Nothing could be additional from the truth. Dr Ryan had warned employees at the unit that her son appeared to be suffering more frequent seizures but her worries had been ignored.
A subsequent 116-webpage independent report, which she pressed for, vinidcated her concerns. The report has catalogued a series of damning errors made by the unit’s workers. The report published last month concluded that Connor’s death was “preventable”.
Staff had failed to assess the posed by Connor’s epilepsy, top to a “series of bad decisions close to his care… the degree of observations in location at bath time was unsafe and failed to safeguard CS [Connor Sparrowhawk].”
An unannounced inspection of Slade Residence by a group from the Care Top quality Commission [CQC] two months soon after Connor’s death was so essential – it discovered the unit was inadequate in all ten measures of assessment and raised concern about staff – that Southern Well being NHS Basis Trust reacted by right away closing it down.
When CQC investigators interviewed 3 of the 5 individuals, housed in the unit, one particular particular person mentioned they felt “unsafe and uncared for”, although an additional mentioned “they hated it”.
Slade House remains shut and is unlikely to reopen. Staff are currently dealing with disciplinary proceedings. In the independent report, the believe in requested that the names of all personnel be anonymised, in doing so defending personnel from adverse publicity.
For Dr Ryan, the new report into her son’s death is vindication for her campaign to discover the truth of what happened to her boy. She wrote a website over the program of his 107 days in the unit, detailing his treatment and describing her very own heartache.
She and other family members have now met Sir David Nicholson, chief executive of NHS England, and chief nursing officer Jane Cummings to talk about the situation.
Dr Ryan, a senior researcher specialising in autism at the Nuffield Department of Principal Care Well being Sciences at the University of Oxford, explained: “He [Connor] should by no means have died and the appalling inadequacy of the care he obtained should not be feasible in the NHS. It has been a long and distressing fight to attain this level and get the details surrounding his death out in the open. He was a outstanding younger guy who was failed by those who need to have stored him secure. We miss him past words.”
The case has been taken up by Inquest, the charity that assists grieving family members and specialises in deaths in custody. Deborah Coles, Inquest’s co-director, stated: “Were it not for the determination and tenacity of his loved ones, who compelled the Trust to commission a highly unusual independent investigation, we may possibly in no way have known the truth about what took place.”
In a statement, Katrina Percy, chief executive of Southern Well being NHS Foundation Trust, mentioned: “I am deeply sorry that Connor died while in our care and that we failed to undertake the essential actions needed to maintain 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 household.”