Lessons learnt from reviews

Patient S

Patient S was a 44 year old woman with known learning disabilities. She lived independently with a support plan and carers visiting. The woman was known to an acute provider’s Safeguarding Adults team. She was admitted to hospital in July 2013 with a history of vomiting and weight loss.

Medical enquiries did not identify any organic cause of her symptoms. Whilst in hospital the woman refused all food, oral medication, and at times fluids. She was reviewed by liaison psychiatry, social services and dieticians at differing times during her stay in hospital and early in August 2013 was sectioned under Section 5.3 of the Mental Health Act 1983. She died five days later and her death was reported to the Coroner.

A Safeguarding Adult Review which involved two Health Trusts commenced in December 2013. Although the organisations shared their findings and learnt lessons in real time there has been some delay in the report publication due to protracted police investigations.

The key learning points from the Safeguarding Adult Review were the need for improved:

  • Information sharing between multi-agency/multi-disciplinary professionals
  • Understanding of the Mental Capacity Act 2005 and the Mental Health Act 1983 (as amended in 2007)
  • Pathways and policy regarding nutritional needs of patients
  • Recognition of the complex needs of S and referrals to specialist safeguarding teams
  • Recognition of malnutrition, and
  • The consideration of specialist capability within the Trust for patients with a learning disability

S had complex needs which required a coordinated and consistent approach. This consistency was compromised by the number of professionals who cared for her, all of whom saw S for short periods of time. Although they all contributed to the patient notes a joined up approach was lacking.

It is apparent that many professionals in their specialist fields endeavoured to follow best practice to care effectively for S but were hampered by their lack of collaboration and understanding of the Mental Capacity Act 2005 and Mental Health Act 1983.

For positive outcomes and the patient experience to be improved, clinicians at all levels need to have a requisite understanding of the Mental Capacity Act 2005 and the Mental Health Act 1983 and when each should be applied in practice. Progress against the multi-agency SAR Action Plan is monitored through the SSASPB SAR Sub-Group. The Group are also considering the roles of the Clinical Commissioning Group (CCG) led Clinical Quality Review Meetings (CQRM) to provide additional monitoring and scrutiny of this Action Plan.


Learning from Experience Database

A number of Safeguarding Adult Boards including SSASPB share learning from Safeguarding Adult Reviews, which are entered into a learning database hosted by Hampshire Safeguarding Adults Board (HSAB).

The Learning from Experience Database contains links to national and local Safeguarding Adult and Serious Case Reviews, reports and inquiries, both historic and current, and aims to support the dissemination of the learning and in doing so promote evidence based practice. Further information can be found at http://www.hampshiresab.org.uk/learning-from-experience-database/