Tuesday morning brought fresh shock to the family of Connor Sparrowhawk, a quirky, funny young man who drowned following a seizure in a bath at an NHS facility nearly three years ago.

On Tuesday Connor’s mother, Sara Ryan, received a copy of a leaked NHS document, dated August 2012, that noted failings at the facility, failings that might have set alarm bells ringing a full 10 months before Connor’s death.

Late last year an inquest jury at Oxford Coroner’s court determined that Connor, who had learning disabilities and epilepsy, had drowned following a seizure in the bath at the Southern Health NHS Trust unit knows as STATT (short-term assessment and treatment team) in Slade House, at Headington, near Oxford. He was 18 years old.

The jury said that Connor’s death, on 4 July 2013, had been “contributed to by neglect”, that there was a lack of training and leadership at the unit and poor communication between staff and the family.

Connor was known to be epileptic, and his mother had warned staff — in writing — that he had an injury to his tongue that suggested a recent seizure. Yet Connor was allowed to bathe unsupervised and behind a closed door. (A support worker at Connor’s inquest said she used a key to open the door which suggests it was locked.)

Connor with his stepdad, Rich, and brothers Owen and Tom 2 weeks before his death (Sara Ryan)

The document leaked this week, dated 22nd August 2012 and headed “Quality and Safety Review Update”, suggests that Southern Health NHS Foundation was aware of failings at the unit 10 months before Connor died and three months before they officially took over the provision in November 2012.

Among detailed criticisms of the short term assessment unit, the document notes a “lack of clarity” in patient care plans. It was “difficult to track care for patients, identify the reason for admission”.

Extracts from document dated 22 August 2012The move of information onto an electronic record system (known as RiO) was “limited”. The document identified “a gap between what is up to date in paper form and what is now being recorded on the RiO.”

(Or rather, it noted: there “seems to be a gap”. Either there was or there wasn’t a gap. The lack of clarity and rigour in the document itself is revealing).

Clinical team meetings, held each week, lacked information. Staff were aware that there had been an audit of care plans on the RiO system, but “they were not aware of any results or action plans to make improvements”.

There were concerns about cleanliness, maintenance and repairs, particularly in the bathrooms “where floors, tiles and units are worn or damaged.” And: “Some items such as broken floor tiles would represent a risk, particularly if a patient might self harm.”

Connor’s brother Tom, now 16 years old, read the leaked document on Tuesday. He said: “This latest news is really sad. It’s not like they were crap because they didn’t check what they were doing. They checked and they didn’t care.”

Connor and his brother Tom (Sara Ryan)

This is only the latest in a series of shocking discoveries for Connor’s family, who were initially informed by Southern Health that he had died of “natural causes”.

Connor’s mother Sara Ryan has recorded on her blog that during the inquest “the big shocker (and there were several)” was the revelation on Day 4 that a patient had died in 2006 in the same bath in which Connor drowned.

Ryan wrote: “The Responsible Clinician let it be known, through her counsel, that she had been actively discouraged by members of . .  senior management from raising the issue of this earlier death. In the same bath . . . Ground spinning stuff.”

In the aftermath of Connor’s death, and in response to his family’s relentless campaigning, NHS England commissioned an audit of deaths at Southern Health from the audit, tax and advisory firm Mazars.

Their report, published in December last year (there’s a PDF here), found that Southern had failed to investigate hundreds of unexpected deaths, and that the likelihood of a death being investigated depended heavily on the patient’s profile. Deaths of learning disabled people were least likely to be investigated. When investigations were carried out, said Mazars: “There was a very poor quality of written investigations at all stages.”

Mazars wrote: “A culture across the Trust has developed that means there was an absence of mortality review in Mental Health and Learning Disability which results in lost learning, a lack of transparency when care and delivery problems occur as well as a lack of assurance to families and commissioners that a death was not avoidable and has been properly investigated.”

The morning after Connor’s death, according to an internal document dated 5 July 2013, Southern Health took the trouble to note “potential media interest” in the incident. That document holds yet another disturbing revelation. The Trust that so thoroughly failed to safeguard Connor Sparrowhawk had, for months, devoted time and resources to monitoring his mother’s blog.

Notes

• • Sara Ryan blogged throughout Connor’s time at Slade House and has continued to do so since Connor’s death. Here is her blog.
• • Connor Sparrowhawk’s family is supported by the charity INQUEST, and represented by INQUEST Lawyers Group member Charlotte Haworth of Bindmans solicitors.
• • Details of the Care Quality Commission inspection report of November 2013 can be found here.
• • The Verita report, commissioned by Southern Health NHS Foundation Trust, which confirms that Connor’s death could have been prevented, can be found here, along with a statement of regret from Southern Health’s chief executive Katrina Percy. (February 2014)
• • The Mazars review: Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015 PDF here. (December 2016)