A MOTHER has called on police to reopen the case into her son’s death after it was revealed a mental health trust’s ‘failings’ had been raised a year before he died in care.

Dr Sara Ryan today spoke of her disgust that in a leaked report by Southern Health NHS Foundation Trust’s lead nurse staff had reported concerns about patient safety at Slade House in Headington, 11 months before her son Connor Sparrowhawk died there in 2013.

The 18-year-old, who had learning disabilities and autism, drowned in a bath following an epileptic fit.

The report is the latest revelation to spark questions about under-fire trust Southern Health after it emerged last year it had investigated fewer than half the 722 deaths of patients in its care between 2011 and 2015.

Dr Ryan, who has been campaigning for those responsible for her son’s death to be held to account, hopes police will now re-open a corporate manslaughter charge against the mental health trust.

And former Care Minister Norman Lamb told the Oxford Mail he was “horrified” at the lack of accountability among senior staff.

He said the report showed how “voidable errors” were made and that the police need to consider whether a new investigation into the trust was appropriate.

He added: “This organisation has continued without any sense of anybody being held to account for these serious concerns.”

Mr Lamb said the Health and Safety Executive had also accepted that the issue had gone beyond “medical error” and had launched its own investigation, which is still ongoing.

He added: “The police need to consider this evidence to determine whether it’s appropriate to re-open an investigation. I would support the family in that regard.

“The other thing that causes me alarm is that we are left thinking ‘What’s the point of doing these investigations, at enormous cost to the public as this report for the Trust will have, if the recommendations aren’t implemented?’.”

The leaked report by Southern Health’s interim divisional lead nurse John Stagg was aimed at evaluating safety at the former Ridgeway Partnership care units before the trust took them over.

Mr Stagg, who was first appointed to investigate Connor’s death, and his team visited a number of the trust’s units including Slade House interviewing staff and patients.

The report found Slade House was particularly poor, flagging up issues with a “lack of clarity of care plans”, “no clear understanding of a ‘locked door policy’”, a “limited” move of information onto the RiO patient care record system and “concerns” related to cleanliness and patients’ physical health needs.

Southern Health’s medical director Lesley Stevens this week said the trust was working with NHS Improvement and had pulled together an action plan.

She added: “We fully accept the need to continue to make changes.

“We acknowledge that there is more work to be done to improve services and are working at pace to achieve this.

“Earlier this month, independent experts were appointed to provide assurance on improvements being made.”

She stressed Mr Stagg’s report was shared with commissioners and formed part of an independent review into Connor’s death - which a coroner ruled was “preventable”.

Previously it emerged that the CQC raised concerns about Slade house in 2013, and told Southern Health not to take any more admissions to the unit.

In the damning report inspectors found nurses were not interacting with staff, equipment did not work and medicines were not being safely administered.

Dr Ryan branded the findings of the latest document as “terrible” and said it proved the trust’s board was aware of the failings which led to her son’s death.

She added: “It is shocking. They knew all of this in August 2012 and did nothing about it.

“We are going to ask police to re-look at it. They had to prove that the board was aware of the failings at the STATT, and I think this is it.”

Last week Southern Health chief executive Katrina Percy was quizzed by MPs last week and the case may be debated in Parliament at the end of this month.

Ms Percy has refused to stand down, despite mounting calls for her to resign as new revelations into the trust have emerged.

At an inquest last year, a jury at Oxford Coroner’s Court agreed Connor’s death in July 2013 had been “contributed to by neglect”.

Dr Ryan said it was “intense and awful” to hear counsel trying to shift the blame away from Southern Health during the two-week inquest.

Less than three months later NHS England published the bombshell Mazars report into deaths of people under the care of Southern Health.

It revealed how between 2011 and last year 722 people had died while being cared for by the trust, but fewer than half of those deaths had been investigated.

But Dr Ryan, who runs the Justice for LB campaign, dismissed the report as sparking a debate in the House of Commons but “very little else”.

She said: “It would great for there to be some justice and accountability, and then we could start thinking about Connor and remembering the fun times we had as a family. But I can’t think about that because I get too angry.”

What next? 

"SERIOUS concerns" about Southern Health NHS Foundation Trust could now be raised at a debate in Parliament.

Its chief executive Katrina Percy was called to address MPs at a meeting of the Hampshire All-Party Parliamentary Group on Tuesday, April 19.

Suella Fernandes, the MP for Fareham in Hampshire, had called the meeting and has said a debate will be held in the coming weeks.

After the first meeting meeting, she said: "Whilst I appreciate Katrina Percy's willingness to answer our questions, I told her that I still have serious concerns about the failings in the trust's governance which have now been highlighted by two investigations.

"The CQC's warning notice is a serious matter, and time is running out for the trust to demonstrate that it has the right leadership to make the changes required."

Oxford East MP Andrew Smith, a staunch supporter of the Justice for LB campaign, was not present but said he supported the idea of a debate in Parliament.

He added: "I had a meeting on the same day with the CQC, where I raised concerns about Southern Health - as indeed did other MPs.

"I strongly support this being further debated in Parliament. It's not just me but other MPS whose constituents died in Southern Health's care and feel the chief executive ought to take responsibility and resign."

Timeline

August 2012 - Lead Nurse John Stagg carries out Quality and Safety review

September 2012 - Southern Health takes over the running of Slade House in Headington from the Ridgeway Partnership

July 2013 - Connor Sparrowhawk discovered unconscious in a bath at the unit after a suspected epileptic fit

November 2013 - CQC inspectors tell Slade House not to take any more admissions following damning inspection

October 2015 - Inquest into Connor's death found Connor's death had been "contributed to by neglect"

December 2015 - Mazars Report reveals 722 people had died in the care of Southern Health, but fewer than half had sparked investigations

April 2016 - CQC tells Southern Health to make "urgent improvements"

April 2016 - leaked documents show Southern Health was aware of health and safety fears 11 months before Connor's death