bath time was unsafe and failed to safeguard Connor

That if a safe observation process had been put in place and Connor had been appropriately supervised in the bath, he would not have died

That the STATT unit lacked effective clinical leadership

That there had been no comprehensive care plan in place for the management of Connor’s epilepsy and his epilepsy was not considered as part of Connor’s risk assessment, in breach of NICE epilepsy guidance.

The report follows a highly critical Care Quality Commission inspection published in December 2013 in which the STATT unit failed on all 10 essential standards of quality and safety. Since that inspection report, the unit has been closed to new admissions.

Sara Ryan, Connor’s mother – who has blogged about her son, nicknamed LB, on her My daft life blog since his death, said: “We are pleased that the report is fair and balanced, and that it has been made public. We encourage people to read it, and to remember that Southern Health were quick to write Connor's death off as natural causes and that all due processes were followed. 

“He should never have died and the appalling inadequacy of the care he received should not be possible in the NHS. It has been a long and distressing fight to reach this point and get the facts surrounding his death out in the open. He was a remarkable young man who was failed by those who should have kept him safe. We miss him beyond words.”

In response, Katrina Percy, chief executive of Southern Health, said: “I am deeply sorry that Connor died whilst in our care and that we failed to undertake the necessary actions required to keep him safe. We are wholly committed to learning from this tragedy in order to prevent it from happening again and I would like to apologise unreservedly to Connor’s family.”

She added that the STATT unit remains closed to admissions whilst Southern Health works with commissioners to design a new model of care for learning disability patients in the Oxfordshire, Buckinghamshire and Swindon areas.