Inquest verdict – Connor’s death was contributed to by neglect

Connor was a much loved son, brother, family member and friend who loved buses, London, Eddie Stobart and speaking his mind. Connor had autism, a learning disability and like 1 in 4 people with learning disabilities he also had epilepsy. On 19 March 2013 he was admitted to the Short Term Assessment and Treatment Team Unit (STATT) run by Southern Health NHS Foundation Trust. 107 days later, on 4 July 2013 he drowned in the bath as a result of an epileptic seizure.

After a wait of over two years, the inquest concluded today with the jury finding that Connor’s death was contributed to by neglect.

The jury reaching their conclusion noted serious failures in his care, including:

  • Lack of clinical leadership on the STATT unit
  • Failure in the systems in place in relation to training and guidance
  • Failure to obtain a history and conduct a risk assessment
  • Inadequate communication with Connor’s family and between staff in relation to Connor’s epilepsy needs and risk
  • Epilepsy toolkit was not provided to staff on STATT despite being available
  • Too few staff were trained in epilepsy on the unit and the training was too limited and insufficient
  • There were errors and omissions made in Connor’s care once admitted to the STATT unit in relation to bathing arrangements
  • There was a lack of communication with Connor’s family whist he was in the unit and missed opportunities
  • Clinical team failed to identify the absence of an epilepsy risk assessment plan.

An independent investigation published in February 2014 found Connor’s death was preventable and there were significant failings in epilepsy management and clinical leadership.

Two months after Connor’s death, an unannounced inspection by the regulator, the Care Quality Commission, found that the unit had failed to meet all of the 10 key safety and quality standards which were the subject of inspection, including respecting and involving people who use services. The STATT unit was subsequently closed down.

The family are still awaiting the final outcome of an independent review of all mental health and learning disability deaths at Southern Health NHS Foundation Trust, after they raised serious concerns as to the adequacy of the Trust’s internal investigation system and responses to deaths.

Charlotte Haworth Hird, solicitor for the family said:

This outcome properly reflects how badly Connor was failed and the wholly inadequate care that he received. The jury’s damning conclusion is testament to the commitment of his family, friends and the JusticeforLB campaign to obtaining the truth. They have been forced to fight for this and should not have had to have to. Connor should not have died. Southern Health and the NHS have a responsibility to ensure that this never happens again and that there are radical improvements in support and care provision provided to individuals with learning disabilities and their families.”

Deborah Coles, Co-Director of INQUEST, who have supported the family throughout, says:

“This inquest provided shocking insight into the neglect of a vulnerable teenager failed by those who should have been there to protect him.

This was a death initially dismissed by the NHS Trust as ‘natural causes’ and not subject to independent investigation. Were it not for the determination and tenacity of the family and their legal representation the truth about this preventable death may not have emerged.

The majority of similar deaths continue to be investigated by the very organisations which may have caused or contributed to the death. The lack of an automatic independent investigation is failing families and failing to protect those in state care. Faced with the damning jury finding NHS England must urgently review the way such deaths are investigated and the high number of deaths of people with learning disabilities. Connor and his family deserve nothing less so that future deaths and ill treatment are prevented.”

Paul Scarrott of Oxfordshire self-advocacy organisation My Life My Choice said:

“I hope that Southern Health learn from the mistakes of what they have done.”

The Coroner will be issuing a Prevention of Future Deaths report.

Statement of Connor Sparrowhawk’s family

“Two years and 7 months ago, our gentle, quirky, hilarious and beyond loved son (brother, grandson, nephew, cousin) was admitted to a short term assessment and treatment unit, STATT, run by Southern Health NHS Foundation Trust. Connor, also known as Laughing Boy or LB, loved buses, Eddie Stobart, watching the Mighty Boosh, lying in the sunshine and eating cake. He was 18 years old.

