Learning from Experience Database - Serious Case Reviews

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Adult X (Cornwall)

On 1st March 2007 a 43 year old woman was admitted to hospital via an ambulance which she had called. She was found to have a fracture to the neck of her left femur and was referred for orthopaedic treatment.  Following surgery she was also treated for alcohol withdrawal but deteriorated and had a fit. She was transferred to the Intensive Therapy Unit where the diagnosis was Hepato-Renal Failure, Alcoholic Liver Disease and left fractured neck of femur (infected). She died on 12th March 2007 having never regained consciousness with the medical cause of death being established as liver failure, alcohol cirrhosis, renal failure and septicaemia in addition to the infected fracture. A Police investigation resulted in a file being submitted to the Crown Prosecutor who decided that no proceedings could follow.

Professional learning:

  • Every professional has a duty of care to an individual and that this duty cannot be discharged through another individual or agency without a formally recorded agreement.
  • All agencies should be invited to attend a multi-agency meeting in respect of a potentially vulnerable adult if their expertise could contribute to a positive outcome (regardless of the agency’s prior or current involvement with the client).
  • Safeguarding should be considered as part of the core assessment processes of all agencies.

2008 Serious Case Review regarding X (Cornwall)