Learning from Incidents A Case Study

1
Learning from Incidents A Case Study

• Effectiveness day April 20th 2007
• Pauline John
• Associate Director Governance

2
Profile

• Very Complex young man with Severe Learning
  Disabilities
• Range of challenging behaviours
• Extreme self injurious behaviour
• Head butting
• Spitting
• Regurgitation of food
• Little speech

3
History

• Early years lived with family in Manchester
• Received respite services from Calderstones
  Hospital
• Family breakdown parents separated
• Full time care at Calderstones Hospital due to
  high level of care needs.

4
History Contd

• Discharged from Calderstones in 1997 as part of
  resettlement programme
• Received 24hour supported care
• Nov 2000 weight dropped , behaviour escalated
• Respite organised
• Placement broke down
• May 2001 alternative placement found for short
  term

5
Contact with MH Services

• Episodic very behaviourally disturbed
• Received depot injections
• Anti psychotic medication appeared to provide
  relief from distress
• No formal diagnosis

6
Incident Details

• Behaviour deteriorated significantly
• Presented at A and E six times b/tween June 01
  and August 01 mainly for sedating medication
• Admitted to general ward in July after severe
  weight loss for re hydration
• Seen by duty psychiatrist and felt not to be
  appropriate for MH services
• Discharged back to residential accommodation

7
Presentation

• Very distressed
• Damage to himself and environment
• Unable to tolerate wearing clothes
• Head banging
• Urinating and faecal smearing
• Not sleeping
• Could not be managed safely

8
Time Line

• Felt to present serious significant harm to
  himself and others he lived with.
• 14th August 12pm presented at A and E
• Remained at A and E for 24 hours
• 16th August admitted to Oxford Ward for four
  nights
• Transferred to Calderstones Hospital for
  assessment period.

9
Issues for Services

• A very complex man
• A very distressed man
• Highly pressurised circumstances
• Extremely disturbed behaviour that was difficult
  to assess and manage
• Complicated physical health issues
• No clear appropriate facility to enable safe
  effective management

10
Learning Identified

• Roles and responsibilities in providing care and
  treatment
• Intensive support of CLDT
• Difficult to access psychiatric support
• Lack of specialist Learning Disability
  Psychiatrist
• No clear psychiatric diagnosis
• Underlying physical health problems not
  identified despite spell in hospital

11
Learning identified

• Interpretation of Mental Health Act
• At the time there wasn't a bed available
• Psychiatric services appeared reluctant to
  provide advice due to a perceived lack of
  expertise in learning disability
• Advice from senior Calderstones staff was that an
  acute psychiatric unit would not be an
  appropriate place to treat/support the service
  user
• In principle the section 2 of the MHA could be
  applied but the decision seemed to rest on
  appropriateness to use given complex needs

12
Learning Identified

• Joint Protocols
• Although a joint protocol was in place between
  services it was relatively new and not well
  communicated.
• This case demonstrated the need to review the
  protocol and strengthen it in certain places
• Noted that Trust nursing staff and LD staff
  worked well together in difficult circumstances
  when providing ward based care.

13
Learning Identified

• Clear lack of an appropriate place to provide
  emergency care and support in a safe way, with
  trained staff to such a complex person.

14
Current work/practice

• Protocol for joint working revised and in place
• Formal quarterly meetings with senior managers of
  LDP and MMHSCT
• Access to specialist psychiatry in LD improved
  and available
• Development of special facility in progress.