Connor Sparrowhawk inquest: Care unit death 'contributed to by neglect'
Neglect contributed to the death of an Oxford teenager who drowned in a bath at an NHS care unit, a jury inquest has ruled.
Connor Sparrowhawk, 18, drowned after an epileptic seizure at Slade House, in Headington, Oxfordshire, in July 2013.
The learning disability unit, run by Southern Health NHS Foundation Trust, has since been closed.
The jury also concluded there were "serious failings" by the trust, including his bathing arrangements.
The court heard that Connor enjoyed taking baths, and would often stay in the bath for three hours.
On 4 July 2013, he was discovered submerged and unresponsive in a bath at the unit.
Jurors at Oxford Coroners' Court heard staff had been told he should be checked every 15 minutes while in the bath, but there was no formal place to log this observation.
A post-mortem examination concluded he drowned after an epileptic seizure.
The trust attributed his death to natural causes, but an independent report later found that the "level of observations in place at bath time was unsafe and failed to safeguard".
The jury ruled his death had been "contributed to by neglect" and said there had been inadequate communication with Connor's family, as well as inadequate training and supervision.
Katrina Percy, the trust's chief executive, said: "It is absolutely clear that Connor should not have been in a bath without observation."
She described it as "an absolutely tragic failure".
She said the unit had shown a "real lack of team-working", "poor assessment" around Connor's epilepsy care, and a "lack of clarity about who was in charge".
As well as members of the frontline team, Ms Percy said senior managers and clinicians had been disciplined.
"I am deeply, deeply sorry to Connor's family - his parents, his siblings, his wider family - we failed Connor in the most tragic way," she said.
Ms Percy said the trust had since made "many changes" to the way it provided services for people with learning disabilities, including implementing mandatory comprehensive epilepsy training for all staff caring for people with learning disabilities.
It had "brought into sharp focus the need to engage more effectively with patients, their families and carers", she said.
On behalf of the family, lawyer Charlotte Haworth Hird said: "Connor's death was fully preventable.
"Over the past two weeks, we've 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."
She added: "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 to us."
She described it as a "long and tortuous battle", adding: "Families should not have to fight for justice and accountability from the NHS."
Alistair Burt, minister of state for community and social care, called it a "deeply distressing case".
He added: "As a government, we are fully committed to ensuring the best quality care for everyone, and expect all providers to prioritise the safety and dignity of all patients."
Connor, who had learning disabilities as well as epilepsy, was admitted to Slade House in March 2013 after his behaviour became aggressive.
Six weeks before his death, Connor's mother Dr Sara Ryan emailed staff to say she thought he had experienced a seizure and bitten his tongue, the inquest heard.
However, a decision was made to reduce observations from every 10 minutes to once an hour, which the report called a "missed opportunity".