Learning from Experience Database - Serious Case Reviews

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MC (Northamptonshire)

MC had Down’s Syndrome, a significant level of learning disability, complex needs and suffered from epilepsy. He died unexpectedly whilst in hospital. MC had been living in residential care since 1994. At the time of his death, he resided in a residential care home in Northamptonshire and his daily care was, therefore, provided by the carers employed at the residential facility where he lived. MC had originally been a resident of Hertfordshire who had placed him in the residential home in Northamptonshire and also continued to be the responsible funding authority. Hertfordshire therefore, retained the care management responsibility for MC. MC had contact with primary care services, outpatient contacts at the local hospital involving three admissions over the course of October and November 2009. He died in Kettering General Hospital on 29 November 2009. The hospital carried out an internal review, to examine the unexpected death and consider whether reasonable adjustments had been made given MC’s communication and mental capacity issues.

Professional learning:

  • Guidance should be provided to professionals on identifying and raising safeguarding issues in regulated settings, including hospitals.
  • Safeguarding investigations should consider the risks posed to other vulnerable adults, in any given situation and not just risks for those who are the subject of the investigation.
  • Individual workers should have access to clear information explaining how to escalate concerns about care within or across agencies, where concerns initially raised are not acted upon.
  • Guidance should be provided about how safeguarding investigations apply where the individual has died. This should include issues of pace, considerations of other potential victims and the role of the police in investigating these situations.
  • Procedures should clarify how the safeguarding process relates to any internal management/serious incident reviews undertaken regarding the case and to ensure these run in parallel with the interfaces between each managed effectively.

2011 October Serious Case Review regarding MC (Northamptonshire)