Connor Sparrowhawk death: 'poor practice' highlighted in report

A post-mortem examination concluded Connor Sparrowhawk drowned after an epileptic seizure

Failures in the care of a teenager who drowned in a care unit were due to "poor practice by clinical staff", an NHS-commissioned report has found.

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

The report also also identified "deficiencies" following organisational change in 2012.

Southern Health NHS Foundation Trust said changes had been made since Connor's death.

On 4 July 2013, Connor was discovered submerged and unresponsive in a bath at the learning disability unit, which has since been closed.

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

An inquest in Oxford last week concluded neglect contributed to Connor's death.

The jury concluded there were "serious failings" by the trust, including those concerning with checking him while bathing.

'Not work effectively'

The second independent report by consultants Verita into Connor's death was jointly commissioned by NHS England South and Oxfordshire Safeguarding Adults Board.

It echoed the earlier report that clinical staff "failed to carry out procedures and processes that were their responsibility and within the competence and knowledge expected of registered health professionals".

"Principally, clinical staff did not work effectively together and follow NICE guidelines regarding the care of individuals with epilepsy," it said.

The report said the failings were not caused by managers or commissioners.

It also highlighted issues with the takeover of the Ridgeway Partnership by Southern Health NHS Foundation Trust in 2012.

Authors said staff in the smaller learning disability service were not supported when they joined the larger organisation, based in Hampshire.

Following the publication of the Verita report, trust chief executive Katrina Percy repeated her apology to Connor's family for his "preventable" death.

"In the two years since he died we have made many changes to the way we provide services for people with learning disabilities.

"The experiences of Connor's family have brought into sharp focus the need to engage more effectively with patients, their families and carers, learning from their experience and expertise and involving them in every decision concerning care."

She said the trust now had a "intensive support team", had strengthened its clinical leadership and introduced mandatory comprehensive epilepsy training for staff caring for people with learning disabilities.