Case reviews 2019

September, 2019 – J

Death of a 21-year-old man following a bowel obstruction

Background: J was born with a genetic condition that meant he was short in stature, he also had poor mobility and used a wheelchair, a walking frame and knee braces. He was doubly incontinent and wore pads throughout his life. He had a sideways curvature of his spine, corrected by surgery, and delayed/arrested puberty all of which resulted in him seeing a number of specialist services as a child. From 2006 J had experienced problems with ‘trapped wind’, abdominal pain, constipation and diarrhoea. He had been prescribed varying amounts of laxatives to manage his condition. J left his family home in 2013 at the age of 19 to live in supported living accommodation following a safeguarding concern disclosed by J himself. During 2014 J was seen in hospital on three separate occasions as an inpatient, twice with abdominal pain which resolved, and he was discharged back to the care of his GP. In January 2015 staff contacted J’s GP as he was again suffering from abdominal pain, diarrhoea and vomiting. The GP diagnosed probable gastroenteritis and telephone advice was given. The following day J was not improving, and staff rang 999, he was transferred to hospital where he died the next day. His cause of death was given as bowel obstruction.

Learning Points: The Mental Capacity Act was used differently by agencies involved with J. Adult Care undertook four capacity assessments and on each occasion found J to have capacity to make the decision required; Other agencies felt that their interactions with J gave them no reason to believe that he lacked capacity to make specific decisions and therefore they did not formally assess J; The transition process for children into adulthood was not as robust as it could be, both from J’s perspective, but also in helping the family to understand the potential adjustments that they would need to be aware of when a child becomes an adult; There was a communication plan in place for J which detailed how he communicated generally but the plan did not include clear information about what J had consented to being shared with his family once he had left the family home.

Recommendations: Information, materials and awareness for both young people and their parents/carers is needed about what ‘preparing for adulthood’ means, to help everyone understand at an early stage the positive and challenging aspects of transition; Families should be signposted to advice and practical support; Assurance is needed from all agencies that arrangements for young people and their families during the ‘preparation for adulthood’ are working effectively and that Health and both Children’s and Adult Services are working together where appropriate to provide support; Multi-agency mental capacity assessment and best interest training should continue to be developed; Professionals from partner agencies should commit to amending existing and future MCA training;  Commissioned providers of community support for people with learning disabilities/difficulties should all access training on the management of constipation and recognition of sepsis; There should be an escalation policy in place and available to staff to use in an emergency and for significant incidents.

Keywords: Mental Capacity Act, Bowel obstruction, Transition, Signposting, Multi-agency

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August, 2019 – Adult L

A 23-year-old man takes his own life while remanded in prison

Background: Adult L had a history of being arrested and had previously spent time in prison. Upon release from prison two years prior to his death, a learning disability assessment was conducted, instigated by his probation officer. Adult L was then assigned to the Learning Disability Social Care Team. Adult L was arrested on a number of occasions over the following 2 years. He was assigned an Appropriate Adult once it was made clear to Police Custody by his social worker that this was a necessity. However, the final time he was arrested before his death, Adult L was not assigned an Appropriate Adult despite attempts made by Probation Service Officer and the Team Manager of the Learning Disability Team. Adult L was found in his cell with a ligature around his neck. He later died in hospital. 

Learning Points: Adult L’s Learning Disability was not identified by agencies until a Learning Disability Screening Assessment was completed by the Probation Services Worker; The Review established that there was effective joint working between the Probation Service, Adult Social Care and housing providers, but this was not recorded clearly within Adult L’s sentence plans; Adult L was a service user of the social care Learning Disability service, his social care records were held on the county council records system. Entering records onto the clinical record system did not therefore aid information sharing; Adult L’s Solicitor refused to share information with his Learning Disability team during the last court process. This decision was on the basis that Adult L would need to give consent to such information sharing and that he was refusing; There was a delay in an assessment of Adult L’s Social Care needs being completed, due to an assumption that the referral had been picked up by the ‘Health’ Learning Disability Team; There are no references found of assessments of Adult L’s capacity to make these decisions and to any legal frameworks which could have been considered.

