Neglect contributed to the death of teenager Connor Sparrowhawk, who drowned in a bath at an assessment and treatment unit, a jury inquest has ruled.

Connor, 18, who had autism and a learning disability, drowned after suffering an epileptic seizure while in the bath at the Short-Term Assessment and Treatment Team Unit (STATT) at Slade House in Headington, Oxfordshire, a unit run by Southern Health NHS Foundation Trust in July 2013. 

The inquest concluded with the jury finding that Connor’s death was contributed to by neglect. The jury noted serious failures in his care, including:

Lack of clinical leadership on the STATT unit

Failure in the systems in place in relation to training and guidance

Failure to obtain a history and conduct a risk assessment

Inadequate communication with Connor's family and between staff in relation to Connor’s epilepsy needs and risk

Epilepsy toolkit was not provided to staff on STATT despite being available

Too few staff were trained in epilepsy on the unit and the training was too limited and insufficient

There were errors and omissions made in Connor's care once admitted to the STATT unit in relation to bathing arrangements

There was a lack of communication with Connor’s family whist he was in the unit and missed opportunities

Clinical team failed to identify the absence of an epilepsy risk assessment plan.

An independent investigation published in February 2014 [www.learningdisabilitytoday.co.uk/death_of_18_year_old_with_learning_disabilities_in_assessment_and_treatment_unit_was_preventable.aspx ] found Connor's death was preventable and there were significant failings in epilepsy management and clinical leadership.

Two months after Connor's death, an unannounced inspection by the regulator, the Care Quality Commission, found that the unit had failed to meet all of the 10 key safety and quality standards which were the subject of inspection, including respecting and involving people who use services. It was subsequently closed.

Charlotte Haworth Hird, from Birdmans, solicitor for the family, said: “This outcome properly reflects how badly Connor was failed and the wholly inadequate care that he received. The jury's damning conclusion is testament to the commitment of his family, friends and the JusticeforLB campaign to obtaining the truth. They have been forced to fight for this and should not have had to have to. Connor should not have died. Southern Health and the NHS have a responsibility to ensure that this never happens again and that there are radical improvements in support and care provision provided to individuals with learning disabilities and their families.”

The family are still awaiting the final outcome of an independent review of all mental health and learning disability deaths at Southern Health NHS Foundation Trust, after they raised serious concerns as to the adequacy of the Trust's internal investigation system and responses to deaths.


Join Connor's mother Dr Sara Ryan at Learning Disability Today on 26 November
in our debate session entitled ‘Promoting access to health care’. 


Unacceptable standard of care

Following the verdict, Connor’s family released a statement: “Two years and 7 months ago, our gentle, quirky, hilarious and beyond loved son (brother, grandson, nephew, cousin) was admitted to a short term assessment and treatment unit, STATT, run by Southern Health NHS Foundation Trust. Connor, also known as Laughing Boy or LB, loved buses, Eddie Stobart, watching the Mighty Boosh, lying in the sunshine and eating cake. He was 18 years old.

“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.

“Connor's death was fully preventable. Over the past two weeks we have 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. During the inquest, eight legal teams (seven of whom we understand are publicly funded) have examined what happened in minute detail. We have had to fundraise for our legal representation.

“Since Connor's death, Southern Health NHS Foundation Trust has 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.

“We would like to thank everyone who has supported the campaign for JusticeforLB, and hope that the spotlight that has been shone onto 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.”

"Deeply sorry"

In response, Katrina Percy, chief executive of Southern Health, 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.

“We have thoroughly investigated the circumstances surrounding Connor’s death and continue to work hard to help ensure that this doesn’t happen again. In the two years since he died we have made many changes to the way we provide services for people with learning disabilities.

“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.

“Among other steps taken, the Trust has strengthened its clinical leadership in learning disability services. We have also implemented mandatory comprehensive epilepsy training for all our staff caring for people with Learning Disabilities.

“The experiences of Connor’s family have brought into sharp focus the need to engage more effectively with patients, their families and carers, learning from their experience and expertise and involving them in every decision concerning care.

"We will reflect on the narrative conclusion of the jury. We will carefully consider evidence heard during the inquest and the jury’s conclusion and act swiftly upon any need for further changes identified as a result.

“I again apologise unreservedly to Connor’s family for his preventable death.”