Connor Sparrowhawk inquest: Care unit was 'chaotic'

Connor Sparrowhawk, who died at Slade House, had epilepsy and experienced seizures

The NHS unit where an Oxford teenager died has been described at an inquest as "chaotic" by a senior staff member.

Connor Sparrowhawk, 18, drowned in the bath after an epileptic seizure at Slade House, in Headington, Oxfordshire, in July 2013.

Dr Valerie Murphy told an inquest jury there was "immense pressure" on staff at the time he died.

Patients' needs were challenging and there was increased pressure to fill beds, she said.

Staff were also worried about their jobs following a recent takeover by Southern Health NHS Foundation Trust, the inquest at Oxford Coroner's Court heard.

Speaking about Connor's death, consultant psychiatrist Dr Murphy told the court: "I think about it every day, it was tragic beyond words that a young man lost his life and I'm sorry for that."

Connor, who had learning disabilities and epilepsy, was admitted to Slade House in March 2013 after his behaviour became aggressive.

'Missed opportunity'

On 4 July 2013, he was left alone in the bath and 15 to 20 minutes after last being checked was found under the water not breathing.

A post-mortem examination concluded he drowned after an epileptic seizure.

Six weeks prior to his death, Connor's mother Dr Sara Ryan emailed staff to say she thought Connor had experienced a seizure and bitten his tongue, the inquest heard.

Dr Murphy told the jury she did not believe that was the case and a decision was made at a team meeting to reduce Connor's observations from every 10 minutes to once an hour.

An independent report into his death, commissioned by Southern Health, said this was a "missed opportunity".

Shortly after Connor died Care Quality Commission inspectors entered the unit and concluded "care and treatment was not consistently planned and delivered" and "the provider did not have an effective system in place to identify and manage risks to health, safety and welfare".

The inquest also heard from Ben Morris, the then manager of the unit, who agreed the findings were fair.

The hearing continues.