16 October 2015

Oxfordshire Coroner, Oxford
Before HM Senior Coroner for Oxford, Darren Salter

Connor was a much loved son, brother, family member and friend who loved buses, London, Eddie Stobart and speaking his mind. Connor had autism, a learning disability and like 1 in 4 people with learning disabilities he also had epilepsy. On 19 March 2013 he was admitted to the Short Term Assessment and Treatment Team Unit (STATT) run by Southern Health NHS Foundation Trust. 107 days later, on 4 July 2013 he drowned in the bath as a result of an epileptic seizure.

After a wait of over two years, the inquest concluded today with the jury finding that Connor’s death was contributed to by neglect.

The jury reaching their conclusion 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 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. The STATT unit was subsequently closed down.

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.

A statement from Connor’s mother, Dr Sara Ryan and stepfather, Richard Huggins is below. 

Charlotte Haworth Hird, 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.”

Deborah Coles, Co-Director of INQUEST, who have supported the family throughout, says:

“This inquest provided shocking insight into the neglect of a vulnerable teenager failed by those who should have been there to protect him.

This was a death initially dismissed by the NHS Trust as ‘natural causes’ and not subject to independent investigation. Were it not for the determination and tenacity of the family and their legal representation the truth about this preventable death may not have emerged.

The majority of similar deaths continue to be investigated by the very organisations which may have caused or contributed to the death. The lack of an automatic independent investigation is failing families and failing to protect those in state care. Faced with the damning jury finding NHS England must urgently review the way such deaths are investigated and the high number of deaths of people with learning disabilities. Connor and his family deserve nothing less so that future deaths and ill treatment are prevented.”

Paul Scarrott of Oxfordshire self-advocacy organization My Life My Choice said:

“I hope that Southern Health learn from the mistakes of what they have done.”


The Coroner will be issuing a Prevention of Future Deaths report.

INQUEST has been working with the family of Connor Sparrowhawk since July 2013.The family is represented by INQUEST Lawyers Group members Charlotte Haworth Hird of Bindmans Solicitors and barristers Caoilfhionn Gallagher of Doughty Street Chambers and Paul Bowen QC of Brick Court Chambers.

All press enquiries should be directed to at INQUEST (0207 263 1111 or 07714857236), George Julian (07967 008201 or [email protected]) or [email protected]

JusticeforLB campaign provided a live tweet of the inquest proceedings at: @LBInquest


Statement of Connor Sparrowhawk’s family

“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 have 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.”