Inadequate hospital care for learning disabled
Failures in basic care, pain assessment, missed examinations, and escalation for learning-disabled adults in hospitals.
173 items
8 sources
2 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
89match
Stephen Dulling
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.
Matched on
terms: care, hospital, inadequate
LGO / SPSO decision
86match
23-013-609b - Royal Free London NHS Foundation Trust - North Middlesex Hospital (23 013 609b)
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found there were avoidable delays in the discharge process,...
Matched on
terms: care, hospital, learning
LGO / SPSO decision
86match
23-013-609a - Royal Free London NHS Foundation Trust - North Middlesex Hospital (23 013 609a)
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found there were avoidable delays in the discharge process,...
Matched on
terms: care, hospital, learning
PFD report
81match
Julie Barrow
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.
Matched on
terms: care, hospital, learning
PFD report
81match
Julie Taylor
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.
Matched on
terms: care, hospital, learning
PFD report
81match
Rose Harfleet
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.
Matched on
terms: care, hospital, learning
PFD report
81match
Myles Scriven
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.
Matched on
terms: care, inadequate, learning
PFD report
81match
Jacqueline Aarons
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.
Matched on
terms: care, hospital, learning
Committee recommendation
81match
#55 - Third Report - Coronavirus: lessons learned to date
People with learning disabilities have experienced significantly higher death rates from covid-19 than the country as a whole. Deaths have been especially high among younger adults with learning disabilities. Initial research suggests that people with learning disabilities entered the pandemic from a position of heightened vulnerability because of existing comorbidities. This was compounded by particular barriers to accessing...
Matched on
terms: care, hospital, learning
Committee recommendation
81match
#55 - Sixth Report - Coronavirus: lessons learned to date
People with learning disabilities have experienced significantly higher death rates from covid-19 than the country as a whole. Deaths have been especially high among younger adults with learning disabilities. Initial research suggests that people with learning disabilities entered the pandemic from a position of heightened vulnerability because of existing comorbidities. This was compounded by particular barriers to accessing...
Matched on
terms: care, hospital, learning
PFD report
77match
Juliet Saunders
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.
Matched on
terms: inadequate, learning
Committee recommendation
77match
#19 - Fifth Report - The treatment of autistic people and people with learning disabilities
In recent years there have been too many incidences of autistic people and people with learning disabilities dying in inpatient settings. Families and friends have too often had to go to extreme and difficult lengths to have independent reviews into such deaths. Of even greater concern is that in some cases, the poor treatment of autistic people and...
Matched on
terms: care, hospital, learning
PHSO casework decision
76match
P-004561 - Milton Keynes University Hospital NHS Foundation Trust
Mrs Y complains about the care and treatment her mother, Mrs D, received from Milton Keynes University Hospital NHS Foundation Trust between May and July 2023. She raises concerns about delays in pain relief and fluids, poor hygiene practices, inadequate post-surgery pain management, failures in fall prevention, and rough handling by staff, all of which impacted her mother’s...
Matched on
terms: care, hospital, inadequate
PFD report
73match
Chloe Every
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.
Matched on
terms: inadequate, learning
Committee recommendation
73match
#12 - Fifth Report - The treatment of autistic people and people with learning disabilities
We recommend that, in addition to the implementation of the Mental Health Units (Use of Force Act) (i.e. ‘Seni’s Law’), all Assessment and Treatment Units (ATUs) are closed within two years and replaced with person-centred services that are: i) designed for easy discharge as well as easy admission; ii) physically designed and maintained to meet the needs of...
Matched on
terms: care, learning
Committee recommendation
72match
#9 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
Prior to the pandemic, people with learning disabilities experienced health inequalities and faced difficulties accessing healthcare and receiving accurate diagnoses and effective treatments. They had increased risks of dying from a range of illnesses, including respiratory infections. These problems have been exacerbated by coronavirus, to which, emerging data suggest, people with learning disabilities may be disproportionately susceptible. It...
Matched on
terms: care, disabled, learning
Committee recommendation
72match
#9 - Fifth Report - The treatment of autistic people and people with learning disabilities
Furthermore, we recommend that autistic people and people with learning disabilities should never be admitted to an inpatient facilities that has received an “inadequate” rating from the Care Quality Commission (CQC). The Department for Health & Social Care must bring forward measures to ensure that service commissioners can no longer buy services from settings that have been rated...
Matched on
terms: care, inadequate, learning
PFD report
69match
Norma Sheppard
The report describes confusion regarding the terms of the deceased's discharge from hospital to the care home, specifically regarding the provision of sub-cutaneous fluids, which presented difficulties in finding a suitable placement.
Matched on
terms: care, hospital
PFD report
69match
Shane West
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.
Matched on
terms: disabled, learning
PFD report
69match
Pamela Singh
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.