Recommendations: All agencies to confirm that clear processes are in place for cover arrangements in the case of staff absence; Contact details for Adult Social Care teams to be shared with Probation Service and Community Rehabilitation Company and vice versa; GP practices receiving correspondence regarding de-registered patients should contact the sender to inform that patient is no longer registered; Custody Officers should seek advice from Liaison and Diversion and/or the care team of a detained person with regards conditions of Police Bail; Where professionals’ meetings take place, these should be minuted, with actions recorded; Where multiple agencies are involved with an adult with care and support needs, a lead agency should be identified; Magistrates to receive training in issues relating to Learning Disability; Magistrates to take account of recommendations with regards to sentencing options for adults with care and support needs; Local NHS to consider sharing assessments/reports with Primary Care in order to ensure a single care record exists, where it is indicated and appropriate, with consent from the patient; For the county council to facilitate access to the Adult Social Care records system for Healthcare Liaison and Diversion staff; For the Adult Social Care Learning Disability Service to ensure assessments take place prior to decisions regarding eligibility for the service.

Keywords: Appropriate Adult, Suicide, Police custody, Learning disability screening assessment, Lead worker, Key worker, Learning disability training, Learning disability awareness

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July, 2019 – Mr D

A 30-year-old man who died suddenly and unexpectedly

Background: Mr D had severe learning disabilities, was diagnosed with sensory defensiveness, cerebral palsy and epilepsy. He used a wheelchair and had limited speech, using gestures and phrases that were familiar to the people that knew him in order to express his wishes. During his personal care, Mr D’s mother noticed that he had “passed blackened stuff with an unusual odour in the bath water he was sitting in”. Mr D was diagnosed with constipation. His mother disagreed with the diagnosis. Within the same week, during personal care, he became agitated and appeared in pain. 999 was called. Mr D was transported to hospital as a non-urgent transfer and joined the queue for emergency assessment. Concern was noted in the chronology that Mr D showed signs of clinical deterioration and probable circulatory failure and it is likely that his condition was now critical with severe circulatory compromise. Mr D was left alone with his mother for a period of over 10 minutes without clinical observation. When the consultant returned to the cubicle, full cardio-pulmonary resuscitation commenced. Mr D was also intubated, auto pulse attempted, and central access blood transfusion commenced. The post mortem attributed Mr D’s death to: Gastrointestinal haemorrhage, Bleeding peptic ulcer, Cerebral palsy.

Learning Points: Failure to make reasonable adjustments; Stereotyping of people with a learning disability by a lack of poor communication, understanding of mental capacity and hidden attitudes affecting the way that professionals dealt with Mr D; Mother’s contribution was not always listened to; Delay from the GP appointment to the A&E assessment; The lack of a communication plan, Health Action Plan and hospital passport; There are a number of documents held by a range of services that would benefit from a more streamlined comprehensive system; How training is monitored for its effectiveness in practice, with particular reference to the MCA, safeguarding and communication skills were not sufficiently documented.

Recommendations: Improve the planning and reviewing process between social care and health, in particular closer working with general practitioners; there needs to be close attention paid to mental capacity and ensuring that all practitioners from health and social care are competent in understanding and translating the Act and code of practice into their work; wide promotion and checks on learning disabled people to have annual health checks, Health Action Plans and Hospital Passports; carers who provide day to day support to people with care and support needs, should be included in devising the plans and they should be accessible to them; An audit identifying take up [of annual health checks], themes, might be considered as part of promoting safeguarding prevention and wellbeing; This review highlighted the need for training and competence testing by agencies providing health and social care to cover: an understanding of learning disabilities, communicating with people who require additional time and support understanding the increased health needs of this group, overcoming barriers in consultations and physical access, collaborative working with carers, consent, the Mental Capacity Act, the Equality Act; In the event that people manage their own budget and personal assistants, there needs to be assurance that people are adequately trained and have the right set of behaviours as outlined by Skills for Care.

Keywords: MCA, Annual health checks, Hospital passport, Health Action Plans, Sensory defensiveness, Cerebral palsy, Epilepsy, Gastrointestinal haemorrhage, peptic ulcer, Reasonable adjustments, Families and carer input, Listening

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June, 2019 – Adult E

A 67-year-old man who died from hospital-acquired pneumonia

Background: Adult E had a learning disability, epilepsy, osteoporosis and scoliosis and was cared for in a supported living property. Adult E’s health began to decline, and in the last few months of her life she was admitted to hospital on four occasions after fracturing her ankle, suffering from dehydration, having low food intake and reduced bowel movements. Adult E became less able to care for herself, even with support. Adult E was readmitted following concerns that she was not eating, drinking or getting up from her seat. The following week, she was discharged to a community hospital but only one day later again readmitted to the acute hospital where she later died. The cause of death was Hospital-Acquired Pneumonia (HAP) with epilepsy, frailty and Learning Difficulties. 

