Neglect contributed to the death of a teenager with Learning Disabilities who drowned in a bath at an NHS care unit, a jury inquest has ruled.

Connor Sparrowhawk, 18, drowned after an epileptic seizure at Slade House, in Headington, Oxfordshire, in July 2013. The unit has since closed.

On 4 July 2013, Connor was discovered submerged and unresponsive in a bath at the unit.

Jurors at Oxford Coroners' Court heard staff had been told he should be checked every 15 minutes while in the bath, but there was no formal place to log this observation.

A post-mortem examination concluded he drowned after an epileptic seizure.

The jury ruled his death had been "contributed to by neglect" and said there had been inadequate communication with Connor's family, as well as inadequate training and supervision.

Katrina Percy, the trust's chief executive, said: "It is absolutely clear that Connor should not have been in a bath without observation." She described it as "an absolutely tragic failure".

She said evidence from the inquest and the trust's own investigations had shown the unit had a "real lack of team-working", "poor assessment" around Connor's epilepsy care, and a "lack of clarity about who was in charge".

"I am deeply, deeply sorry to Connor's family - his parents, his siblings, his wider family - we failed Connor in the most tragic way," she said.

Connor, who had learning disabilities as well as epilepsy, was admitted to Slade House in March 2013 after his behaviour became aggressive.

Six weeks before his death, Connor's mother Dr Sara Ryan emailed staff to say she thought he had experienced a seizure and bitten his tongue, the inquest heard.

However, a decision was made to reduce observations of him from every 10 minutes to once an hour.

An independent report into his death, commissioned by the trust, said this was a "missed opportunity".

After Connor died Care Quality Commission inspectors entered the unit and concluded "care and treatment was not consistently planned and delivered" and "the provider did not have an effective system in place to identify and manage risks to health, safety and welfare".

Source: BBC