'We thought our son would be safe in assessment unit'
As the National Audit Office (NAO) publishes its report into the lessons of the Winterbourne View scandal, which saw people with learning disabilities abused by staff in an assessment unit outside Bristol, one family shares their experience of poor care.
Connor Sparrowhawk's woodland grave is adorned with models of the things he loved most - buses and police officers.
The 18-year-old drowned in the bath at an NHS assessment unit in Oxfordshire after having a fit in July 2013.
Connor had epilepsy, autism and a learning disability, but had always lived at home with his parents and siblings. He had been admitted to the unit 107 days earlier after becoming agitated and aggressive.
Sara Ryan, his mother, said: "He was a fit and healthy young man. He should have been supervised. If you have epilepsy, you shouldn't be left in the bath. I'm astonished they weren't supervising him in the bath, it's such a basic level of care."
A damning independent report by Verita for Southern Health NHS Foundation Trust found Connor's epilepsy had not been properly assessed or managed, and that his death was "preventable". Jeremy Hunt, the Health Secretary, has personally apologised to the family.
Ministers pledged in December 2012 that any inpatient with a learning disability or challenging behaviour, who would be better off cared for in the community, would be moved out of hospital by June 2014.
The promise came after BBC's Panorama exposed abuse of patients by staff at Winterbourne View.
But the National Audit Office's report said ministers had failed, as they had underestimated the "complexity and level of challenge" involved in discharging so many patients into the community.
Slade House, where Connor was treated, and Winterbourne View - both now closed - are examples of the assessment and treatment units (ATUs) that still house 2,600 people with learning disabilities in England.
His mother said of Slade House: "You always worry with kids like Connor, that there's risk of abuse. But the one thing we thought about the unit was that he would be safe."
His stepfather, Richard Huggins, added: "I didn't expect much from the unit except him being safe and assessed. I felt it would be a short-term breathing space, for maybe a month.
"We've got several children and from the moment you have them, you worry about everything. But I never worried that one of my children would die in NHS medical provision."
The NAO report is the latest in a series to outline the government's failure to honour the commitments made in the wake of Winterbourne View.
For Connor's family, the root issue is that people with learning disabilities are not treated as full citizens.
Mrs Ryan says: "Within our family, he was a fully-fledged member of society. As soon as he was taken away, he was treated as an object, there was no value attached to him.
"These ATUs are warehouses to house people who are seen as problematic. It's way too easy to forget about them. I dread to think what kind of lives people are leading inside them."
The family are determined to ensure that lessons are learned from Connor's death and things do change. They want all deaths in these ATUs to trigger an independent investigation, as happens in prisons, for example.
But whatever they achieve in their fight for justice on Connor's behalf, they say his death has left a gaping hole in their family.
When he was in the unit, they said, "all he wanted to do was come home".
The meeting to arrange the support package that would have enabled him perhaps to do that had been scheduled for the week after his death.
Watch Katie's report on Newsnight on 4 February on BBC Two at 22.35 GMT.