Learning Points:  The domiciliary care agency did do specific assessments of mental capacity, for example, finding that Adult E had capacity around choosing food and clothes, her ability to wash up and go to the toilet, but not around taking medication; On admission to GWH, “all efforts were made to save Adult E’s life”. The hospital had a pre-arrival alert that Adult E had sepsis and she was put on a pathway of treatment in line with national guidance and best practice; Adult E had experienced a generally high standard of care in the community. Her GP told the review that he “always felt the carers were caring in the truest sense”; Despite failures in the communications between agencies, the review did evidence notable dialogue between partner agencies about Adult E’s needs and how these should be met. For example, there was a meeting between RUH staff and other agencies about how the hospital staff could engage with Adult E more to establish her needs.

Recommendations:  Should a patient who is receipt of community care be admitted to hospital, there should be effective communication between the hospital and both the home care provider and patient’s family; The Board should share information about Healthcare Passports with all agencies and undertake evaluation of current usage Greater use should be made of the Learning Disability Nurse role; Commissioning arrangements should ensure that on admission to hospital, and in the absence of regular contact with family or close friends, regular carer workers are enabled to visit the adult at risk to provide consistency and therapeutic care; Geographical provision of advocacy services should not leave those who are entitled to provision without an advocate to speak on their behalf; The Board has undertaken three other reviews which highlight the need for improved application of the Mental Capacity Act (2005).

Keywords: Domiciliary care, Mental capacity, Sepsis, Multi-agency working, Dialogue

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May, 2019 – Mr D 

A 21-year-old man moved into a residential placement following hospital admission for grade 4 pressure sore and osteomyelitis

Background: Mr D had a history of involvement with health and care services. He experienced neglect and was removed from his parents when he was 11 years old. He lived in stable care homes from this point and attended college when he was 16. There were instances of self-harm and anxiety following unplanned contact with his mother as he approached 18. At 18 Mr D chose to return to the family home. Mr D had previously suffered from obesity but was now a healthy weight following measures taken whilst in foster care. His weight almost doubled in the 3 years following moving back in with his parents. His college attendance declined, he had a number of accidents, and appointments were frequently missed or cancelled by his mother. Pressure areas were noted and Mr D was not complying with advice on eating, drinking and mobilising. His mother continued to provide unsuitable food and drinks, and there were also concerns about the home environment. In September 2017 Mr D was admitted to hospital on an emergency basis with a grade 4 pressure sore and osteomyelitis, requiring surgery. It was deemed by all professionals that it was not safe for Mr D to return home. Mr D was judged to lack capacity to make informed decisions regarding his health needs. Mr D was discharged to a residential placement.

Learning Points:  Agencies focussed on referring on, but not on addressing the causes of the concerns; Agencies did not help Mr D to express what his desired outcomes were; There is no record of a s9 assessment being undertaken or reviewed since October 2015, when Mr D was not present; He was not supported by an advocate; There was a culture of ‘Professional Optimism’ that assumes the best of service users and their families, leading to a lack of challenge; There was a lack of ‘Professional Curiosity’ to look beyond the presenting issues other than to refer to another agency; There was a failure to consider the whole family, and recognise that Mr D's mother and father may well have had care and support needs; There was an apparent lack of recognition of the long-term impact of abuse and neglect; The circumstances that led to Mr D's removal from his family as a child did not lead to any substantial action when he became an adult, despite a range of agencies being aware of them.

