THE death of a teenager at a crisis-hit mental health unit could have been prevented, an investigation found.

A report said 15-minute checks on Connor Sparrowhawk, 18, while he was having a bath were unsafe and a result of poor overall care at Slade House, Headington.

He was last seen by staff at 9am on July 4 and was found underwater at 9.15am.

Mr Sparrowhawk, who had learning difficulties, was taken to Oxford’s John Radcliffe Hospital where he died later that day.

A post-mortem examination found he died from drowning likely to have been caused by an epileptic seizure, the NHS has said. An inquest has yet to be held.

The unit and another that comprise Slade House closed to admissions last year after a Care Quality Commission (CQC) inspectors’ report in November raised concerns about staff practices.

Southern Health NHS Foundation Trust yesterday apologised for the failings.

But Mr Sparrowhawk’s mother, Sara Ryan of Wharton Road, Headington, said: “He should never have died and the appalling inadequacy of the care he received should not be possible in the NHS.

“It has been a long and distressing fight to reach this point and get the facts surrounding his death out in the open.

“He was a remarkable young man who was failed by those who should have kept him safe. We miss him beyond words.”

Ms Ryan wrote in her blog at “I feel battered, embattled, crushed and physically shrunken.”

Among the 23 findings from the report (which you can read in full below) were:

  • No evidence an epilepsy profile was completed when he was admitted, a “key omission”.
  • Epilepsy not considered part of his risk assessment.
  • No “comprehensive care plan” to manage his epilepsy and “contradictory” care notes.
  • No evidence of how the 15-minute bath observations were agreed and no risk assessment over bathing.
  • No evidence he was observed in the bath every 15 minutes after June 3.
  • No evidence his parents’ “experience and knowledge” was considered.

Its 15 recommendations include a review of epilepsy care, more complete risk assessments, medical reviews for all new admissions and full engagement with families.Mr Sparrowhawk had learning disabilities, autistic traits, epilepsy and suffered seizures, an independent report said.

He was admitted to the seven-bed adult mental health unit on March 19 and enjoyed “long baths”, it said.

It said: “The failure of staff at the unit to respond to and appropriately profile and risk assess CS (Mr Sparrowhawk’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.”

The report said team-working in the unit and the community learning disability team was “weak” and lacked “effective clinical leadership”.

Oxford East Labour MP Andrew Smith said last night: “The report is a terrible indictment of the failure of Southern Health to provide the care Mr Sparrowhawk should have been entitled to.

“It is awful to think how his death was preventable.”

He said: “It calls into question the fitness of Southern Health to run these services.”

Trust chief executive Katrina Percy said: “I am deeply sorry that Mr Sparrowhawk 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.”

Two external leaders are helping build a “new model of care” and training and audits were taking place to make improvements, she said.