Learning from Experience Database - Serious Case Reviews

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Mr A (Hampshire)

Mr A had a learning disability and was 52 years old when he died at the Queen Alexander Hospital, part of Portsmouth Hospitals Trust (PHT) on 31st May 2010. Many agencies had been involved in Mr A’s care prior to his death and it was considered that an SCR would be the best approach in which to capture learning on a single and multi-agency basis. 

Professional learning:

  • The SCR highlighted critical failings in the care and support of Mr A in both community and acute NHS settings and issue regarding his support planning and review. These have been addressed through the development of single and multi-agency actions plans the implementation of which has been monitored via the Hampshire Safeguarding Adults Board.

2013 June Serious Case Review regarding Mr A (Hampshire)