Connor Sparrowhawk – or Laughing Boy, LB, as his mum called  him on her blog – died in the ‘care’ of Southern Health NHS Foundation Trust at their Short-Term Assessment and Treatment Team (STATT) unit on 4 July 2013. That is, an 18-year-old died  whilst in an institution specifically designed, commissioned and paid to support him and keep him safe.
An independent inquiry by Verita into Connor’s death was published on 24 February 2014.
The conclusion of the independent inquiry is unambiguous:
“We conclude that the death of [Connor] was preventable… We found two broad areas where [Connor’s] care and treatment had failed significantly: his epilepsy care and the overall care provided by the unit.
“The failure of staff at the unit to respond to and appropriately profile and risk assess [Connor’s] epilepsy led to a series of poor decisions around his care – in particular the agreement to undertake 15-minute observations of his baths. The level of observations in place at bath time was unsafe and failed to safeguard [Connor].
“… The unit lacked effective clinical leadership and they operated a team-based approach in which no individual/s held the responsibility for ensuring that the care and management of [Connor] was appropriate and coordinated effectively. The impact of this was that standalone key safety decisions such as those pertaining to bath time observations were not validated by other professional colleagues.”
Within this inquiry’s findings there are so, so many issues and questions about the ‘care’ that Southern Health ‘provided’. These have been highlighted and explored already by others, including @GeorgeJulian, @thesmallplaces, and @indigo_jo.
In the rest of this post are shared some reflections on themes of this tragedy  that stand out for me. Throughout, it is vital to remember that this was a unit for a maximum of seven in-patients and there were five at STATT at the time Connor was there.
Southern Health demonstrated a complete lack of understanding of epilepsy.
Ask a layperson about epilepsy and they’ll mention “fits” or “seizures” and talk about driving and baths. Look at the most basic guidance from organisations like NICE or Epilepsy Action and they will tell you “around one in every four people with epilepsy has learning disabilities [and] half of all people with learning disabilities has epilepsy”.
And yet Southern Health observed Connor less frequently in the bath (every 15 minutes) than when he was just around the unit (every 10 minutes). There was no record about why 15-minute observations were considered to be appropriate. The practice that Southern Health had written down was unsafe – e.g. waiting 10 minutes to contact emergency services if Connor experience a seizure, when NHS advises this should be no more than 5 minutes. They ran out of epilepsy medicine on 30 March. Only 3 of 17 members of unit had had epilepsy training between October 2010 and August 2013. Worse, S11, who undertook one of the first risk assessments of Connor when he was admitted to the STATT, had attended epilepsy training on 13 February 2013 (paragraph 6.76), i.e. just five weeks before Connor was admitted to the STATT.
There was a complete lack of engagement with Connor’s epilepsy and its relevance to his presence at the unit. There was no epilepsy profile, no medical review, no comprehensive care plan, no epilepsy pathway in operation in Oxford, and epilepsy was not part of Connor’s risk assessment. It was known that Connor enjoyed taking long baths, but yet no specific risk assessment was undertaken on this topic.
There was contradictory information about whether Connor had recently had a seizure. In parts of their ‘care’ of him, Southern Health thought he was seizure free, and yet had done at least two things that indicated they thought he had had a seizure whilst at the unit (epilepsy sensors and moving Connor to a downstairs bedroom).
Staff and ‘leadership’
One (S14), possible two (S14 and S5) could be seen to have been doing their job and possibly something beyond that during Connor’s time at the unit. Everyone else was not just not doing their jobs, but actively seeming to not be doing it. In concluding that Connor’s death was preventable, Verita note that staff at the unit had both the knowledge (paragraphs 6.81-6.83) and the opportunity (paragraph 6.84) to stop his death happening.
Consider the sheer number of people involved in Connor’s ‘care’, and yet no comprehensive assessment or plan was put in place. At a short-term treatment and assessment unit, there was nothing short-term about it, there was little treatment beyond medication and there was insufficient assessment done 
There was no clinical leadership at the unit – not just relating to Connor (though this is obviously most important in this case) but to everyone. There is no identifiable responsibility, accountability or professional conduct.
S1 and S3 are particularly shameful in their behavior .
Paragraphs 6.45-6.46 demonstrate, in S1, someone who takes absolutely no personal responsibility for what happened.
