"Connor died on 4 July 2013 at
"Connor died as a result of drowning following a seizure in the bath, contributed to by neglect ."
"Lack of clinical leadership and lack of training and supervision; failure to conduct a history and conduct a risk assessment. Inadequate communication with Connor’s family and between staff in relation to LB’s epilepsy needs and risks."
"Was there a failure in the systems in place? Yes, in training and guidance. Too few staff were trained in epilepsy on the unit; training was too limited and insufficient on the unit. Guidance was considered inadequate, the epilepsy toolkit was not provided to staff on STATT despite being available . Lack of clinical leadership on the STATT unit."
Ned Ludd gives his condolences to the family of Connor Sparrowhawk and asks some questions:
"How was a death after an epileptic fit in the bath accepted by anyone initially as from 'natural causes'?"
"Where was (and is) CQC in this tragedy - and more importantly why weren't they there to prevent it (Too busy to have carried out an inspection)?"
"Why is it that the only real check on the quality of care is still the family?"