Learning from Experience Database - Serious Case Reviews

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Adult X (Lincolnshire)

X had Epilepsy and Autism Spectrum Disorder (ASD). His family home was in Nottingham, but his parents took the decision that he would be better cared for in specialist accommodation. Accordingly, during 1996 he became resident at a specialist residential unit in Lincolnshire. Following several seizures in 2006 his usual prescribed medication (Epilim) was supplemented by Keppra which should have been administered twice each day at 9am and 9pm. On Saturday 2 September 2006 night staff completed an entry in a handover/communication book indicating that X was about to run out of Keppra. No immediate steps were taken to obtain further supplies and records show that at 2100 on Sunday 3 September 2006 X had his last dose of Keppra. At 0910 on Wednesday 6 September 2006 he was found dead in bed. By this time he had missed four doses of Keppra and had been due a fifth at 0900 that day. An inquest jury later concluded that the failure to provide Keppra had materially contributed to his death. The jury also decided that systemic failures in relation to stock keeping, record keeping, and a lack of sufficient training, communication and vigilance by staff to follow policy and procedures had all contributed to the death.

Professional learning:

  • Staff in management/supervisory roles should be appropriately supervised.
  • Staff in management/supervisory roles should be suitably qualified, inducted and trained to fulfil their responsibilities.
  • Clear procedures and training for staff involved in the administration of medication.
  • When service users are placed in other local authority areas, the host authority should be informed of the placement.
  • Annual reviews of placements within other authorities should take place and that information from the host authority forms a part of the review of care arrangements.
  • In the event of a serious incident within a care setting, multi-agency procedures should be promptly instigated with a focus on investigating adult safeguarding concerns and safeguarding other service users.
  • Where a serious incident within a residential care setting occurs, placing authorities should be informed at an early date. A thorough assessment of risk should include the desirability or otherwise of also informing the families/carers of service users.

2006 September Serious Case Review regarding X (Lincolnshire)