Matched on
terms: care, learning
Committee recommendation
69match
#11 - Fifth Report - The treatment of autistic people and people with learning disabilities
Inpatient facilities do not consistently meet the needs of autistic people and people with learning disabilities and too often this is because of factors such as the unnecessary use of restrictive practices; inpatient facilities being unable to accommodate individuals’ needs to avoid sensory overload; and the distance inpatient facilities are from individuals’ homes.
Matched on
terms: care, learning
Committee recommendation
69match
#5 - Fifth Report - The treatment of autistic people and people with learning disabilities
While we welcome the vision set out by Helen Whately MP (Minister of State, Department of Health & Social Care), we believe this is a matter of delivery and The treatment of autistic people and people with learning disabilities 39 not a matter for further review. At present, the work and output of The Building the Right Delivery...
Matched on
terms: care, learning
Committee recommendation
69match
#1 - Fifth Report - The treatment of autistic people and people with learning disabilities
Autistic people and people with learning disabilities have the right to live independent, free and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so. It is also more expensive to detain autistic people and people with learning disabilities in inpatient settings and this takes...
Matched on
terms: care, learning
PPO recommendation
69match
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners with learning disabilities are clearly recorded, staff receive relevant learning disability training and follow NHSE/I guidance for prisoners with learning disabilities.
Matched on
terms: care, learning
LGO / SPSO decision
69match
NIPSO-201912943 - Belfast Health and Social Care Trust
The sister of a man with Downs Syndrome has received an apology from the Belfast Trust following our investigation into his treatment in Belfast City Hospital.
Matched on
terms: care, hospital
Committee recommendation
68match
#4 - Fifth Report - The treatment of autistic people and people with learning disabilities
Since the Winterbourne View scandal, over 10 years ago, successive governments have committed to reducing the number of autistic people and people with learning disabilities in inpatient settings and prioritising community support for these individuals. However, missed and delayed policy targets suggest a more radical approach to unlocking funding for community provision is urgently needed. Too often autistic...
Matched on
terms: care, learning
Committee recommendation
65match
#20 - Fifth Report - The treatment of autistic people and people with learning disabilities
We therefore recommend that the Government and NHS England & Improvement bring forward the necessary financial and workforce resources required to mandate the independent review of the deaths of all autistic people and people with learning disabilities in inpatient and community settings, and ensure there is a structured way to make sure any learning that emerges is disseminated...
Matched on
terms: care, learning
PHSO casework decision
65match
P-001454 - Barnsley Hospital NHS Foundation Trust
Mrs E complains that hospital staff did not properly account for her husband’s dementia when caring for him during his admission. Mrs E says the Trust decided Mr E was ready to be discharged despite not having the right care in place, and told her that Mr E was ready for discharge, but he suddenly passed away shortly...
Matched on
terms: care, hospital
PHSO casework decision
65match
P-003084 - Sheffield Teaching Hospitals NHS Foundation Trust
Ms N complains the Trust discharged her brother, who was autistic and non verbal, from hospital before his infection had cleared and without suitable provision for his care.
Matched on
terms: care, hospital
Committee recommendation
64match
#2 - Fifth Report - The treatment of autistic people and people with learning disabilities
We recommend that the Department of Health & Social Care provides us with a complete assessment of the cost of providing community support for all autistic people and people with learning disabilities currently in inpatient units. Alongside this, an assessment should also be made of the cost of providing community support for all autistic people and people with...
Matched on
terms: care, learning
LGO / SPSO decision
64match
NIPSO-201916181 - Belfast Health and Social Care Trust
We investigated an incident in which a woman suffered a fractured vertebrae after a fall in hospital. We found that the Belfast Trust failed to prepare a proper falls assessment for the patient, and failed to fully investigate how the fall happened.
Matched on
terms: care, hospital
LGO / SPSO decision
64match
PSOW-202100024 - Wrexham County Borough Council
Mrs X complained that the Council failed to provide appropriate and adequate support to her sister, Ms Y, in the months leading to her death, including whether information was shared appropriately between the Council and a third-party organisation providing services on behalf of the Council (“the Provider”), and whether the Council took appropriate action in relation to any...
Matched on
terms: care, learning
PFD report
61match
Jessica Birkhead
Mainstream adult support services were ill-equipped to provide appropriate care for individuals with intellectual disabilities, suggesting a need for a specific pathway review.
Matched on
terms: care
PFD report
61match
Tripta Bhanote
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.
Matched on
terms: care
PFD report
61match
Freda Lennox
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.
Matched on
terms: inadequate
Committee recommendation
60match
#22 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
In the light of starkly disproportionate and tragic data on death rates from coronavirus of disabled people, including shocking figures for deaths of people, including young people, with learning disabilities, there must be a discrete independent inquiry into the causes. It must be a wide-ranging inquiry, including consideration of the role of the Government’s and public authorities’ policies...
