Learning from Experience Database - Serious Case Reviews

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Mr S (Central Bedfordshire)

Mr S died on 24 February 2009 following re-admission to hospital from a home where the Coroner described the nursing care as “woefully inadequate”. The Coroner determined that Mr S ‘whilst incapacitated by rapidly deteriorating physical and mental health, died on this date for want of care by those charged with it.” 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. The Serious Case Review panel identified issues with the quality of community care assessments; inconsistent standards for assessment, care management and support for self- funding service users compared to those who were publically funded; irregular on the part of the provider.

Professional learning:

  • In Serious Case Reviews, where there is to be a Coroners inquest, discussion should take place with the Coroner about the timing and scope of the review.
  • Any Safeguarding Investigation following the death of a vulnerable adult should consider at an early stage if it would be appropriate to offer support to the family/carer either through involvement of a statutory agency or other recognised body.
  • The Crown Prosecution Service should identify a lead prosecutor for cases involving vulnerable adults.

2009 Serious Case Review regarding Mr S (Central Bedfordshire)