Inadequate hospital care for learning disabled
27 items
2 sources
Failures in basic care, pain assessment, missed examinations, and escalation for learning-disabled adults in hospitals.
Cross-Source Insight
Inadequate hospital care for learning disabled has been flagged across 2 independent accountability sources:
2 inquiry recs
25 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (2)
17 — Improve Furness General Hospital delivery suite
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital, including particularly access to operating theatres, …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
R29 — Patient weighing equipment
Recommendation: Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission and at least weekly thereafter.
Gov response: Section 3.1 of the Scottish Government's response addresses the need for appropriate equipment by detailing investment in NHS estates, assets, facilities, and equipment. The government has committed over £400 million to improve NHS infrastructure between …
Accepted
PFD Reports (25)
Jacqueline Aarons
Concerns: A lower hospital admission threshold for patients with learning disabilities is required. Furthermore, doctor's discharge instructions and safety netting advice for non-medical care staff must be clear and actionable.
Response: The Department for Health and Social Care acknowledges the concerns but states that these matters are more appropriately addressed by NHS England directly, who will provide a full and comprehensive …
Responded
Pamela Singh
Concerns: There is a lack of specific practice tools for family and care staff to recognise and escalate acute health deterioration in people with learning disabilities, despite national recommendations for such tools.
Responded
Myles Scriven
Concerns: The hospital failed to implement necessary adjustments for a patient with Learning Disabilities and Autism, with existing policies and training having no impact on care and staff failing to act on crucial information.
Overdue
Myles Scriven
Concerns: GPs demonstrated insufficient understanding of Learning Disability and Autism needs, resulting in inadequate adjustments and ineffective use of the Learning Disabilities Register, contributing to a lack of appropriate secondary care referral.
Responded
Rose Harfleet
Concerns: The hospital lacked guidance for managing children with profound disabilities, failed to adequately consult or respond to their parents, and did not offer a Learning Disability Liaison Nurse, leading to poor care.
Responded
David Lodge
Concerns: The emergency department failed to accurately assess pain in a non-verbal patient, conduct basic examinations for pneumonia, and appropriately escalate high NEWS2 scores, coupled with a lack of internal incident review.
Responded
Chloe Every
Concerns: The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.
Responded
Stephen Dulling
Concerns: The Crisis Team offered insufficient practical advice during a mental health crisis call, failing to escalate risks. Concurrently, basic nursing care in hospital had multiple lapses, including inadequate nutritional assessments and delayed responses to critical incidents.
Responded
Shane West
Concerns: Inconsistent medication records, challenges in assessing a learning-disabled patient's condition, and an unclear appreciation of respiratory risks associated with laxative administration for abdominal distension.
Responded
Joseph Maunick
Concerns: National care shortages force cognitively impaired patients into inappropriate Emergency Department settings, where severe staff and resource pressures prevent adequate supervision and timely transfer, increasing their risk of harm.
Responded
John Stiff
Concerns: Insufficient ortho-geriatric provision for elderly patients with hip and pelvic fractures, despite repeated requests, risks future deaths due to inadequate recognition and treatment of co-morbidities.
Overdue
Freda Lennox
Concerns: Inadequate pre-operative assessment stemmed from uncompleted tests, poor information sharing between consultants, and a lack of funding and resources for a dedicated high-risk anaesthetic clinic.
Responded
Arthur Hall
Concerns: A bowel perforation was abandoned without full investigation, relying on limited diagnostic tools and making assumptions about pain. Signs of sepsis were missed, and no surgical opinion was sought post-discharge.
Overdue
Tripta Bhanote
Concerns: Care staff demonstrated a lack of clarity regarding escalation procedures for acutely unwell patients, the role of enhanced care teams, and accurate identification of Do Not Attempt Resuscitation (DNAR) status.
Overdue
Ben King
Concerns: The provided text is a generic statement of concern, without specifying the particular matters that led to the risk of future deaths.
Responded
Juliet Saunders
Concerns: Multiple failures included poor weekend ED support for learning disability patients, inadequate record-keeping, lack of junior doctor supervision, and repeated diagnostic overshadowing leading to missed acute conditions.
Responded
Alfred Jones
Concerns: National shortages of MRI scanners and radiology staff led to prolonged hospital stays, increasing patients' risk of falls and contracting nosocomial infections.
Responded
William McKibbin
Concerns: Delayed diagnosis prolonged hospitalisation, and a fatal fall was caused by nursing staff failing to secure bed rails and brakes during a patient's stay.
Responded
Julie Taylor
Concerns: The hospital failed to implement a reasonable adjustment care plan and conduct best interests meetings for a patient with learning disabilities. There was also poor inter-agency communication and a severe lack of specialist acute learning disability beds.
Responded
Julie Barrow
Concerns: The hospital failed to hold best interest meetings, implement a reasonable adjustments care plan, and communicate effectively, exacerbated by poor staff awareness and loss of a learning disability liaison role.
Responded
Dorothy Webb
Concerns: A radiologist failed to assess a "mass" on a scan and note a fracture on an x-ray, missing critical opportunities for further investigation and timely diagnosis.
Responded
Jessica Birkhead
Concerns: Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need for a specific pathway review.
Responded
Janet Blackman
Concerns: Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental health.
Overdue
Norma Sheppard
Concerns: Significant confusion existed regarding the terms of Mrs. Sheppard's discharge to a care home, specifically concerning subcutaneous fluids, with conflicting information between the written discharge and verbal understanding.
Overdue
Mohammed Chaudhury
Concerns: The patient developed severe infected pressure sores due to the prolonged absence of an air mattress and insufficient turning, directly caused by nursing staff shortages.
Overdue