The care Connor received in the STATT unit was of an unacceptable standard. The introduction of new medication led to increasing seizure activity on the unit, a fact denied by the consultant psychiatrist for reasons only known to her. Connor was allowed to bathe unsupervised and drowned, 107 days later.

Connor’s death was fully preventable. Over the past two weeks we have heard some harrowing accounts of the care provided to Connor. We have also heard some heartfelt apologies and some staff taking responsibility for their actions for which we are grateful. During the inquest, eight legal teams (seven of whom we understand are publicly funded) have examined what happened in minute detail. We have had to fundraise for our legal representation.

Since Connor’s death, Southern Health NHS Foundation Trust have consistently tried to duck responsibility, focusing more on their reputation than the intense pain and distress they caused (and continue to cause us). It has been a long and tortuous battle to get this far and even during the inquest, the Trust continued to disclose new information, including the death of another patient in the same bath in 2006. Families should not have to fight for justice and accountability from the NHS.

We would like to thank everyone who has supported the campaign for JusticeforLB, and hope that the spotlight that has been shone onto the careless and inhumane treatment of learning disabled people leads to actual (and not just relentlessly talked about) change. It is too late for our beautiful boy but the treatment of learning disabled people more widely should be a matter of national concern.”


23 responses to “Inquest verdict – Connor’s death was contributed to by neglect”

  1. Lawraine Hails says:

    Bittersweet victory for your beautiful son, you and your family. Feeling mixed emotions jumping for joy that you’ve won this victory ..yet angry at the horrible system that caused his death! You and the family have been put through turmoil and your strength and dignity shone tnroughI’m pleased you’ve won hugs Lawraine

  2. Geoff Elliott says:

    Your strength and determination do you so much credit. Your fight for justice for LB will hopefully mean that his legacy is lasting change and that a preventable tragedy of this type can never happen again.

  3. Barbara says:

    Such a sad tale! And one that is sadly repeated by poor care! I do hope this outcome will give the family some closure and peace. But have no idea how one can move on positively from such a traumatic outcome. Poor LB – he should have been shown kindness and understanding and had a level of care that was needed to make his life a happy one. Too sad! Sat in tears!

  4. Yvonne smith says:

    My heart goes out to LB family and friends….I hope this story isn’t soon forgotten and people act on it…

  5. Craig Dennis says:

    Your determination for justice for your loving son has been an inspiration for so many and has touched a huge number of people previously unaware of such shortfalls and now actively engaging to fight against it happening to other vulnerable patients. That legacy is scant solace for the lose of your beloved son. Your integrity under immense duress from those ‘Carers’ has been a model for any parent fighting for their child in such horrific circumstances, it shouldn’t have been required in the first place. I can only hope that your vindication provides some comfort. My thoughts are with you.

  6. Cindy says:

    My heart goes out to you, my son is the same age. Huge respect for fighting to get the justice your son deserves. If parents fought like you every time, perhaps we could go some way to improving the sub standard care our young people are often subjected to. RIP LB.xx

  7. Simon Carr says:

    I’m glad that today you have finally been able to achieve justice in this. Nothing can bring back Connor, but your tenacity in fighting for justice against Southern Health is testament to how much Laughing Boy meant to you all, and how he was let down by the health service that should have been there to care for him, and for you.
    I hope this enables you all to move forwards in your lives once again.

  8. lori says:

    Thank you. Thank you for fighting thank you for being strong thank you for being the family who will stop others going through the he’ll you have been put through. Love and respect

  9. Audrey O'Keefe says:

    Bittersweet victory – Everyone could see your pain but you carried on fighting for Justice and Recognition for your wonderful LB ”the dude” I admire your courage through such a challenging time.

    ….. and as for the other lot – this was not about LB but about Southern Health NHS Foundation Trust safeguarding themselves and trying to control the situation – Southern Health NHS Foundation Trust are worthless – beneath consideration, I hold them in contempt.

