Learning from Experience Database - Serious Case Reviews

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Mr R (Central Bedfordshire)

Mr R was an 87 year old man who suffered a CVA and was admitted to Luton and Dunstable Hospital on 29th June 2008. A care management assessment was undertaken on 21st July 2008 which identified that Mr R was predominately bed/chair bound and was totally dependent in all aspects of care requiring hoisting by two people to transfer from bed to chair or commode. He required full assistance with washing, dressing and toileting, supervision when eating and when taking his medication. Mr R was incontinent. The outcome of the assessment was that Mr R needed 24 hour residential care and support. Mr R was discharged to a care home where he remained until his admission to Luton and Dunstable Hospital where he died on 23rd November 2008. The cause of death recorded by the Coroner was sepsis, pressure sores, historical illness, and stroke. In response to the concerns raised about the care home in question, the Council conducted a review of the support received by all residents of the home, and suspended the funding of places there until satisfied that acceptable standards were operating. The regulator (the then Commission for Social Care Inspection) was fully involved in this process.

Professional learning:

  • Tissue viability issues should be considered, particularly when any assessment or reviews are undertaken. Staff should receive training relevant to their professional needs about tissue viability.
  • If a resident of a residential care home develops a pressure sore then a risk assessment and review must be undertaken as well as a safeguarding referral.
  • As part of the safeguarding procedure consideration needs to be given to acquiring detailed case records of individuals in residential or nursing home care in order to assist in any subsequent SCR.
  • The Safeguarding Adults Board should seek to establish a Safeguarding Adults champion with the CPS.
  • There should be GP representation for all  SCRs.

2009 Serious Case Review regarding Mr R (Central Bedfordshire)