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Learning from Experience Database - Serious Case Reviews

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Mr C (Hampshire)

Hampshire Safeguarding Adults Board

Learning Summary following the Mr C SAR and the Thematic Review of Learning from SARs related to Learning Disability and Physical Health Care



The Hampshire Safeguarding Adults Board undertook a Safeguarding Adult Review regarding Mr C. Mr C had complex care and support needs and was being supported by a number of agencies. Mr C experienced a series of placement moves which had an impact on his emotional wellbeing resulting in a deterioration of behaviour. He stopped eating and drinking which led to a decline in his physical health. Concerns were expressed by Mr C’s care team that there may be an underlying physical cause for him not eating and drinking and losing weight. He was admitted to the local acute hospital trust for observations and diagnostic tests. Mr C was discharged 7 weeks later as it was felt that his condition was due to behavioural and not physical causes. Mr C was discharged to a nursing home in a poor physical state where he received end of life care and he died four days later.

Following Mr C’s death, concerns were raised about his care whilst in hospital, specifically that during his admission, he had not received the necessary tests to rule out a physical health condition as a root cause of his physical presentation. There were also concerns that he was transferred to a nursing home apparently at the end of life when this was not known to those that were receiving him into their care or the community learning disability team.

In addition to the Mr C SAR, the Hampshire Safeguarding Adults Board simultaneously commissioned a thematic review to examine this case alongside two previous SARs carried out under similar circumstances – Mr A (June 2013) and Ms B (Dec 2015). In all three cases, the adults had a learning disability and there were concerns about how their deteriorating physical health was managed. In each case, the death had been premature and unexpected. This raised questions about the effectiveness and embedding of the learning from the previous two SARs and so HSAB undertook a thematic review to identify progress in implementing learning from the previous cases. The Thematic Review also provided an opportunity to explore the blocks and barriers to embedding of learning and solutions to these.


Common issues identified across all three cases include:

  •  Understanding and application of the Mental Capacity Act.
  •  Access to advocacy.
  •  Effective management of transitions in placements and transfer to acute hospital care.
  •  Involving family in treatment decisions.
  •  Availability and access to the Learning Disability Liaison Nursing Service.
  •  Effective hospital discharge planning.
  •  Use of the Hospital passport.
  •  Continued use of the Care Programme Approach during hospital admission.


The learning from both the Mr C SAR and the Thematic Review is outlined below. HSAB has produced a multi-agency action plan designed to drive the improvements identified in the review recommendations:


1.  Understanding and application of the Mental Capacity Act 2005 (MCA)

All local agencies to:

  •  Adopt the national MCA Competency Framework and to review organisational training plans and provision against this.
  •  Adopt the refreshed Hampshire MCA toolkit as one tool for use across Hampshire.
  •  Introduction of agency executive MCA leads.
  •  Introduction of MCA champions in all service delivery areas.
  •  Ensure managers use supervision to support and assess competency and confidence of staff in application of MCA.
  •  Ensure staff can access guidance on eligibility and entitlement to advocacy support.
  •  Develop and support a culture of professional curiosity which enables professionals to explore and understand what is happening within an environment rather than making assumptions or accepting things at face value.


2. Communication and coordination

Health partners to:

  •  Agree a joint protocol for continuance of CPA when a person with a Learning Disability is admitted to hospital.
  •  Use the multi-agency Risk Management Framework to improve coordination and communication where patients who are admitted to hospital are not subject to CPA.
  •  Map current provision regarding the learning disability liaison nursing service.
  •  Introduce Learning Disability champions within hospital wards and departments.


3. Hospital passport

Health partners to:

  •  Review and develop the hospital passport to address the issues highlighted in the reviews and to include a persons wishes on who they want involved in their care, treatment, environment and discharge.


4. Discharge Planning

Health partners to:

  •  Review hospital discharges processes and revise to reflect learning from the reviews.
  •  Ensure care providers are advised of any change in clinical condition that occurs between the initial assessment and actual discharge date.


5. Transition

Local partners, led by Adults Health and Care to:

  •  Produce guidance on transitions/placement moves that sets out responsibilities of commissioners and providers as well as key agencies.


6. Escalation and challenge

  •  Professionals should feel able to challenge care and treatment decisions when it is felt these are not in the best interests of the service user and where necessary, escalate concerns to senior managers for resolution. HSAB has developed a multi-agency protocol to support this practice.


HSAB - Report of the Workforce Subgroup HSAB Mr C SAR

HSAB - Report of the Workforce Subgroup HSAB Thematic Review