The monitoring of a teenager with autism who died after suffering a seizure while taking a bath at an NHS assessment unit was reduced a month before his death, an inquest has heard.
When Connor Sparrowhawk, 18, was admitted to the unit in Oxfordshire, a plan was drawn up that included observations of him carried out every 10 minutes because of his epilepsy.
But a month before Sparrowhawk died, a decision was made at a care plan hearing to cut observations to one an hour, even though he had recently bitten his tongue, which could have indicated a seizure.
Sparrowhawk had moved into the Statt (short-term assessment and treatment team) unit at Slade House in March 2013 after becoming aggressive, a jury at Oxford coroner’s court was told.
On the morning of 4 July, he took a bath ahead of an outing. But the alarm was raised by a staff member who found Sparrowhawk submerged in the bath, his face blue. Nurses tried to resuscitate him but he died later.
Among the topics for the two-week inquest are how Sparrowhawk’s care was planned, risk assessments around his epilepsy and communication with his family.
Kieran Dullaghan, a nurse who worked closely with Sparrowhawk, told the inquest the teenager loved to take baths and would lie in the tub for as long as three hours.
Dullaghan said, on the morning of Sparrowhawk’s death, a colleague ran a bath for him. Ten minutes later, at about 8.55am, he said he popped his head around the bathroom door to check on Sparrowhawk. The two did not speak but Sparrowhawk seemed fine, he said.
About 20 minutes later, a fellow staff member told him that Sparrowhawk was submerged. They fetched a defibrilator and called an ambulance but he was pronounced dead in at John Radcliffe hospital in Oxford.
Dullaghan – one of Sparrowhawk’s “named nurses” responsible for overseeing his care and doing the bulk of paperwork connected to him – said he was aware of a decision taken on 3 June to reduce the level of observation from once every 10 minutes to hourly.
Paul Bowen QC, representing Sparrowhawk’s family, asked Dullaghan if he had carried out a risk assessment around the young man’s epilepsy and bathing. Dullaghan was advised by his legal representative not to answer the question.
Asked if he was aware of guidelines from National Institute for Health and Care Excellence (Nice) on care for people with epilepsy and learning difficulties at the time of Sparrowhawk’s death, Dullaghan said: “Possibly.”
Bowen put to Dullaghan that Sparrowhawk had been in the bath for longer than his timings suggested and that he had not carried out the check on the teenager at all. Dullaghan insisted the timings were right and he had carried out the check.
The inquest has heard Sparrowhawk became suddenly prone to violent outbursts shortly before his 18th birthday, to the surprise of his mother, Sara Ryan, and stepfather, Richard Huggins.
His mother told the inquest: “He was quirky, loving, funny and loved off the planet by his family. He talked to himself constantly and was forever asking questions.”
She said that a few months before his 18th birthday he became anxious, agitated and sometimes aggressive. “He would punch and hit his head against the wall when distressed. He was behaving in ways which were very concerning,” she said.
He was admitted to the Statt unit, operated by the Southern Healthcare NHS Foundation Trust, after an incident where he had punched a teaching assistant. During his time at the unit, there had been an improvement in Sparrowhawk’s well-being and plans to discharge him from the unit were in progress.
The inquest continues.
