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Trust statement regarding Connor Sparrowhawk’s death

Almost three years ago Connor Sparrowhawk died while in our care, for which we are deeply sorry, and we would like to take this opportunity to again offer our unreserved apologies to his family for his preventable death.

We have now been able to come to a successfully mediated settlement with Connor’s family, as detailed in the statement below. The statement and an easy version of the statement are also attached on the right hand side of this page as pdf documents.


1. Southern Health NHS Foundation Trust (“the Trust”) accepts that it was responsible for the death of Connor Sparrowhawk, an 18-year-old boy who was a much loved son, brother and friend. He died on 4th July 2013 whilst in the care and custody of the Short Term Assessment and Treatment (“STATT”) Unit, Slade House, for which the Trust was responsible. Connor’s preventable death was the result of multiple systemic and individual failures by the Trust in the care provided to Connor on the STATT Unit.

2. The Trust accepts:

(i) The findings of the independent investigation into the death of Connor Sparrowhawk by Verita, dated February 2014, which concluded that his death was preventable and found significant failings in the care provided to Connor in particular concerning the management of his epilepsy;

(ii) The findings of the inquest jury on 16th October 2015, which determined that Connor died by drowning following an epileptic seizure while in the bath, contributed to by neglect* due to a number of very serious failings. These failings included both failures in the systems and processes in place to ensure adequate assessment, care and risk management of epilepsy in patients with learning disability at the STATT Unit, and in terms of errors and omissions in relation to Connor’s care whilst on the Unit. The Trust accepts that contributory factors included:

  • (a) A lack of clinical leadership on the STATT Unit;
  • (b) A lack of adequate training and the provision of guidance for nursing staff in the assessment, care and risk management of epilepsy;
  • (c) Very serious failings in relation to Connor’s bathing arrangements;
  • (d) Failure to complete an adequate history of Connor’s epilepsy;
  • (e) Failure to complete an epilepsy risk assessment soon after admission;
  • (f) Failure to complete an epilepsy risk assessment thereafter;
  • (g) Inadequate communication by staff with Connor’s family regarding his epilepsy care, needs and risks.

3. Southern Health NHS Foundation Trust acknowledges and accepts that:

(i) The failings identified by Verita and by the inquest jury:

  • (a) Caused Connor’s death.
  • (b) Were negligent breaches of the duty of care the Trust owed to Connor.
  • (c) Violated Connor’s right to life protected by Article 2 of the European Convention on Human Rights.
  • (d) Violated the Article 2 rights of Connor’s family.

(ii) The Trust failed to take all reasonable steps to locate all relevant evidence and to disclose this to the Coroner and Connor’s family.

4. The Trust will pay Connor’s family the sum of £80,000 by way of compensation for its unlawful acts and omissions.

5. The Trust fully acknowledges that Dr. Sara Ryan has conducted herself and the Justice for LB campaign in a dignified, fair and reasonable way. To the extent that there have been comments to the contrary by Trust staff and family members of staff, these do not represent the view of the Trust and are expressly disavowed.

*As that word is understood in coronial law.

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View the Trust statement regarding Connor Sparrowhawk's death

View the Trust's easy read statement regarding Connor Sparrowhawk's death