Learning from Experience Database - Serious Case Reviews

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Alice Porter (Northamptonshire)

On 20th April 2011 Alice was being accompanied by Mencap staff to attend church when she fell. The Mencap staff called an ambulance and, despite some initial discussions about whether to take Alice home, the ambulance crew took her to hospital for assessment. Alice was admitted to Northampton General Hospital on 20th April 2011, where she died on 26th May 2011. Alice was 54 when she died. Serious concerns were raised about the care and attention Alice received from both East Midlands Ambulance Service and Northampton General Hospital in the time between her fall and her death. Northamptonshire County Council received three safeguarding alerts regarding Alice’s care while Alice was in hospital. Northampton General Hospital undertook a serious incident investigation and the findings from this and from the safeguarding investigation were considered by an Adult Safeguarding Case Conference on 27th July 2011. EMAS also undertook a serious incident investigation and the case conference found neglect in respect of both East Midlands Ambulance Service and Northampton General Hospital. The circumstances of Alice’s care were escalated to the Northamptonshire Safeguarding of Vulnerable Adults Board who decided that a serious case review should be undertaken, to understand the reasons behind a failure to meet Alice’s care and clinical needs and to learn lessons to improve services going forward.

Professional Learning:

  •  Communication – both internal communication and with Alice and her family and carers
  •  Failure to make reasonable adjustments which negatively impacted on the diagnosis and treatment plan for Alice.
  • Failure to properly apply the Mental Capacity Act and make best interest decisions.

These are the same themes that run through the plethora of research documents and inquiries into the health care of people with learning disabilities that have been published over recent years. While it is recognised that these publications have largely been in respect of the ongoing health care needs of people with a learning disability and access to services, it is suggested that the findings could also be applied to emergency interventions. There is resonance with Alice’s experience in particular findings of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities (CIPOLD), March 2013 which are summarised as follows:

  • Delays or problems with diagnosis or treatment; problems with identifying needs and providing appropriate care in response to changing needs
  • The lack of reasonable adjustments to facilitate healthcare of people with a learning disability, particularly attendance at clinic appointments and Investigations
  • GP referrals commonly did not mention learning disabilities and hospital “flagging” systems to identify people with learning disabilities who needed reasonable adjustments were limited
  • Professionals in both health and social care commonly showed a lack of adherence to and understanding of the Mental Capacity Act 2005, in particular regarding assessments of capacity, the process of making “best interest” decisions and when an Independent Mental Capacity Advocate (IMCA) should be appointed
  • Despite numerous previous investigations and reports, many professionals are either not aware of, or do not include in their usual practice, approaches that adapt services to meet the needs of people with a learning disability
  • There is a continuing need to identify people with learning disabilities in health care settings and to record, implement and audit the provision of “reasonable adjustments” to avoid serious disadvantage
  • Communications within and between agencies need to be improved It is evident, and it is acknowledged, by those involved in Alice’s treatment