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Publication of investigation report into the death of Connor Sparrowhawk

 

Katrina Percy, Chief Executive of Southern Health NHS Foundation Trust said:

Connor was a young man with learning disabilities who was admitted to one of our in-patient units last year. He was found submerged in the bath on the unit on 4 July 2013 and tragically died in hospital shortly afterwards. Post-mortem findings showed that he died as a result of drowning, likely to have been caused by an epileptic seizure.

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.

Following Connor’s death we commissioned an external company, Verita, to investigate the circumstances in which Connor died. The investigation reviewed all the facts relating to the event and the care provided to Connor. Clinical records were reviewed, staff and family members interviewed and Connor’s family were given the opportunity to comment on a draft version of the report. The final report has now been completed by Verita and received by Connor’s family and ourselves. This has provided us with a set of key findings and recommendations.

A couple of months after Connor’s death, the unit was also inspected by the Care Quality Commission and was found to be non-compliant with a number of standards. We were most concerned to learn of the issues highlighted through their inspection and immediately closed the unit to new admissions. We undertook an investigation into what had led to these failings and why it was that our governance processes had not allowed us to pick up on them sooner. HR investigations in this regard are ongoing.

The unit remains closed to admissions whilst we work with our commissioners to design a new model of care for Learning Disability patients in the Oxfordshire, Buckinghamshire and Swindon areas which will better meet their needs. This has been our intention since the acquisition of the former Ridgeway Trust in November 2012 in order that services in these areas be brought in line with the model of service delivery that the Trust has provided with good results in Southampton and Hampshire.

The CQC re-inspected three of the original quality standards at the unit in December 2013 and sufficient  improvements were found in all these areas to make them compliant. The final three areas are awaiting re-inspection in the next few months. 

A number of actions were taken soon after Connor’s death and also following the CQC inspection. We will now look to ensure the overarching action plan also includes all the recommendations and findings from the Verita investigation report so that we can provide the best possible care to our patients.

Key actions taken to date and planned for the coming months include the following:

  • We have made the decision to further strengthen our leadership team in the Oxfordshire, Buckinghamshire, Wiltshire and Swindon areas and have appointed two leaders external to the organisation. They will work with us to establish a new model of care, which is effective in our Hampshire and Southampton teams.

  • We have reviewed the training our staff receive in relation to writing care plans and developing risk assessments for patients with epilepsy. All staff across the Learning Disabilities Division will undergo enhanced training and this will be mandatory. The doctors in the division will also undergo a specialist training day to further enhance their skills in epilepsy care.

  • A specialist nurse with skills and knowledge in epilepsy has audited all care plans for in-patients with learning disabilities to ensure they are appropriate and has made amendments and changes where needed.

  • We are looking to take part in a national study into epilepsy care. This will help us to benchmark ourselves against identified best practice and will provide us with information to help ensure that we are taking every opportunity to improve the care we provide.

  • Our senior nurses are leading an audit into all care plans. They have received specialist training and will start this in March. The plans will then be reviewed again in six months. This will give us assurance that care plans are providing the best care for the patients and staff can be given training and support as required. This will also include ensuring the social history of a patient is included along with advice and details provided by family members and carers.

  • We are looking closely at the relationship between our various learning disability teams and services to make sure they are working together to best effect. We have already reviewed and changed the management structure to include a senior manager who oversees both the inpatient and community teams. This has been complemented with the appointment of a Clinical Service Director who is providing consistency between the teams and ensuring the Care Programme Approach (CPA) for each patient is working across all teams and services. A new matron has also been appointed to enhance this clinical leadership further. They will be providing clinical advice and quality assurance to teams across Oxfordshire and Buckinghamshire.

  • We are committed to listening to our patients and acting on their feedback. We have revised our patient experience feedback questionnaire and have rolled this out to all teams. We are collating the data on a regular basis and feeding this into our plans and ways of working.

We will continue to make improvements to our services where necessary until we are assured that we are offering the highest quality service to those in our care and that we continue to do so.

We again would like to express our deep regret and sincere apologies to the family of Connor.