Recommendations: Review and revise as appropriate the Transition Process from Children’s to Adult Services; SCB should monitors its partner agencies’ implementation of the Mental Capacity Act 2005; Local authority’s Legal Services review and revised as appropriate its procedures and practice for advising both Children's and Adult Services on the implications of the Mental Capacity Act 2005; SCB to ensure parents and carers are challenged appropriately if they do not cooperate with agreed Care Plans; SCB should ensure staff are supported to develop professional working relationships and encouraged to show ‘professional curiosity’; Seek assurance from partner agencies that they and the services they commission, have appropriate systems and processes in place to ensure the effective implementation of the Mental Capacity Act 2005; Children's Social Care to review and revise the Looked After Children Review process to ensure it is fit for purpose and that independent Advocates are used to ensure that those children who may have difficulty participating in the Reviews are enabled to do so effectively; Board to seek assurance from partner agencies that they, and the services they commission, have appropriate process and systems in place to monitor adults with care and support needs who make frequent use of their emergency and out-of-hours services; Board to seek assurance from Adult Social Care that they are compliant with the Care Act 2014; Board to seek assurance from partner agencies that they and those services they commission have reviewed and revised as appropriate, their 'did not attend' (DNA) policies and procedures; Seek assurance from partner agencies that they have reviewed the processes by which consideration is given as to whether there are grounds for a formal investigation into whether any offences have been committed under s44 of the Mental Capacity Act 2005; Ensure that assessments are holistic and multi-agency and that staff are encouraged to demonstrate ‘professional curiosity’ to look beyond the ‘presenting issue’; Board to seek assurance from the Health and Wellbeing Board that services are being developed to ensure that they are accessible to all, including those who are obese; Hospital to ensure that adults with additional care and support needs are discharged safely into the community; Board to seek assurance from partner agencies that they and the services they commission have in place effective staff development and monitoring processes to ensure that staff know when and how to raise safeguarding concerns with the local authority; Board to seek assurance that the Adult Multi-Agency Safeguarding Hub has reviewed and revised as appropriate its Policies and Procedures for triaging safeguarding concerns to ensure proportionate responses in accordance with the principles of Making Safeguarding Personal; Board to seek assurance from the Health and Wellbeing Board that the lessons identified in recent research into the health outcomes for adults with a learning disability have been recognised and addressed locally by both health and social care agencies, including the development and implementation of Health Action Plans.

Keywords: Mental Capacity Act, Family, Carer, Care Act, Transition, Child services, Adult services, Health Action Plans, Unwise decisions, Neglect, Obesity

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May, 2019 – Mr B

A 26-year-old man who experienced neglect

Background: Mr B was diagnosed with autism at 4 years of age and later identified to have a condition of epilepsy at 8 years old. He has severe learning disabilities and was provided with care and support by agencies throughout his life. Shortly before transitioning into adulthood he was identified as being at risk of significant harm owing to concerns in relation to neglect. His mother was his carer. The recurring issue of neglect continued for several years after he became an adult. A “Best Interest” decision was eventually made, and he was removed from the family home. His mother was later found guilty of wilful neglect. Mr B now resides permanently in respite care.

Learning Points:  There are lessons which need to be learnt not only in relation to improving how the partnership safeguards “Adults at Risk” but equally how we support carers in this often challenging and difficult role.

Recommendations: Adult Social Care should develop appropriate Terms of Reference for the Complex case panel; SAB should assure itself the extent to which the Mental Capacity Act 2005 has been effectively implemented; SAB should review current practice to ensure multi-agency meetings are held to share information and develop risk management plans; SAB should raise awareness of the existing transition pathway to safeguarding partners, managing the transition of “Adults at Risk” from child into adult services; SAB should seek to challenge agencies that operate a “Did Not Attend policy”. Agencies should consider renaming and operating the policy as “Was Not Brought”; SAB should seek assurance of the quality and effectiveness of current practice in relation to ASC response to safeguarding concerns and whether risk assessments are being conducted; SAB should raise awareness and seek assurance amongst the Safeguarding Partnership of the requirement of when to raise a safeguarding concern; ASC should seek assurance that a Carers Assessment as per the Care Act 2014 is offered where it is apparent “Carers” require additional support; SAB should develop policy, guidance, practitioner toolkits and training regarding the identification and response to “disguised compliance” applied by carers of “Adults at Risk”; SAB should track progress of the agency IMR recommendations through the board’s quality assurance framework; SAB should develop a multi-agency practitioner tactical toolkit detailing powers of entry, which may be utilised when agencies are unable to access premises where concerns exist regarding an “Adult at Risk”; SAB should assure itself that ASC Social Workers are provided with appropriate training and risk assessment management tools used in responding to safeguarding concerns.

