Dan Parton cutConnor Sparrowhawk’s tragic death again highlights the need for urgent reform of hospital-type accommodation for people with learning disabilities.

The list of failings in the care of Connor Sparrowhawk makes for distressing reading. Connor, who had autism, a learning disability and epilepsy, died on July 4, 2013 after being found unconscious in the bath on the Short Term Assessment and Treatment Team (STATT) unit at Slade House in Headington, Oxfordshire, run by Southern Health NHS Foundation Trust.

This week, an independent report found a catalogue of “significant failings” in his care and treatment that contributed to his “preventable” death. This included staff failing to respond to and appropriately risk-assess Connor’s epilepsy, which led to a series of poor decisions around his care, and unsafe levels of observation in place at bath time that failed to safeguard Connor.

That the STATT unit failed to meet any of the Care Quality Commission’s (CQC) minimum standards of care in an assessment later in 2013 may not come as a surprise. Southern Health has said that the unit is still closed to new admissions, but that improvements have been made.

But that all this happened some two years after the abuse at the former Winterbourne View assessment and treatment centre was uncovered by the BBC’s Panorama programme makes Connor’s death all the more shocking.

Following Winterbourne the CQC undertook a programme of inspections and also found that many assessment and treatment units were failing to meet at least one essential standard. This was supposed to mean providers upped their game. In addition, there have been numerous reports and pronouncements from government departments that reform of the sector was needed and that care standards had to improve. But still, cases such as Connor’s come to light.

More worryingly, his is not the only case. In a joint statement in response to the report into Connor’s death, Jan Tregelles, chief executive of Mencap, and Vivien Cooper, chief executive of The Challenging Behaviour Foundation, said: “Sadly we know that Connor’s death is not the only tragedy. We are currently working with families in similar, dreadful situations.”

How many cases is not stated, but even one is too many. 

Progress in reforming the sector seems to be painfully slow. The Government’s final response to Winterbourne View was meant to speed things up, but from what I have heard from people working on the ground to get people with learning disabilities out of these institutions, it can still be a hugely difficult and lengthy process.

I have blogged on this topic numerous times over the past three or so years and I make no apologies for coming back to it again. Pressure needs to be kept up on the authorities that continue to commission places in such institutions, as well as on central government, to ensure that reform is delivered and tragedies like Connor’s don’t occur again.

A tweet today from the Winterbourne Joint Improvement Programme (@WinterbourneJIP) – which was established to help local areas fundamentally transform health and care services for people with learning disabilities or autism and behaviour that challenges, and is now led by MacIntyre’s Bill Mumford – offers hope: “We r challenging commissioning of long stay settings: reduce nos & improve quality. Progress not quick enough”.

This change has to happen: assessment and treatment units – although in some it seems that precious little of either happens – both privately and NHS-run, are still failing and the consequences for the people in them can be devastating, as Connor’s case demonstrates.

It doesn’t have to be like this because we know what ‘good’ looks like: high quality care provided in community settings, as outlined by the late Professor Jim Mansell. There are numerous examples of where this works, so it should not be beyond the wit of commissioners and providers to replicate these services. 

For the small minority of people who do need in-patient care, a plan for their return to the community should be in place, from day one, and their stay should be short – a few months at the longest.

But fundamentally, inadequate care has to be rooted out. As Sara Ryan, Connor’s mother, said in the wake of the report: “He should never have died and the appalling inadequacy of the care he received should not be possible in the NHS.”