An NHS trust has admitted guilt over the death of a teenaged patient who drowned in the bath while in its care.
Southern Health Trust pleaded guilty at Banbury Magistrates’ Court earlier to breaching health and safety law in the case of Connor Sparrowhawk, 18, who died at Slade House in Oxford in 2013.
His death led to the discovery the trust only properly investigated 272 unexplained deaths of 722 in its care.
Sentencing is due to take place on 12 October at Oxford Crown Court.
The trust was prosecuted by the Health and Safety Executive (HSE) under Section 3 of the Health and Safety at Work Act 1974 following its investigation into the death of a patient under its care.
Paul Spencer, defending the trust, said Mr Sparrowhawk’s death was “deeply tragic” and should “never have happened”.
District Judge Tim Pattinson said the court expressed its “deepest sympathy” over the teenager’s death.
In a statement following the hearing, attended by Mr Sparrowhawk’s mother Sara Ryan and other members of his family, Julie Dawes, the trust’s interim chief executive, described his death as “entirely preventable”.
She said: “Connor’s loss continues to have a devastating impact on his family and we are truly sorry that we didn’t keep him safe.”
She continued: “There have been times when our actions unintentionally added to the distress of Connor’s family.”
Ms Dawes said his death had led to “significant changes and improvements” at the trust and added she hoped “all families and service users will now experience a more compassionate approach from Southern Health”.
A medical tribunal in August found a doctor failed to carry out risk assessments for Mr Sparrowhawk who had epilepsy and drowned in a bath at an NHS care unit.
Slade House closed in 2014.
Southern Health NHS Foundation Trust provides specialist mental health and learning disability services to patients in Hampshire and parts of Oxfordshire.
The trust’s former boss Katrina Percy resigned in October 2016 amid public pressure.
Dr Nick Broughton, leader of Somerset Partnership NHS Foundation Trust, will take up the chief executive role at the trust in November.
Southern Health Timeline
July 2013 – Connor Sparrowhawk, 18, drowns after an epileptic seizure at Oxford unit Slade House. An inquest later rules neglect contributed to his death
10 December 2015 – The BBC reveals details of a leaked independent report into the trust, produced by Mazars, which highlights a “failure of leadership”. Health Secretary Jeremy Hunt says he is “profoundly shocked”
17 December 2015 – The report is officially published and shows out of 722 unexpected deaths over four years, only 272 were properly investigated
6 April 2016 – The Care Quality Commission (CQC) issues a warning notice to significantly improve protection for mental health patients
29 April 2016 – A full CQC inspection report is published which says the trust is continuing to put patients at risk
30 June 2016 – Following a review of the management team competencies, it is announced that the trust’s boss Katrina Percy is to keep her job
29 July 2016 – The BBC reveals the trust paid millions of pounds in contracts to companies owned by previous associates of Ms Percy
30 August 2016 – Ms Percy announces she is standing down as chief executive, but is staying on in an advisory role
19 September 2016 – Interim chairman Tim Smart resigns after admitting he created a job for Ms Percy
7 October 2016 – Ms Percy resigns completely from the trust
13 December 2016 – A CQC report, the culmination of a one-year inquiry, says investigations into patient deaths are inadequate
16 March 2017 – All the non-executive directors resign from trust
19 August 2017 – Medical tribunal finds a doctor failed to carry out risk assessments for Connor Sparrowhawk
12 September 2017 – The trust announces Dr Nick Broughton, leader of Somerset Partnership NHS Foundation Trust, will takes up the Southern Health’s chief executive role in November
18 September 2017 – The trust admits breaching health and safety law in the case of Connor Sparrowhawk