Connor Sparrowhawk (known as Laughing Boy, or LB) drowned in the bath in an NHS Assessment and Treatment Unit (Slade House) in Oxford on 4.7.13. He was 18 and diagnosed with epilepsy and autism. The specialist learning disability unit, run by the Hampshire based Southern Health NHS Foundation Trust (Sloven), had four members of staff on duty 24 hours a day and 5 patients. It was jointly commissioned by Oxfordshire Clinical Commissioning Group (OCCG) and Oxfordshire County Council (OCC). LB was admitted to the unit after becoming anxious and unpredictable. He died 107days later.
A 15 minute film, to find out more about LB, what happened to him and our subsequent campaign for justice, can be seen here:
You can read earlier (funny) posts about LB from about here, pressing ‘next’ in the top right hand corner.
Two months after LB’s death, an unannounced Care Quality Commission inspection of Slade House found the unit to be inadequate in all 10 measures of assessment. Enforcement notices were issued and it has since closed. Other learning disability provision run by Sloven in Oxfordshire also received CQC enforcement notices and their Oxfordshire contract won’t be renewed this year. [Andrew Smith, MP, is currently campaigning to stop Sloven selling the Slade House site and keeping the loot. He is joined in this campaign by local self advocacy group, My Life My Choice].
In Feb 14 an independent report by Verita, commissioned by Sloven after a considerable fight by us, found his death was preventable. It was the outcome of a combination of poor leadership and poor care in the unit.
A police investigation continues into LB’s death alongside a Health and Safety Executive investigation. The police investigation was closed in August 2015. Sloven staff have been referred to the General Medical Council and the Nursing Midwifery Council and remain under investigation. The responsible clinician was suspended for 12 months and was then let back to practice in part because ‘‘At the time of these events you were a young consultant in the difficult field of adult learning difficulties”. A full account of the holes in the panel decision can be found here. After giving evidence at the tribunal, I ended up having nearly 6 months off work due to ill health. I captured this experience in Writing Trauma.
A broader review, commissioned by NHS England and the Oxfordshire Adult Safeguarding Board is underway, again conducted by Verita. This review looked at national, regional and local issues around learning disability provision and what happened to LB. It sank without a trace in October after bizarre findings. NHS England have also commissioned Mazars to investigate Sloven responses to all deaths in their learning disability and mental health provision dating back to 2011. [David Nicholson agreed to action this the day he retired after we met him with Jane Cummings]. We requested this review (see the Connor Manifesto) after Sloven labelled LB’s death as natural causes and we were concerned about the non investigation of other deaths in their provision. This review was published on December 17th 2015 after unprecedented challenge by Sloven to stop publication. The report was leaked on December 9th sparking an Urgent Question sessions in the House of Commons. The text of this debate can be read here (from 11.51am)
OCC commissioned an ‘independent review’ into LB’s death without involving us or informing us. They were made to disclose this document to us in Mar 15. It contains numerous inaccuracies and defamatory content and we’re currently seeking legal advice about this.
The inquest After four pre-inquest reviews, LB’s inquest was held in Oxford 5-15th October in front of a jury. The full determination can be read here (neglect and failings) and the Prevention of Future Deaths pointlessness here. It emerged during the inquest that a patient had died in the same bath in 2006. Sloven were aware of this death but failed to disclose it to the police, coroner, HSE or us. The inquest proceedings were live tweeted by George Julian and can be read here.
The criminal prosecution The Trust eventually pleaded guilty to the deaths of Connor and another patient, Teresa Colvin (TJ), and was sentenced in March 2018. The sentencing remarks of the Judge, Mr Justice Stuart-Smith, can be read here. Well worth a read to see what depths NHS Trusts are prepared to sink too, to defend their reputations. The Trust received the biggest fine in the history of the NHS for Connor and TJ’s deaths.
The campaign/social movement #JusticeforLB was created/emerged to draw attention to LB’s preventable death, ensure that people know about him and that change occurs for others. It’s unfunded and draws on the skills, ability, enthusiasm, love and goodwill of many people. George Julian is informal campaign manager, PR person and a lot more.
#107days and the #LBBill
Between Mar 19-Jul 4 2014 #JusticeforLB ran what turned out to be a remarkable crowd sourced and spontaneous campaign to celebrate LB’s life, raise awareness about provision for learning disabled people and fundraise for legal costs at the inquest. (Families have to pay for their own legal representation at inquests despite public bodies being able to draw on the public purse to defend themselves. The costs, an estimated £25,000, have been raised.) A second version of #107days ran this year.
The #LBBill emerged out of the first #107days campaign from an idea Mark Neary had about changing the law so that learning disabled people couldn’t be moved against their wishes. Ideas from the #LBBill fed into the last government’s Green Paper No Voice Unheard, No Right Ignored. The Bill has also fed into the current Law Commission consultation on Mental Capacity and the Deprivation of Liberty. We are hoping the Bill will be adopted as a Private Members Bill in the next Private Members ballot.
This is a skim through what has been and continues to be a tale of atrocity, rage, deceit and bullying, but also extraordinary solidarity, collectivism, joy, celebration, humour and creativity. Over two years on, the dark side of public bodies remain hellbent on crushing us with no whiff of remorse, commitment to change or any demonstrable positive action. This is documented in painful detail on the pages of this blog.
It also turns out, without much digging, that despite much (so much) talk about ‘learning lessons’, members of the Sloven management team, including their award winning CEO, Katrina Percy, have been involved in a previous Verita investigation into poor care at Fordingbridge Hospital (2007/8). A heavily redacted version of this review is available here. [Update: Percy eventually resigned over contract irregularities in October 2016.]