Southern Health NHS Foundation Trust has accepted full responsibility for the death of Connor Sparrowhawk and has admitted that it was negligent and violated Connor’s and his family’s human rights.
Connor Sparrowhawk, aged 18, died on July 4, 2013 while in the care and custody of the Short Term Assessment and Treatment (STATT) Unit, Slade House, which was run by Southern Health.
In a statement, Southern Health said: “Connor’s preventable death was the result of multiple systemic and individual failures by the Trust in the care provided to Connor on the STATT Unit.”
Southern Health also accepted the findings of the independent investigation into the death of Connor by Verita in February 2014, which concluded that his death was preventable and found significant failings in the care provided to Connor in particular concerning the management of his epilepsy.
Likewise, the trust accepted the findings of the inquest jury on October 16, 2015, which determined that Connor died by drowning following an epileptic seizure while in the bath, contributed to by neglect due to a number of serious failings. This included failures in the systems and processes in place to ensure adequate assessment, care and risk management of epilepsy in patients with learning disability at the STATT Unit, and in terms of errors and omissions in relation to Connor’s care whilst on the Unit.
The Trust accepts that contributory factors included:
• A lack of clinical leadership on the STATT Unit
• A lack of adequate training and the provision of guidance for nursing staff in the assessment, care and risk management of epilepsy
• Very serious failings in relation to Connor’s bathing arrangements
• Failure to complete an adequate history of Connor’s epilepsy
• Failure to complete an epilepsy risk assessment soon after admission
• Failure to complete an epilepsy risk assessment thereafter
• Inadequate communication by staff with Connor’s family regarding his epilepsy care, needs and risks.
Southern Health NHS Foundation Trust acknowledged and accepted that the failings identified by Verita and by the inquest jury:
• Caused Connor’s death
• Were negligent breaches of the duty of care the Trust owed to Connor
• Violated Connor’s right to life protected by Article 2 of the European Convention on Human Rights
• Violated the Article 2 rights of Connor’s family
• The Trust failed to take all reasonable steps to locate all relevant evidence and to disclose this to the Coroner and Connor’s family.
The Trust will pay Connor’s family compensation for its unlawful acts and omissions.
Southern Health also fully acknowledged that Connor’s mother, Dr Sara Ryan, conducted herself and the Justice for LB campaign in a dignified, fair and reasonable way. “To the extent that there have been comments to the contrary by Trust staff and family members of staff, these do not represent the view of the Trust and are expressly disavowed,” the statement said.
Charlotte Haworth Hird of Bindmans, the family’s solicitor, said: “This full admission finally shows what Connor’s family have known for years – that Connor and they were repeatedly failed by Southern Health. It comes after a three year struggle by Connor’s family and the #JusticeforLB campaign. They have fearlessly fought for truth and accountability in relation to Connor’s death and at last, the full extent of the Trust’s failings in Connor’s care have been accepted. It is shameful that this was not done sooner. Over an extended period, Connor’s family have had to learn of the harrowing circumstances of his time at the STATT unit and of his death.
“In the face of that horror, they have remained dignified and dedicated to ensuring that no other individual receives the treatment that Connor and they have. I am therefore glad that the Trust has also publicly acknowledged that Sara Ryan has conducted herself and the #JusticeforLB campaign in a dignified, fair and reasonable way. Nothing less could have been said of her.”
Deborah Coles, director of INQUEST, which have supported Connor’s family since his death, added: “The truth only came about as a result of the family's fight for it. This took place against a background of Trust secrecy, denial and resistance to effective scrutiny. Southern Health argued against the Article 2 inquest with a jury. It was this process, at which the family were legally represented, that enabled the systemic failings and neglect to be exposed. What about those who have no one to fight for them? The ongoing failure to set up a process whereby deaths of learning disabled and mental health patients are independently investigated sends a message out that these lives do not matter.”