Keywords: Mental Capacity Act, DNA Appointments, Adult at Risk, IMCA, Care Act, Neglect, Carer, Multi-agency meetings

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February, 2019 – Mr N

Concerns about the way in which professionals and services worked together to safeguard a 32-year-old man with severe learning disabilities

Background: Mr N lived with his family who provided much of his care. He had Down’s Syndrome and epilepsy. On 27th October 2015, Mr N had an episode of vomiting and his family received advice from the GP. He appeared to improve until the 31st October when further advice was sought from NHS 111 as he was not drinking. The advice provided followed the algorithm for the condition selected. However, the adviser was not fully aware of Mr N’s underlying epilepsy and learning difficulties. Two ambulance admissions followed in early November, the second resulting in a ward admission.  On the 3rd November Mr N’s condition rapidly became much worse and by the 4th November he was admitted to an intensive therapy unit, receiving mechanical support with his breathing and was having regular convulsions. His diagnosis was of pneumonia. A tracheostomy and Percutaneous Endoscopic Gastrostomy followed. On 21st December 2015 Mr N was transferred to a medical ward and discharged from hospital on 31st August 2016 to a rehabilitation facility.

Learning Points:  The advice provided followed the algorithm for the condition selected. However, the adviser was not fully aware of Mr N’s underlying epilepsy and learning difficulties; All communication was undertaken with a member of Mr N’s family acting as an interpreter. There is no record that those treating him considered if this was an appropriate method of communicating with an adult and what capacity Mr N had to consent; The accident and emergency discharge letter which was  provided to the family and the GP was inaccurate as it stated that he was suffering from asthma. Mr N did not have asthma and the entire discharge letter is inadequate; Prior to this admission Mr N had no hospital passport.

Recommendations: NHS 111 should review the training provided to all staff relating to learning disabilities and non-verbal patients and assure itself that it is fit for purpose; NHS 111 should consider if the prompts for discussion relating to tolerance of critical medication in patients who are vomiting are sufficiently robust to offer assurance; LAS should consider if their prompts relating to the assessment of non-verbal patients are sufficiently robust; LAS should again remind GP’s of their approach to allocating transport; GP’s should consider the proactive use of special patient notes to NHS 111 for non-verbal patients, in the same way that patients who are approaching the end of life, to promote effective communication; Local authority, LAS and NHS 111 should explore with hospital the most effective way of identifying non-verbal clients to their services; Use of Hospital Passports should be promoted throughout area and supported by primary care as well as secondary services; Establish that multi-agency care plans highlight long term considerations which meet the emotional needs of parents who care for their children who are adults with learning disabilities. Specifically pathways for those with Down’s syndrome and dementia need to be developed; All services mentioned in this report should be prompted to ensure that their services meet the requirements of the Mental Capacity Act and that staff are trained to use these; All services should be prompted to ensure that they consider effective use of independent interpreters when discussing complex issues to ensure that there is a complete and accepted understanding for all parties to a discussion.

Keywords: Down’s syndrome, Multi-agency working, Mental Capacity Act, Epilepsy

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May, 2019 – Josanne Wadsworth

A 31-year-old female died following planned hospital admittance

Background: A 31-year-old female with a severe learning disabilities, she also suffered from epilepsy. She was admitted to hospital to undergo a planned replacement procedure of a Percutaneous Endoscopic Gastrostomy (PEG). IV required the PEG primarily for administration of anti-epilepsy medication and for nutritional purposes. A series of missed opportunities occurred during her 16 day stay in hospital resulting in the PEG procedure not being undertaken. IV started to refuse oral medication and therefore was not receiving all of her anti-epileptic medication. A few days later, IV started to have seizures, began vomiting and pulled out her intravenous cannula on 2 consecutive days and reinsertion was not successful until the afternoon of the third day. The seizures became more frequent. The following day, IV developed aspiration pneumonia secondary to the seizures. The following day to this, IV died. The medical cause being recorded as aspiration pneumonia. A coroner’s inquest found that IV died of natural causes, contributed to by neglect.

Learning Points: Continuity of care when a person with learning disabilities and complex/multiple heath needs is admitted to hospital should always be paramount; Putting each individual and their needs at the centre of their care and decision making, promoting the opportunity to hear the persons voice even when they don’t use words to communicate is essential for person centred holistic care; The process for ‘flagging’ that a person has a learning disability and may need additional support/reasonable adjustments needs to be explicit and ‘everyone’s’ responsibility; Multiple attendances/admissions should have triggered a multi-disciplinary meeting/review; Awareness of the 6 Safeguarding adult principles, individual responsibilities within the care act as well as good understanding of the management of process to report and respond to concerns/complaints including escalation.

