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Mr C (December 2017)

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.


HSAB Thematic Review of Learning from SARs related to Learning Disability and Physical Health Care