“What I’m telling you is yes, I was involved at that time, yes, I had knowledge of all those development, yes, I was party to those conversations, but it’s not the case that at any point in that particular instance I was required to say well I think this…”
Paragraph 9.24 sees S1 sharing more thoughts on what they thought their responsibilities weren’t:
“What you’re asking me is if there is any central document where everything is put together; I don’t do that. I don’t sit down and write an entire document about what every other professional is doing because that wouldn’t be appropriate for me to do.”
Finally, paragraph 9.36 shows the pressures S1 was working under:
“It certainly threw me. It threw me out of my stride, I didn’t know what was happening and it took me a while to recover from it.”
This, remarkably, is S1’s description of a CPA meeting that didn’t follow the “set format”. (S4 shared S1’s disquiet: “[I]t seemed that this was becoming a person-centred meeting” (paragraph 9.41). Heaven forfend!)
Actually, what these quotes show is senior clinical leaders who have no grasp of anything happening within their own unit.
S3 – whose engagement with the whole situation is an embarrassment to any professional and, frankly, negligent (see “engagement with the family” below) – didn’t follow up on basic actions agreed at the Clinical Team Meeting of 24 June (paragraphs 8.8 and 8.9).
Finally , Connor probably should never have been at the unit in the first place; what’s worse, at least two professionals – our friends S1 and S3 again – thought he should have been discharged but took no personal responsibility, despite being in positions of authority, to do so (paragraphs 10.8 , 10.9 and 10.16). Page 81 of the report is the first place where any mention of Connor’s possible discharge from the unit is mentioned.
As Verita’s report finds (F19):
“The unit lacked clinical leadership, in particular from S1 and S3.” 
(See also @ChrisHattonCEDR’s post on Bystander Apathy).
Engagement with the family
The first mention of Winterbourne View  in the report relates to the Department of Health’s report into that scandal, noting that “families were often not involved” in the care of their family members, and that this “is sadly a common experience and totally unacceptable” (paragraph 7.2).
Southern Health’s staff didn’t just not engage with Connor’s family; the report indicates they actively chose not to engage with them. For example, “Trust staff had little or no prior knowledge of [Connor], so they should have found out more about his family’s understanding of his needs” (comment after paragraph 7.11). Furthermore, there was “no evidence that the experience and knowledge of [Connor’s] parents were captured at the beginning of his admission or included as part of his risk assessment and care plan” (F13).
Actually, Southern Health staff’s approach to the family was adversarial. Read in paragraphs 7.17-7.18 how S3 talked to the family about whether they could visit or not; read in paragraph 7.19 what S3 had to say when Connor’s younger brother wanted to visit the person he’d shared a room with for his whole life; read in paragraph 7.20 how a member of staff lied directly to Connor’s parents about whether Connor wanted them to visit; read also in paragraph 7.20 how S3 thought (a) it was reasonable to put am 18-year-old to bed at 7pm and (b) contradict their own unit’s visiting hours in order to deliberately prevent Connor’s parents from seeing their son; read in paragraph 7.31 how S3 reduced an experience Special Educational Needs teacher to a distressed state through their interrogations.
But this isn’t just a question of tone. The most crushing element of the impact of unit’s staff deliberately sidelining Connor’s parents is paragraph 6.60 – that Connor’s family would “supervise him, keeping the door open and talking to him” when he was in the bath; that there was “no evidence that staff knew about the way [Connor’s] parents supervised his bathing”. That staff had no idea how his parents had kept him safe to date .
Where to start with Southern Health as an organisation? Let us begin with what the Verita report has to say directly.
Paragraph 2.4 notes that Southern Health has a range of policies and guidelines that provide the framework within which their ‘care’ is provided. Throughout – see paragraphs 5.29, 5.32, 5.56, 5.60, 5.70, 6.3-6.5, 6.13, 6.17, 6.29, 7.5, 8.11, 9.20 – we see that this paperwork was only that, paperwork.
Staff interviewed by Verita, as part of an inquiry into the death of someone in their ‘care’, hadn’t been given relevant paperwork, such as the guide for interviewees and the terms of reference, before their interview. This is surprising, because events during the Inquiry (on which more later) would suggest that Southern Health’s main concern in the inquiry phase was its own reputation and protecting its staff.
