The Guardian report that a senior psychiatrist failed to carry out any risk assessments on 18 year old Connor Sparrowhawk before he had a seizure and drowned in a bath, a medical tribunal has found.

Dr Valerie Murphy was the lead clinician responsible for treating Connor, who died in an NHS care unit in Oxford on 4 July 2013.

The psychiatrist, who now works in Cork, Ireland, admitted 28 failings but a Medical Practitioners Tribunal Service (MPTS) found a further nine failings and 18 not proved.

Connor, who was affectionately nicknamed Laughing Boy, had epilepsy, autism and learning difficulties and was admitted to Slade House, a residential care unit run by Southern Health NHS foundation trust, in 2013.

Lee Hollins, Risk Manager for Securicare says, “This case highlight the tragic consequences of failing to risk assess fully and thoroughly around an individual unique vulnerabilities. For the family this must be an incalculable tragedy, my heart goes out to them. Quite rightly they want to get to the truth of their son’s death. For healthcare professionals it’s a case that must serve as a warning. When managing risk in a case like this, there can be no such thing as being ‘too thorough’ or ‘too careful’…”

“Training also has a role to play in developing competence at all levels within an organisation. Whether it’s induction care courses,  preventing and managing Challenging behaviour training courses, or even Physical intervention training courses. The knowledge and skills provided should be used on a person centred basis, with discretion, with care and with compassion. Everyone is unique and should be treated as such”

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Read the full story at The Guardian