In July 2013 I was referred to a blog that made my heart sink. On Sara’s blog: “my daft life” I learned that Sara’s son, Connor Sparrowhawk, a fit and healthy young man, had died while an inpatient in the care of an assessment unit for individuals with learning disabilities and mental health needs.
Like most people, I felt terribly sad and shocked for Sara and her family. I started to follow Sara on twitter and learned that Connor had died due to the indifference of a system that we would expect to protect and care for those of us amongst us who have learning disabilities when they can’t protect themselves and for whatever reason need support additional to that provided by their family. Connor’s story sounded similar to many of the cases I deal with and the cases you read about in Court of Protection judgments. But the way it ended was not the same.
I confidently told a client recently that I had never ‘lost’ a challenge to a placement authorised by the Deprivation of Liberty Safeguards. Later, I was proud to see him moved to a placement closer to his home and we are now very close to ‘proving’ that he has capacity to make up his own mind about where he lives and receives care. The CW team works hard to empower adults to make their own decisions, but if the evidence points to them really not having the requisite decision making capacity to do so, we do everything we can to argue them to a position closest to what they want.
Connor, however, missed the chance to go back to his family.
Connor was a generally fit and healthy young man, had a learning disability, displayed some autistic behaviours and had epilepsy. On 19 March 2013 he was admitted to Slade House and was sectioned under S2 of the Mental Health Act. This meant he was not able to leave the unit and he was supposed to be checked by staff every ten minutes to make sure he was well. He later became an informal patient and a new care plan was put in place. On the morning of 4 July 2013 Connor was found under water in his bath and later died.
An independent investigation concluded that Connor’s death was preventable. Findings in the report show that Connor’s epilepsy was not properly assessed or managed. No epilepsy plan was put in place and there was no evidence that a review of Connor’s health, including a physical inspection, took place when he joined the unit. In addition, supervision at bath times was found to be inadequate and the unit failed to properly engage with Connor.
The Care Quality Commission inspected the Unit in November 2013. The inspection report was highly critical of the Unit. CQC inspected ten essential standards of quality and safety: it found that none of these standards had been met and six of the failings had a major impact on the individuals.
The circumstances surrounding Connor’s death have been widely reported through the media; the unit at Slade House has now closed; some members of staff were suspended and some became subject to disciplinary investigations. But despite the anger at what happened, bringing about any real change to the service has been a struggle.
It is over a year since Connor died, but #107days – the campaign begun by Sara and her supporters – continues to inspire action and they are determined to “harness the energy, support and outrage that has emerged in response to LB’s death and ensure that lasting changes and improvements are made.”
As a solicitor working alongside the mental health services I was aware of Sara’s campaign, but I admit that it took a while before I became fully engaged in the social media storm that was spreading. Since the beginning of June, however, most of the organised events that I have attended have highlighted Sara’s campaign, exposing the indifference of services to academics, counsellors and my colleagues in the legal profession. Jess Flanagan has written about some of those events in in the latest edition of our Court of Protection newsletter, but for me they have acted as a catalyst – it seems to me that at last we are taking notice of #JusticeforLB and determined to do something.
It is the next step that is going to make the most difference and I hope to be able to share more information about the #LBBill in the next edition of our newsletter coming soon.