Psychiatrist who failed in care of teenager with epilepsy who died in bath is suspended for 12 monthsBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k908 (Published 23 February 2018) Cite this as: BMJ 2018;360:k908
A consultant psychiatrist who failed to carry out a risk assessment on a teenager with autism, learning difficulties, and epilepsy, and who drowned in the bath following a seizure, has been suspended from the UK medical register for 12 months.
Valerie Murphy was in charge of the care of Connor Sparrowhawk, who was 18 when he died in July 2013 at Slade House, Oxford, a residential care home controlled by Southern Health NHS Foundation Trust.
Sparrowhawk was admitted to Slade House in April 2013 after his behaviour had become obsessive, difficult, and violent, to the point where his family struggled to cope. Murphy prescribed risperidone for his anxiety, but failed to properly inform him or his mother of the drug’s potential side effects.
Murphy admitted not holding a “best interest” meeting in his case, and not following NICE guidelines or Epilepsy Action advice referred to in the care plan that nurses had prepared. She also performed no risk assessment herself, the tribunal found.
She admitted failing to draw up a treatment plan or take adequate notes, failing to take an adequate history of his epilepsy, and failing to consult his GP or neurologist. She also admitted not considering the implications of letting him bathe with staff checking on him only every 15 minutes.
Most of the factual charges were resolved last August, and Murphy’s fitness to practice was found impaired in November. At that point, the tribunal’s chairman, Martin Jackson, said that Murphy “still appeared to be looking for excuses,” and had “only accepted responsibility for those parts which cannot be denied.”
He added, “Furthermore, the tribunal has noted that there has been an absence of apology to Patient A’s mother and an absence of remorse for the consequences.”
Days before the hearing resumed on 19 February, Murphy wrote a reflective statement expressing deeper contrition. Jackson said that the “penny started to drop” about her own responsibility as she answered the tribunal’s factual questions, leaving her “visibly devastated.”
But Sparrowhawk’s mother, Sara Ryan, was unimpressed by the reflective statement, in which Murphy conceded: “I really did ‘take my eye off the ball’ in this case.”
“I just don’t think that’s an acceptable statement to make for a situation that’s led to a boy’s death,” Ryan told the Guardian. In earlier testimony, she had described Murphy’s attitude before Sparrowhawk’s death as “dismissive, arrogant, and distant.”
Murphy did not apologise directly to the family, an omission she said was because of the trust’s instruction not to contact them. But she should have ignored this directive, Jackson told her.
Counsel for the General Medical Council asked the tribunal to strike Murphy off the register, pointing out that she had missed two earlier “red flag” incidents which could have indicated unwitnessed seizures. Sparrowhawk had bitten his tongue on one occasion and later he was found with a bloody nose after taking a bath.
But the tribunal found that there had been a “sea change” in the development of Murphy’s insight, and she was using her failings to help others by promoting a yellow card system for patients with epilepsy in psychiatric settings.
Slade House has since been closed. A damning audit commissioned by NHS England found that Southern Trust had failed to adequately investigate hundreds of deaths of mentally ill and learning impaired patients, or to communicate properly with families.1
In September 2017, the trust pleaded guilty in Banbury magistrates court to charges brought by the Health and Safety Executive of failing to provide safe care for Sparrowhawk.
A further tribunal hearing will review Murphy’s case before her suspension ends. After leaving the trust in 2014 she took up a post in her native Ireland, where the suspension does not apply.