Learning from Experience Database - Serious Case Reviews

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DN (Solihull)

DN moved to the area in 2004 from another part of England to be nearer to her son and family. She had a range of serious health problems including osteoporosis, severe deafness, very impaired sight, rectal prolapse and hypertension. Her physical and her mental health had deteriorated over the years. She died in February 2009 aged 96. Her death certificate stated that she died from vascular disease. In January 2009, just three weeks before her death, during concerns came to light about her care at the home, specifically about the severity of a pressure sore on her heel. A safeguarding investigation was carried out and it was assessed that DN a nursing home placement to meet her increasing health needs. She moved in distressing circumstances to a nursing home two days before she died.  One of the overall lessons from this SCR is that caring for potentially vulnerable people in a way that enables them to maintain control over as many aspects of their life as possible, whilst at the same time keeping them, and the staff who are involved with them safe, is an extremely complex task.

Professional learning:

  • Clear policies and procedures are needed to manage
  • end of life care and to consider what extra supports may need to be made available to homes to enable residents to die ‘at home’.
  • Alignment between individual safeguarding investigations and large scale reviews of provider services is required to ensure individual vulnerable people are not lost in the process.
  • To ensure advocacy, both general advocates and Independent Mental capacity Act Advocates (IMCAs) are used appropriately in safeguarding proceedings.

2010 February Serious Case Review regarding DN (Solihull)