Matched on
terms: disabled, learning
PHSO casework decision
60match
P-001113 - Northern Lincolnshire and Goole NHS Foundation Trust
Mrs L complained about the Trust’s decision not to provide further treatment to her daughter, Miss A, who had COVID-19. She also complains the Trust would not allow her in the hospital to be with Miss A who had learning difficulties.
Matched on
terms: hospital, learning
Committee recommendation
60match
#14 - Fifth Report - The treatment of autistic people and people with learning disabilities
We recommend that staff involved in the treatment of autistic people and people with disabilities in inpatient settings receive training in care planning which has a clear and unhindered focus on: i) understanding that autistic people and people with learning disabilities have non-treatable conditions and therefore should not be assessed as having treatable or preventable conditions; ii) putting...
Matched on
terms: care, learning
Committee recommendation
60match
#13 - Fifth Report - The treatment of autistic people and people with learning disabilities
We have significant concerns about the quality of training and support provided to staff working in inpatient facilities and the negative consequences this can have on the treatment of autistic people and people with learning disabilities in inpatient facilities. While we welcome the pilot of the ‘Oliver McGowan’ training, it is clear that, in some cases, there is...
Matched on
terms: care, learning
Committee recommendation
60match
#10 - Fifth Report - The treatment of autistic people and people with learning disabilities
We welcome the Government’s announcement that it will bring into force the Mental Health Units (Use of Force) Act 2018 in November 2021. This will go some way to reducing the use of restricted practices in inpatient facilities. However, we remain concerned that the use of restrictive practices remains commonplace in many inpatient facilities and therefore still presents...
Matched on
terms: care, learning
Committee recommendation
60match
#8 - Fifth Report - The treatment of autistic people and people with learning disabilities
In pursuing that policy, we recommend that by the end of 2021 the Department and NHS England & Improvement: i) introduce weekly formal reviews of the suitability of admission for all autistic people and people with learning disabilities who have been kept in inpatient facilities for three months or more; and such reviews should be used to determine...
Matched on
terms: care, learning
Committee recommendation
60match
#7 - Fifth Report - The treatment of autistic people and people with learning disabilities
We recommend that the Trieste model of care is implemented for autistic people and people with learning disabilities by the Department of Health & Social Care and NHS England & Improvement. All new long-term admissions of such people to institutions should be banned except for forensic cases. For cases where there is a severe co- morbidity any admission...
Matched on
terms: care, learning
Committee recommendation
60match
#6 - Fifth Report - The treatment of autistic people and people with learning disabilities
The Trieste model of care—characterised by simplified and quicker admissions to and discharges from inpatient facilities; limited number of individuals in inpatient facilities for lengthy durations; and emphasis on well-resourced community support—presents a clear and better alternative to supporting autistic people and people with learning disabilities than is currently in place in England. Crucially, the Trieste model demonstrates...
Matched on
terms: care, learning
PHSO casework decision
60match
P-002909 - Mid Cheshire Hospitals NHS Foundation Trust
Mrs O complains about the Trust’s care and treatment of her father. She says it failed to refer him to the Speech and Language Therapy (SLT) team soon enough after his admission, it inappropriately changed her father’s fluid provision, it failed to treat her father as nil by mouth and it inappropriately inserted a nasogastric (NG) feeding tube.
Matched on
terms: care, hospital
PHSO casework decision
60match
P-003645 - Barnsley Hospital NHS Foundation Trust
Ms G complained about the care her mother received as an inpatient and the Trust’s communication with her family at the end of her life.
Matched on
terms: care, hospital
PHSO casework decision
60match
P-003666 - Great Western Hospitals NHS Foundation Trust
Mr F complains about a lack of physiotherapy and poor nursing care his father received at the Trust. He also complains staff gave his father antibiotics he was allergic to.
Matched on
terms: care, hospital
PHSO casework decision
60match
P-003755 - North East and North Cumbria Integrated Care Board
Mr C complains about the ICB’s decision that his son was not able to have his carers with him while he was in hospital in February 2024.
Matched on
terms: care, hospital
PHSO casework decision
60match
P-004140 - Oxford University Hospitals NHS Foundation Trust
Miss A complains about the aftercare her daughter received following a kidney and pancreas transplant at the Trust. She says the Trust should have been caring for her daughter in the intensive care unit and did not monitor her heart rate or carry out appropriate observations.
Matched on
terms: care, hospital
PHSO casework decision
60match
P-004640 - The Hillingdon Hospitals NHS Foundation Trust
Miss B complains about the care and treatment The Hillingdon Hospitals NHS Foundation Trust provided to her mother, Ms J, during an inpatient admission from 27 April 2020 to 4 May 2020. She specifically complains about falls assessments, nursing care, communication and complaint handling.
Matched on
terms: care, hospital
PFD report
57match
Janet Blackman
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.
Matched on
terms: care