Southern Health NHS Foundation Trust has pleaded guilty in relation to a Health and Safety Executive (HSE) prosecution for the death of a patient at a learning disability unit in Oxford.Connor Sparrowhawk had a seizure and drowned in a bath at the Slade House unit in 2013. He had epilepsy, autism and learning difficulties.
The trust said it was ‘truly sorry’ that it didn’t keep Sparrowhawk safe.
His death led to an independent inquiry which, according to documents seen by the BBC, claimed the Trust had not properly investigated more than 1,000 deaths of patients with either mental health problems or learning difficulties over a four year period.
According to the BBC, the inquiry said there had been a failure of leadership and a lack of effective management. It also said there was not a system of learning from deaths or using data related to them.
The guilty plea was made at Banbury Magistrates Court on Monday (18 September). The Trust will be sentenced on October 12 at Oxford Crown Court. The HSE declined to comment until after sentencing had taken place.
Julie Dawes, interim chief executive of Southern Health NHS Foundation Trust said: “Connor’s death whilst under our care was entirely preventable and today we have pleaded guilty to the charges brought against the Trust by the Health and Safety Executive. Connor’s loss continues to have a devastating impact on his family and we are truly sorry that we didn’t keep him safe.
“The effect of Connor’s death has been far reaching and whilst it in no way compensates for the loss his family has suffered, it has led to significant changes and improvements in the Trust. There have been times when our actions unintentionally added to the distress of Connor’s family. However as a result of the changes we have made we hope that all families and service users will now experience a more compassionate approach from Southern Health.
“Connor is a constant reminder why we must continue to do everything we can to improve the quality and safety of our services.”
But Sparrowhawk’s mother, Dr Sara Ryan, said in a series of personal blog posts that the Trust had blamed everyone but themselves. She also claimed that the Trust had fought the family every step of the way during the hearing into his death.
As an example, she referenced how distressing it had been to listen to the Trust describe death by drowning as a natural cause.
She said: “Just imagine. A guilty plea from a trust who have forced us to fight every step of the beyond distressing way for accountability.”
Jan Tregelles, the chief executive of the charity Mencap, said: “Twelve hundred people with a learning disability are dying avoidably in the NHS every year. This is a national scandal.”
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