    Solitary as always from Liverpool

    #JusticeforLB ‘The Cool Dude’ xxxx

  10. Lizzie D says:

    Heartfelt thanks for your courage and tenacity in this horrible process. It could have been any of us, but you have been an example to us. I am so very sorry that you have had to go through this, and live the nightmare we all fear.

  11. Pam says:

    I echo all the comments above. I’ve followed the whole wretched unforgivable events throughout.
    Could so easily have been my son but I’m no Sara Ryan although she and the justice shed have taught me so much. I remind others of Connor whenever I can and shall continue to do so. I can’t see a london bus or Eddie Stobart truck without thinking of him and the great stories I’ve read about him.thank you for your tenacity and sheer determination in raising awareness for those who need others to do just that. You must all be exhausted but I hope with a sense of pride in the achievement…. LB was so loved by you and now by so many who never met him but so wished they had. Thanks to all involved.

  12. Sally says:

    Thank you. Thank you for fighting so hard for LB and for all the others, even in the middle of your awful grief.Thank you for your grace and humour even when you were being attacked and attacked. Thank you for speaking for your son and for all the others, my son included, who cannot speak for themselves.
    We couldn’t leave messages and we couldn’t speak to you while the inquest was going on, but we were all thinking of you and following it helplessly all the way.
    I am so angry at the weasel words still burbling forth from the Sloven CEO and others.

  13. Ali Gardner says:

    You should never have been there to do what you did but there are many individuals and families who are glad that you stood up for justice. Your work is not the end of it and has touched so many people. I promise to teach every social work student who passes through my university what happened to LB

  14. Sharon Kite says:

    I live in Ottawa, Canada. I have just learned of your family tragedy and I’m so sorry for your terrible loss. I admire your unwaiving determination to get a thorough investigation to expose the truth, despite the veil of secrecy and denial by certain individuals within the SH NHS FT. No family should have to go through the nightmare that you lived through, due to the incompetence of health care providers under the umbrella of the NHS, who are there to serve and protect the public in their care…and are fully accountable for their actions. Through your huge love for Connor and your courage, his and your personal story will go down in history as a Torch of Justice and hope…a guiding light, for those who may find themselves living similar experiences. Much love xxx

  15. Tricia says:

    Please can you share information on how we can donate towards your legal fees. We do admire the strength and perseverance you and your family have shown and so glad the truth came out. Hoping it will benefit all.

  16. Julie Newcombe says:

    Now is the time for senior management at Southern Health to stand up and shoulder the blame for this shambles of a service that they created. If they continue to avoid this responsibility, then their already shattered reputation should never recover. They are only kidding themselves now.

  17. Kat says:

    Biggest thank you to the family and all involved in working tirelessly during an unimaginably hard time to campaign for all with learning disabilities. LB’s legacy will continue to change lives for better.
    My thoughts are with you Connor and family.

  18. Becky Fish says:

    This will change everything. It is terrible that you have had to do this, and the hell that you have been through, but your courage will save many lives in future. Thoughts with you all.

  19. PAUL DAVIES says:

    This could have been a story told by any of us who love and care for our autistic children. Your courage and determination that this story should and would be told humbles us and we thank you.

  20. Danuta Gillespie says:


  21. Melanie Rimmer says:

    I agree with Paul. When I first heard about LB I could see so many parallels with my own family. I could easily and vividly imagine this happening to us. The way the authorities behaved enraged me. His family have behaved with more dignity and composure than I could have summoned. I hope this decision begins to bring them some peace.

  22. Avril Osbourn says:

    So sorry for your terrible loss, and thank you for persevering in such difficult circumstances to bring this terrible tradegy, and disgraceful neglect to light, it must have been very hard to take this through court, and have to listen to what your darling son went through, in a place we should be able to trust 100%. Please take comfort in knowing you will have helped others, and most likely saved lives. I hope and pray you can get comfort and peace now

  23. […] the conclusion that we’d always known was true from the start. LB’s family issued a statement at the end of the inquest that […]

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