Independent review into issues that may have contributed to the preventable death of Connor Sparrowhawk

The inquest into the death of Connor Sparrowhawk found that his death was contributed to by neglect and very serious failings in systems and care provided by Southern Health NHS Foundation Trust. This report by Verita provides more evidence of these failings. 

We are surprised that the errors and mistakes detailed within this report did not constitute evidence for the investigators to find a direct causal link to Connor’s death. 

We consider that the senior management at Southern Health neglected to act on the information collected during the due diligence process they engaged with when taking over Ridgeway Trust. Southern Health failed to manage the integration of the Ridgeway services or staff with the CEO, Katrina Percy, insisting on moving immediately to a ‘business as usual’ approach, despite knowing that the two key staff members involved would not be in post once the transfer was complete. 

We believe that the poor attention to detail in post-acquisiton phase, poor communication, poor epilepsy policies and guidance and the absence of any meaningful leadership must have directly contributed to Connor’s ‘care’ and ultimately his death. A view fully supported by the jury at his inquest. 

We await the final outcome of an independent review of all mental health and learning disability deaths at Southern Health NHS Foundation Trust, commissioned after we raised serious concerns as to the adequacy of the Trust’s internal investigation system and responses to deaths.

We request that the report’s authors and commissioners reconsider their conclusions in the light of the unanimous jury findings.

You can read the full jury verdict here

Dr George Julian, the family’s lay representative on this investigation says: 

“Having been involved with this process from the beginning I am unable to accept and support the conclusions drawn by the investigators. I consider that the evidence collected and the findings presented in the report clearly indicate that Southern Health had information available to them, that they failed to act upon. This failure to act appropriately on what was known, the lack of leadership, and the poor communications once Southern Health acquired Ridgeway, combined with the passive absence of Oxfordshire County Council commissioners, led to a situation that cost Connor Sparrowhawk his life.”

Bill Love, the second lay representative, has written to the investigators supporting some of the process findings and disagreeing with the final conclusions. 

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