THE death of Connor Sparrowhawk is a tragedy that we now know could and should have been avoided.
Checks in place to ensure he was safe while bathing were not good enough, an independent report has found.
Given that he drowned in the bath, this is perhaps no surprise.
But the report into his death is a troubling read.
Southern Health has admitted that it failed to keep him safe.
It has apologised to the family and said it is committed to learning from the death.
The Care and Quality Commission has already raised serious concerns about the standards of care there.
The overall picture, therefore, is one of an institution that was not working properly.
Officials say they have a series of measures in place both to address the CQC’s report and to answer the criticisms levelled in the report into Connor’s death.
But what has happened is quite frankly not good enough.
Failure is a strong word, but in this case it is not unfair.
Indeed, the trust has admitted as much.
Someone vulnerable who was being cared for has died.
This is what the case boils down to.
Official reviews, reports, measures and statements must not take away from that.
Running a mental health unit is not an easy job – but that is what those managing it are there to do.
As the family of Connor today tells us, he should not have died.