The story starts with a young man named Connor Sparrowhawk. Connor was 18 years old when he had a fit in the bath at Slade House (an NHS treatment and assessment centre) in Oxford. He was already diagnosed with autism, a learning disability and epilepsy but to seek further support when Connor became more aggressive and agitated he was admitted to Slade House for further assessment.
In the report following his death it was found that Connor had not been risk-assessed appropriately and drowned from an epileptic seizure whilst bathing unsupervised. The unit was closed in November this year after failing all 10 quality and safety standards from CQC.
Connor’s family didn’t give up. They started the ‘Justice for LB’ (laughing boy) campaign for an independent enquiry into his death. In the process they are standing up to the Southern Health NHS Foundation Trust who could ultimately have prevented Connor’s death.
Yesterday the news broke that over 1,000 unexpected deaths, like Connor’s, had been left uninvestigated by the Southern Health Trust since 2011. Only 1% of investigated deaths had been that of people with learning disabilities. A worryingly low percentage compared to the -still low- 30% of adults with mental health problems who died unexpectedly investigated.
How was this allowed to happen? The report found that there was neither “effective” management of deaths and investigations nor “effective focus or leadership from the board at Southern Health”. The report states that the NHS Trust had: “lost learning, a lack of transparency when care problems occur”. Connor’s family had been concerned about him and had made staff at Slade House aware of his needs, such as epilepsy, repeatedly. If appropriate assesments and proceedures were to have been followed he would likely still be here today.
“We have little confidence that the trust has fully recognised the need for it to improve its reporting and investigation of deaths.” – Mazars
The worst part of this case is that the trust has shown little to no signs of acknowledgement of its failures and the immense need for changes to be made. The final report is yet to be published.
Connor is lucky to have the support of an amazing family- both in his eighteen years of time with them and the time in their hearts now. However it is worth baring in mind that in over-65s with mental health problems only 0.3% of unexpected deaths were investigated. Many of these patients may not have had family to pursue the reasons behind their deaths. No one dies for no reason. There is always a reason. For the safety and care of future cases all unexpected deaths should be investigated. If malpractice is to blame then these people have been tragically neglected by a service that is supposed to be caring for them. The reasons behind their deaths are covered up by not searching for the cause. How is this acceptable? Anyone who brings about the death of another should face the consequences. Whether it is an individual, a group or an NHS Trust. An investigation into one death could be the finding of a fault that could prevent 1,000 more unnecessary deaths.
Many thanks to Sara Ryan for letting me share her and her sons story and message.