25th February 2014

Southern Health NHS Foundation Trust has published a report which confirms that the death of 18 year old Connor Sparrowhawk, who had autism, a learning disability and epilepsy, could have been prevented. Connor was found unconscious in the bath on the Short Term Assessment and Treatment Team Unit (STATT unit) on 4 July 2013 and died that day.

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

  1. That Connor’s death was preventable
    2. That there were significant failings in his care and treatment
    3. 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
    4. That the level of observations in place at bath time was unsafe and failed to safeguard Connor
    5. 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 on 4 July 2013
    6. That the STATT unit lacked effective clinical leadership
    7. 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 CQC 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, 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.”

Deborah Coles, co-director of INQUEST said:

“This report reveals the shocking neglect of a very vulnerable teenager whose preventable death was at first dismissed by the Trust responsible for his care as natural causes.

“Were it not for the determination and tenacity of his family, who compelled the Trust to commission a highly unusual independent investigation, we may never have known the truth about what happened.

“The lack of an automatic system for independently investigating deaths is failing families. It is vital that deaths of people with learning disabilities in the care of the state are subject to robust independent scrutiny.”

Connor’s family is being represented by INQUEST Lawyers Group member Charlotte Haworth Hird of Bindmans solicitors. INQUEST has been working with the family since his death in 2013.


Notes to editors:

  1. The report can be found here
  2. Connor’s mother blogged throughout Connor’s time on the STATT unit and has continued to do so since Connor’s death. Her blog can be accessed here
  3. Details of the CQC inspection report of December 2013 can be found here