I’ve spent the last fortnight in Oxford live-tweeting the inquest into the death of Connor Sparrowhawk – you can learn more about Connor here:

You can learn about the campaign at JusticeforLB website and you can read the inquest happenings over on twitter @LBinquest. At some stage I’ll write about the inquest process, the amazingly resilient and love filled family and friends of Connor; the forensic attention to detail, care and expertise of the legal team; the smatters of candour juxtaposed with complete refusal to change anything even with hindsight that we heard from witnesses [only the psychiatrist was that arrogant]; and the whole process.

For now I just wanted to pick up on one small [but really massive] language point.

Connor’s death was not tragic.

Preventable deaths are not tragic.

Connor’s preventable death was described in great detail over the two weeks, the time immediately before it and on the day of it, with some minor attention paid to what happened after it (up to the Care Quality Commission unannounced inspection two months after LB’s death where they looked at 10 different aspects of care and the unit failed every one – subsequently being closed down).

Southern Health NHS Foundation Trust, it’s CEO Katrina Percy, and their Medical Director Lesley Stevens all keep trotting out the same apology. None of them reference that Connor’s death was due to neglect, none of them reference the appalling way that they have treated Connor’s family during his care and in the more than two years since. All of the Southern Health apologies rely on the use of the word tragic or tragedy and given journalists wish to produce a balanced piece, they are nearly always ending with a statement from Southern Health.

The jury, nine men and women of Oxford, listened to everything discussed in that Coroner’s Court for two weeks and they determined:

Connor Sparrowhawk died by drowning following an epileptic seizure while in the bath, contributed to by neglect.

The jury used 463 words to explain what happened to Connor and none of them were tragic or tragedy or any derivative of that word. You can read all of their words here but they included:

neglect

very serious failings  

errors and omissions

lack of clinical leadership

lack of adequate guidance

failure

missed opportunities

inadequate

limited

insufficient

no apparent proactive support and guidance 

lack of guidance from clinical leadership on the unit

no specific information was sought from Connor’s family

lack of appropriate follow up and communication

lack of 1-1 communication with Connor’s family

lack of leadership on the unit

So please can we stop talking about the tragedy of Connor’s death.

It was not tragic, it was utterly preventable and avoidable and careless.

Until people start taking actual responsibility for their failings, and yes I’m looking at the senior managers of Southern Health NHSFT, nothing will change or improve. Let’s not forget the Trust tried to pass LB’s death off as natural causes on more than one occasion and that’s not mentioned in their apology either.

They could do with learning some lessons from the student nurses in their service, told off for being too hands on, and the nurse who stood up with such courage and compassion and candour and apologised for her failings. That was a meaningful apology and the management team could learn a lot from her.