Learning from Experience Database - Serious Case Reviews

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WL (Northamptonshire)

WL died in Hospital on the 5 August 2009. He had complex needs, health and social care and was also registered blind. He had a diagnosis of Down’s syndrome. He had lived with his parents until his admission into care in 1997 where he stayed until June 2009. The records from a number of key agencies involved with this Serious Case Review (SCR) indicate WL’s health and social care needs started to change noticeably from the beginning of 2008. His increasing frailty can be seen to continue in the multi-agency recordings and in the latter part of 2008 a move for WL to a care service with nursing capability was being discussed; but not implemented prior to his admission to Northampton General Hospital NHS Trust (NGH) by Ambulance on the 1st June 2009. His presenting physical condition was of marked concern to WL’s Father. He was admitted with sores, dehydration and infections. He subsequently died in Hospital on the 5th August 2009.

Professional learning:

  • Implementation of a defined learning disability care pathway for A&E and general wards in hospitals to enable reasonable adjustments to be made.
  • Implementation of communication passports providing essential information about the patient in order to ensure staff are aware of the patient needs and to inform care and treatment plans.
  • Implementation of a carers’ policy to support both formal and informal carers.
  • Ensuring that patients with learning disabilities and/or their carers are informed and participate in patient satisfaction survey.
  • Development of resource/tools, with reasonable adjustments so that patient’s experiences within hospital are recorded.
  • Guidelines on referrals to safeguarding and to the coroner should include specific reference to neglect.
  • Escalation arrangements in care services and competencies in this regard which include specific reference to capacity and consent issues (linked to the Mental Health Act and DOLS).

2012 November Serious Case Review regarding WL (Northamptonshire)