Tariq Hussain and Kathryn Hyde-Bales

Southern Health NHS Foundation Trust, 2014

Connor Sparrowhawk (CS) an 18-year-old man, was admitted to a trust short-term assessment and treatment unit on 19 March 2013. The unit is part of the learning disability assessment and treatment service Southern Health NHS Foundation Trust provides across Buckinghamshire, Hampshire, Oxfordshire, Southampton, Swindon and Wiltshire.

CS had Klinefelter’s syndrome, a genetic disorder, with learning disabilities, autistic traits and epilepsy. He experienced tonic clonic and partial seizures.

CS lived at home before his admission. He went to John Watson School but had started to refuse to attend at the beginning of 2013. Social services was taking steps with CS and his family to plan for his transition to adult provision.

CS was initially admitted to the unit as an emergency because of his aggressive and threatening behaviour at school and at home. A record in CS’ care plan dated 24 March said he should be checked every 15 minutes during baths to ensure he was ok.

On the morning of 4 July CS was found submerged in the bath. He died later the same day.

The Trust commissioned an independent review in November 2013 into the care and treatment provided to CS up until his death