Most damagingly, Verita received “substantial additional documents” relating to the review (paragraph 4.9) on Weds 19 Feb – less than three working days before the report was published, after the draft report had been sent to Southern Health, all relevant people and Connor’s family. What were these documents? Why were they sent only then? (See FOI request later)
(We must also ask: where are commissioners? The only mention I can see in the report of local authority commissioners is in paragraph 11.15; no mention I can see is made of the relevant Clinical Commissioning Group (CCG).)
Now let us consider what the statutory regulator of health and social care services had to say of Southern Health.
The Care Quality Commission visited the STATT Unit on 16, 17 and 23 September 2013, two months after Connor died. Their first inspection found that the Unit was not compliant in any of the 10 standards. Of the 10, six had enforcement action taken, including on (a) Care and welfare of people; (b) Assessing and monitoring the quality of service provision; and (c) Records.
The inspection report notes the following:
People did not always experience assessment, care, treatment and support
Remember, this is in an assessment and treatment unit.
“Whilst we were there, up to four staff mainly worked on administrative tasks within their office… There appeared to be an impoverished environment with little therapeutic intervention of meaningful activities to do.
Assessment and Treatment Units cost, on average, £3,500 per person per week.
[T]he emergency oxygen was significantly out of date… We inspected the emergency equipment [the defibrillator and oxygen cylinder], and found some of it wasn’t working.
The equipment wasn’t working because there was no battery in the defibrillator, and the oxygen cylinder was out-of-date. Remember, this is two months after someone had died at the unit in circumstances that are likely to have required both a defibrillator and oxygen.
Whilst much audit work was undertaken, there was little that impacted positively and directly on the care of the people that were being looked after on the STATT unit.
The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of people using the service[.]
Again, remember this is two months after a lack of appropriate risk management led to a preventable death at the unit.
By 16 December, a follow-up inspection by the CQC found three of the areas that required enforcement action had met the standard. These were (a) Cleanliness and infection control; (b) Safety and suitability of premises; and (c) Safety, availability and suitability of equipment. I.e. those actions that required practical changes only, rather than cultural or attitudinal ones
All CQC reports on STATT can be found here.
Verita should be congratulated on an excellent and rigorous independent report into the circumstances of Connor’s death. People familiar with the language of Serious Case Reviews and similar inquiries will note the obvious difficulties that Verita had with Southern Health in bringing together this report. For example, paragraph 1.12 notes they were “directed by the trust” to put in place anonymisation in the report that “makes it difficult to read”. Similarly, paragraph 4.2 notes that some interviewees for the report didn’t receive relevant paperwork before they were interviewed.
Questions, questions and Freedom of Information
Verita’s report covers the period until 4 July 2013. Notwithstanding any criminal investigation by the police, any professional standards investigation by any representative body, or any Southern Health staff disciplinary proceedings , in my view, there is need for a second inquiry into Southern Health’s actions after 4 July, inquiring into a range of issues. Those issues include, but aren’t limited to:
- Their initial response to Connor’s death
- The steps they have taken with regard to staff involved in the unit
- Their relationship with organisations that commission their services
- Their engagement with Connor’s family following his death
- Their actions in relation to the commissioning, interviewing, drafting and publication (including permission to publish) of Verita’s independent inquiry
- Information relating to any public relations or communications advice they have received since 4 July.
Freedom of Information requests will be submitted to Southern Health to explore these issues.
(For more information about #justiceforLB, the summary is here and all information and reaction on Twitter is channeled through @JusticeforLB.)
These additional notes have been separated from the main body of the post above because they are personal reflections only.
 – Past tense. In the minutiae of the death of a loved one, these small things are, to me, the most terrible. I will be able to kiss my children tonight, to speak with them. These opportunities have been taken away from Connor’s family.
 – When does “died” become “manslaughter” becomes “killed”?
 – “Tragedy” implies something inevitable. We know what happened to Connor, as we know what has happened to hundreds of people who have died by indifference in ‘care’ settings before. What, therefore, of calamity, devastation, evasion, abandonment, dereliction, neglect, crime?
 – STATT didn’t do what it said on the tin. It did nothing.
 – Collective noun for staff at Southern Health: “An abandon of S’s”.
 – What if? what if…
 – What disciplinary action will S1 and S3 face? Will they be referred to their professional bodies?
 – “Post-Winterbourne”. We’re not post- anything.
 – What of those people who don’t have family, or advocates, or people who can look out for them, and speak for them if they wish? What of them?
 – Yeah, I know.
 – What could “justice” possibly mean?