Recommendations: It is recommended that joint work is undertaken between community, primary and third sector and hospital staff to review and develop mechanisms for communication and person-centred care planning and evaluate Hospital Passport/about me- ‘My Purple folder’; Details contained within the ‘My Purple folder’ and the ‘grab sheet’ needs to be urgently and jointly reviewed; It is recommended that clinical (Medics, Nurses and Allied Health Professionals) representatives work together to ensure that the most relevant information to inform/support clinical decision making and intervention when attendance/admission to hospital or appointment with GP or other community professional is included within the grab sheet; How the LD flag is utilised as part of the agreed policy to support fair and equal treatment for people with a learning disability when attending or admitted to hospital should be reviewed with representatives from both frontline and senior hospital staff, the Learning Disability Liaison team, Local Authority, and community staff i.e. a representative from General Practice. Mental Capacity Act and Deprivation of Liberty; All stakeholders to undertake a quality assurance exercise relating to the local system for identifying repeat attendances to health settings; There is joint working between to develop a framework to test holistic care for people with learning disability coming into hospital.

Keywords: Epilepsy, PEG, Annual Health Checks, Learning disability flagging, Reasonable adjustments, Neglect, Natural causes, Aspiration pneumonia

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January, 2019 – Adult W

A 64-year-old man died of Aspiration Pneumonia, Acute Bowel Obstruction and Cerebral Palsy following hospital admission

Background: Adult W was a 64-year-old man who had severe learning disabilities; cerebral palsy; epilepsy; severe oropharyngeal dysphagia; and long standing issues with constipation. He required 24-hour support and lived in supported living housing. In May 2017, Adult W’s health started to deteriorate. He was referred to the hospital due to pain and swelling on his right leg. He was found to have a hip fracture. The decision was made that the fracture could only be treated conservatively due to the osteoporotic and he was discharged from hospital. Adult W’s health continued to deteriorate. Adult W’s appetite deteriorated, and he had episodes of vomiting. Two weeks following discharge, Adult W was having difficulties breathing and was taken to hospital by emergency ambulance. Adult W died the following day. The cause of death on the Medical Certification was Aspiration Pneumonia, Acute Bowel Obstruction and Cerebral Palsy.

Learning Points: Support provider do not employ healthcare professionals as this is not part of their requirement as a supported living environment; Hospital assumed that Adult W was being discharging to a care home where an allied health professional would be available; IMCA referral was made too late; Professionals were not able to evidence that Adult W did not have capacity to consent; Hospital did not consistently record who visited Adult W; Community Healthcare Services were unaware of the discharge plan, therefore did not carry out a review of his pressure are care when Adult W returned home; A referral should have been made to the wheelchair service; There were missed opportunities to undertake a full review of Adult W’s care and support needs to ensure that that current services were able to support Adult W; Evidence to suggest a lack of person-centred discharge planning.

Recommendations: Care providers must ensure that they have communication plans in place which ensure that information sharing with other agencies is easily accessible and person centred. Through utilising schemes such as: Hospital Passports; Red Bag Scheme; Learning Disability flagging systems; Summary Care Records; Coordinate my Care; Multi-disciplinary team Hubs.; Commissioners and service providers should evidence that staff are able to apply the statutory requirements of the Mental Capacity Act in practice; Providers must ensure that there is personalised discharge planning in place.; Staff who support people with a learning disability must be able to identify when an advocate is required and how to refer to one; Staff supporting people with a learning disability have clear policies, procedures and support to escalate concerns where the mental capacity framework is not being followed.; Commissioners and providers must ensure that there are agreed processes in place to support identification and escalation of deteriorating health conditions, in particular constipation, pneumonia and sepsis.; Commissioners to consider extending the Locally Enhanced GP service to Supported Living provision; Commissioners and providers must demonstrate improvements in the development and use of early warning systems and record keeping regarding comorbidities.; Commissioners and providers must ensure the management of fractures for people with a learning disability comply with the NICE guidelines:; Providers should commit to viewing non- adherence to these guidelines as a patient safety incident and investigate accordingly.; Management of fractures must include timely reassessment by the multidisciplinary team for adults with a learning disability to ensure care and equipment meets any changing needs, in the short term and longer-term rehabilitation phase to ensure the most positive outcome.

Keywords: MCA, Best interests, IMCA, Aspiration Pneumonia, Acute Bowel Obstruction and Cerebral Palsy, Communication, Cross agency working

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2019 Case Review Summaries | V1 April 2020



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