Learning from Experience Database - Serious Case Reviews

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CS (Oxford)

CS, an 18-year-old young man, was found submerged in the bath at his residential unit on 4 July 2013. Staff administered CPR and he was transferred by ambulance to hospital accident and emergency department but sadly died later the same day. He had Klinefelter’s syndrome and experienced learning disabilities, autistic traits and epilepsy and tonic clonic, partial and absence seizures.

CS was admitted to a specialist unit on 19 March 2013. This is a seven-bed in-patient facility for adults with learning disabilities, mental health problems and/or challenging behaviour. At the time of admission, CS was under medication for his epilepsy and his care plan said he should be checked every 15 minutes during baths to ensure he was ok. On the morning of 4 July CS was found submerged in the bath. He sadly died later the same day. Southern Health Foundation Trust commissioned an independent review in November 2013 into the care and treatment provided to CS up until his death. A summary of the professional learning is summarised below:  

Professional Learning

  • Epilepsy profiles should be completed for anyone admitted to the trust with a history of epilepsy.
  • Risk assessments should always be undertaken to ensure risks such as bathing arrangements are identified and addressed.
  • Professionals ask service-users’ families and carers for information about risk and include it in that person’s risk profile.
  • Staff working with patients with a history of epilepsy have access to appropriate advice and support from epilepsy specialists.
  • All relevant staff should be competent to manage an epileptic seizure and be trained in life support.
  • The Assessment and treatment inpatient care pathway should be followed to ensure a patient-centred planning meeting is carried out within three weeks if none has been carried out within the previous six months.
  • All in-patients should have a medical review on admission.
  • When a patient is subject to an emergency admission and is unknown by the unit or community team, a comprehensive assessment of the family or carer’s knowledge and experience of the patient should be undertaken.
  • Clinical teams should ensure that families and carers are fully engaged in the planning and delivery of care.
  • Organisations should ensure collaborative working across inpatient and community services, agreeing models of inter-team working with commissioners.
  • A process for evaluating incidents involving resuscitation (by a resuscitation specialist) should be implemented.