Learning disabilities dating agency
Mrs D was an elderly woman with a number of disabilities and health concerns prior to the incident which ultimately led to her death. This serious case review examines the underlying causes of Mrs D’s death and provides recommendations to reduce the likelihood of their recurrence in the future.Professional learning: The SCR focused on Msaada Care Services after a safeguarding investigation highlighted widespread and systemic failings in care on the part of the provider.EMAS also undertook a serious incident investigation and the case conference found neglect in respect of both East Midlands Ambulance Service and Northampton General Hospital.The circumstances of Alice’s care were escalated to the Northamptonshire Safeguarding of Vulnerable Adults Board who decided that a serious case review should be undertaken, to understand the reasons behind a failure to meet Alice’s care and clinical needs and to learn lessons to improve services going forward.Many agencies had been involved in Mr A’s care prior to his death and it was considered that an SCR would be the best approach in which to capture learning on a single and multi-agency basis.Professional learning: Mrs Foster was left alone for nine days without her essential privately funded care and support service when the provider company ceased trading.The collar itself caused friction to her skin resulting in the formation of a pressure ulcer.This ulcer in turn eventually became infected and Mrs D died as a result of the septicaemia, or infection based blood poisoning which it caused.
There was a lack of clear governance, direction and oversight from managers, nursing and care staff.
This is a seven-bed in-patient facility for adults with learning disabilities, mental health problems and/or challenging behaviour.
At the time of admission, CS was under medication for his epilepsy and his care plan said he should be checked every 15 minutes during baths to ensure he was ok.
CS, an 18-year-old young man, was found submerged in the bath at his residential unit on 4 July 2013.
Staff administered CPR and he was transferred by ambulance to hospital accident and emergency department but sadly died later the same day.