Care Patient's Death Ruled 'Preventable'

The Death Of An 18-Year-Old Man With Learning Difficulties Was Preventable, A Report Has Stated


It has been found that the death of an 18-year-old man with learning difficulties was preventable.

Connor Sparrowhawk, 18, was found unconscious in a bath at the Slade House unit in Headington on July 4th 2013 and later died in hospital.

It is thought that the teenager had an epileptic seizure while he was in the bath, causing him to drown.

Katrina Percy, chief executive of the Southern Health NHS Foundation Trust, which controlled Slade House, apologised for her organisation's failings and pledged to look into recommendations made by independent healthcare consultancy firm Verita.

The trust will now further its relationship with leadership teams in Oxfordshire, Buckinghamshire, Wiltshire and Swindon and learn from their care models so that the same mistakes are not made again.

One of the other recommendations acted on is that a specialist nurse with knowledge of epilepsy has audited all care plans to make sure they comply with government regulations and provide appropriate levels of safeguarding.

But while investigations continue into how Mr Sparrowhawk's care could have been better managed, the Slade House unit has been closed and will remain so until the safety of its patients can be guaranteed.

In a statement released on the Southern Health NHS Foundation Trust website, Ms Percy said: "I am deeply sorry that Connor died whilst in our care and that we failed to undertake the necessary actions required to keep him safe.

"We are wholly committed to learning from this tragedy in order to prevent it from happening again and I would like to apologise unreservedly to Connor’s family. The unit remains closed to admissions whilst we work with our commissioners to design a new model of care."

The hygiene practices of patients with advanced learning difficulties remain an area of sensitivity.

While safety must be considered, the privacy and dignity of the patient must also be protected, which presents health care professionals with a difficult challenge to overcome.

Expert Opinion
This is a tragic case that quite simply should not have happened – Mr Sparrowhawk’s death was preventable.

“We are pleased to see that the residential unit will remain closed to admissions until patient safety can be guaranteed.

“The Southern Health NHS Foundation Trust must now take on board all recommendations made by the health consultancy to improve the standard of care if provides.

“Sadly this case is not alone and we regularly see vulnerable people not being given the good quality care to which they are entitled. We hope lessons are leaned and shared across the NHS about the importance of having the appropriate resources and standards in place to protect the safety of patients with learning difficulties.”
Julie Lewis, Partner