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This article was published in March 2014. The information may be out of date. Please check our epilepsy information or our site A-Z.

Preventable death points to poor care

26 Mar 2014

Connor Sparrowhawk died of drowning as a result of a seizure in a bath. His death has sparked outrage after an investigation tested his care home against 10 criteria – and it failed on every one

Connor was 18 years old and had active epilepsy and learning disabilities. He was an inpatient at Slade House, run by Southern Health NHS Foundation Trust in Headlington, Oxford.

Staff at the unit were made aware of Connor’s epilepsy. They knew he had experienced a seizure two months before his admission in March last year. Unfortunately, no care plan was in place just for Connor’s epilepsy. It was only mentioned in one section of his overall care plan. The existing plan specified that he should be checked on every 15 minutes while taking a bath.

Unfortunately, this was not enough to ensure Connor’s safety. On 4 July 2013, he was found in a bath under the water. He was then rushed to hospital, where he died shortly afterwards. Connor died of drowning, most likely as the result of a seizure while in the bath.

Serious shortcomings

What followed reflected very badly on the standards of care at Slade House and caused outrage at Connor’s death. An investigation was carried out by an independent company called Verita. This was followed by an investigation of Slade House by the Care Quality Commission (CQC). Neither returned positive results.

The Verita report pointed out that checking on Connor every 15 minutes while in the bath was unsafe for someone with active epilepsy. Unfortunately, no risk assessments had been done generally for Connor’s epilepsy or specifically on his bathing. This fact was said to be the direct cause of his death. According to the report, it would have been preventable if only a better process had kept him safe while in the bath.

A bathThe report also showed that Connor had had a suspected seizure in May last year, while he was in care at Slade House. This event may have led to a review of Connor’s care and better monitoring of his epilepsy. The opportunity was missed, however.

The CQC investigation assessed the quality of care offered at Slade House against 10 quality standards. The unit failed to meet even one of these standards. Slade House was then forced to close to all new admissions and was issued with six warning notices to make improvements at the facility.

After an inspection at the end of 2013, improvements had been made in the three areas, with other areas to be looked at in the near future. The facility has been quick to point out these improvements. However, some people have quickly pointed out that the three areas that had improved were all environmental standards – not patient care.

A shock for the family

Katrina Percy is chief executive of Southern Health NHS Foundation Trust. In a statement on the Verita report, she said: “I am deeply sorry that Connor died whilst in our care and that we failed to undertake the necessary actions required to keep him safe. We are wholly committed to learning from this tragedy in order to prevent it from happening again and I would like to apologise unreservedly to Connor’s family.”

Despite the apology, Connor’s mum Sara Ryan is still angry. In a BBC news report, Sara asked that people read the report into Connor’s death and “remember that Southern Health were quick to write Connor’s death off as natural causes”.

Sara continued: “He should never have died and the appalling inadequacy of the care he received should not be possible in the NHS.”

Connor’s death highlights the importance of effective care planning for epilepsy. Epilepsy Action’s A Critical Time for epilepsy in England report was published in January 2013. The report highlights the fact that only 14 per cent of the people with epilepsy surveyed had a written care plan.

In 2012, Epilepsy Action worked with the former Strategic Health Authority for Yorkshire and the Humber to develop an electronic Epilepsy Care Plan (ECP). The ECP is a software template that is now being directly used in one of the major medical computer systems, SystmOne.

Meanwhile, Greg Rogers is Epilepsy Champion for the Royal College of General Practitioners. Following the publication of A Critical Time for epilepsy in England, Epilepsy Action worked closely with Dr Rogers and epilepsy specialist nurses to develop a paper care plan. This document is available to download or from epilepsy specialist nurses. You can fill it in yourself and take it along to consultations.

 

 

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