Yesterday was a remarkable day. After two and a half years of Sara Ryan and her family being on the receiving end of the most abhorrent behaviour from Southern Health NHS Foundation Trust, the jury at the inquest of Connor Sparrowhawk delivered its verdict. I was at a conference in Croydon but I wasn’t really there. Whilst the other speakers delivered their presentations, I was glued to Twitter, waiting for the verdict to come in. Death by drowning with a contributory factor being neglect. And a list of “serious failings” as long as an 8ft man’s very long arm. I cried all the way home on the train. I got back to Uxbridge and found a secluded spot in the Slug & Lettuce and cried some more. The relief that the jury saw through the appalling tactics of Sloven merging with the unspeakable sadness that a young man’s life had been so needlessly lost. I got back home and couldn’t tear myself away from the news bulletins and Twitter for the rest of the evening. More tears came when I read a tweet from a mother who had just broken the news to her two kids. One of them asked: “But why was Connor in hospital?”
That is the big question. I appreciate that at the pre-inquest hearings it was agreed that the question was outside the scope of the inquest but I hope that one day it is answered. I find it incredible that more time was devoted at the inquest to Sara’s “Dr Crapshite” blogpost than it was to the role Oxford Commissioners played in the preventable death. In fact, they didn’t appear at all. I’d like to try and answer that little boy’s question.
The discredited, unlicensed (in the UK) psychiatrist said in her evidence that people are admitted to STATT because they are “very unwell”. In one respect, you can’t blame a psychiatrist to see the person through a medical lens. That is her training and it certainly serves her purpose to see young men like Connor as “very unwell”. But from the starting point of seeing Connor as “very unwell” a whole train of events were set in motion that ultimately led to his death. Needless to say, the psychiatrist’s first action was to change his medication, riding roughshod over the family’s concern that Connor never reacted well to medication changes. The evidence from court suggests it is highly likely that the change in medication led to an increase in Connor’s seizure activity. Even that might have been manageable if the arrogant doctor hadn’t dismissed the family’s concern and decided that what was clearly an increase in seizure activity was nothing of the sort. The fatal, dreadful consequence of that decision was that Connor had a seizure in the bath and drowned. To compound this horror up to the very last minute, the psychiatrist’s counsel proceeded to try and discredit not only Sara but the court appointed epilepsy expert.
I’ve written about this many times before but I have a real huge question mark over this idea of “very unwell”. I’d love someone in the autism field to take up the cudgels and do some serious research into what happens to our young dudes sometime during mid puberty. Like Steven at 17, Connor became very unsettled. We have heard many many similar stories online of young autistic men and women struggling and in distress. Is it a psychiatric crisis? Or is it an existential crisis? If, as I believe, it’s the latter, it doesn’t necessarily need medication intervention and it certainly doesn’t need the person to be taken away from everything they know and treasure. I use the word “treasure” as I’ve tried to understand how Steven made sense of his time in the ATU. From his autistic perspective, the things he treasures are his routine and his familiar surroundings and people. For all those things to disappear overnight must be the greatest terror in the world. I’d suggest that the word “routine” and its importance to someone with autism holds the clue to the crisis. I can only really speak for Steven but I know he is very alert to potential change, very sensitive to the possibility of his foundation stones being rocked. And here’s the thing. You go through school and around 16, you start to get wind that everything you have known for the past 12 years is about to change. You may not understand the word “transition” but a whole army of new professionals suddenly enter your life. I imagine, that no matter how sensitive those new professionals may be, the danger signals are flashing. People start discussing new ideas, either with you but more probably, around you. New words like “work”, “college”, “placements”, “day activities”, “support teams” hang dangerously in this new, frightening space. Connor, like Steven, clearly had a very well tuned bullshit radar, that is probably going to pick up the shams and the spin long before the parents have twigged. All the ingredients of a terrifying existential crisis. But not “very unwell”. Enter at this point the likes of Dr M who will blithely diagnose a chemical imbalance and prescribe some anti psychotics to correct the imbalance. Shamefully being too conceited to acknowledge that her prescription is creating the imbalance whilst surrounding herself with staff too shit scared to question the judgement of the senior. And all this has to take place on the psychiatrist’s own territory. For the “patient” this is a territory of terror. The original crisis increasing tenfold.
I think that is why Connor was in hospital. It was why Steven was in hospital. And is probably the reason why others like Chris, Tizane, Stephen and Eden are trapped there.
I wish I had both the brain and the money to research this more thoroughly. There must be someone, some organisation out there who could provide this crucial service.
I don’t want to end on that note. I want to end with my own thanks and expression of admiration to the following:
On Monday, in court, I found myself sitting in the row behind Connor’s brothers and sister. Every few minutes I had to swallow hard to hold back the emotion of witnessing these incredibly courageous, dignified young people.
George Julian is a phenomenon. I have never witnessed anything like her live tweeting and I think I have witnessed history being made. Things will never be the same again after George’s incredible achievement.
And Sara and Rich. Carrying such unspeakable pain but both with hearts as big as the world. You mean the world to me, and I’m sure all the @justiceforLB supporters.
I tried to break the news to Steven last night. The concept of “neglect” was a bit beyond him. I asked him if there was anything he wanted to do for Connor and his family. Steven has never really been into lorries or buses but one area where he and Connor resonate is….. cake.
Connor. This is for you mate: