Search results

A role available to adult protection committees is the consideration of local issues and making recommendations to promote protection locally. While policy development in health and social care has been the result, at times, of national inquiries, local inquiries also provide valuable opportunities to explore issues, to reflect and to learn. This article considers the processes through which local inquiries or reviews may be developed.

The custody environment is not designed nor can it hope to meet the needs of individuals who are experiencing acute mental distress. The article reports the findings of analysis of the recorded incidents of self‐harm that occurred in the custody of one English police force during an eight‐month period in 2006. There were 168 such incidents in this period. The ratio of male/female detained persons, who harmed themselves was 3:1. The most common method used was a ligature either from the detained person's own clothes or the paper suits that are used in custody. Alcohol or substance misuse was identified as a clear risk factor. The police response is analysed and recommendations made for improved access to health care for those in custody.

This paper aims to outline the process of undertaking the Confidential Inquiry (CI) into the deaths of people with learning disabilities and discusses three particular issues: engaging with professionals; maintaining confidentiality; and the tension between wanting to base the findings on a sufficiently large number of cases so that the findings are robust and reliable, but also wanting to make immediate changes to any potentially modifiable factors found to contribute to the deaths of people with learning disabilities.

The CI into the deaths of people with learning disabilities reviews the deaths of all people with learning disabilities living in the (former) Avon and Gloucestershire areas. It has been commissioned by the Department of Health to run until March 2013. One of the key drivers for a CI has been the work of Mencap in exposing the unequal health care that some people with learning disabilities received in the NHS.

The principal goal of the CI is to improve the standard and quality of care for people with learning disabilities and ultimately their health outcomes. The CI team aims to detect potentially modifiable contributory factors in the care of a person with learning disabilities who has subsequently died, share any examples of good practice in their care and provide information to guide the commissioning of services.

It is anticipated that the findings of the CI will provide a considerable amount of evidence on which to improve the standard and quality of care for people with learning disabilities and ultimately their health outcomes.

The purpose of this paper is to report the findings of the Confidential Inquiry into premature deaths of people with intellectual disabilities (CIPOLD) in relation to the Mental Capacity Act (England and Wales) (MCA) 2005.

CIPOLD reviewed the deaths of all known people with intellectual disabilities (ID) aged four years and over who had lived in the study area and died between 2010 and 2012.

The deaths of 234 people with ID aged 16 years and over were reviewed. There were two key issues regarding how the MCA was related to premature deaths of people with ID. The first was of the lack of adherence to aspects of the Act, particularly regarding assessments of capacity and best interests decision-making processes. The second was a lack of understanding of specific aspects of the Act itself, particularly the definition of “serious medical treatment” and in relation to Do Not Attempt Cardiopulmonary Resuscitation guidelines.

CIPOLD did not set out to specifically evaluate adherence to the MCA. It may be that there were other aspects relating to the MCA that were of note, but were not directly related to the deaths of individuals.

Addressing the findings of the Confidential Inquiry in relation to the understanding of, and adherence to, the MCA requires action at national, local and individual levels. Safeguarding is everyone's responsibility, and in challenging decision-making processes that are not aligned with the MCA, the authors are just as effectively protecting people with ID as are when the authors report wilful neglect or abuse.

CIPOLD undertook a retrospective, detailed investigation into the sequence of events leading to the deaths of people with ID. To the authors’ knowledge, this is the first time that such research has associated a lack of adherence to the MCA to premature deaths within a safeguarding framework.

This paper aims to provide a commentary on the previous paper in this issue “The Confidential Inquiry (CI) into the deaths of people with learning disabilities – the story so far.”

The author considers the potential impact of the CI in reducing the health inequalities and premature deaths of people with learning disabilities.

The author considers how the process of conducting the CI described in the paper will address the fundamental issues of indifference and discrimination documented in the Mencap report, Death by Indifference.

The author suggests that, in conjunction with the findings that the CI will publish in the future, that the political will to change the way health services are delivered to people with learning disabilities in the future will be crucial.

This article aims to assess the standard local recommended management of women with severe pre‐eclampsia and eclampsia in relation to recommendations in a national clinical guideline using a criterion‐based survey.

A total of 227 maternity units in the UK were asked to provide a copy of their guideline for the management of severe pre‐eclampsia and eclampsia. Responses were obtained from 107 units (47.1 per cent), 37 units were using regional guidelines and 72 guidelines were available for assessment. A total of ten audit criteria were agreed by committee, based on national recommendations. Guidelines were then audited to assess concurrence with these criteria.

The standard of guidelines was highly variable with only four guidelines (4.5 per cent) satisfying all ten key guideline points. The majority of guidelines had clear criteria for inclusion (87.5 per cent) but in almost a quarter of all guidelines no mention was made of informing consultant staff once these criteria were met.

The study shows that the standard of local guidelines for management of these potentially fatal conditions is highly variable. Confidential inquiry has repeatedly recommended the use of regional guidelines. Perhaps it is time for the development of a national guideline representing consensus agreement of an evidence‐based approach.

In the UK eclampsia and pre‐eclampsia continue to be a leading cause of maternal mortality and morbidity. This paper provides a valuable insight into the standard of guidelines used in the management of these conditions.

Since 1990, the National Confidential Enquiry into Perioperative Deaths (NCEPOD) has published a total of 14 reports. These are intended to assist clinical staff in applying the lessons learned from the analysis of post‐operative deaths to help prevent future incidents. However, anecdotal evidence suggests that the dissemination of this information does not always take place. Access to these reports should be encouraged and perhaps considered more formally during surgical training. Their use is also advocated in the multidisciplinary setting and as part of clinical audit. Unacceptable standards of medical record keeping are frequently highlighted in the NCEPOD reports. All health‐care professionals have a responsibility to raise these standards such that clinical documentation conforms with a basic acceptable standard that does not compromise patient care. Risk managers should also make use of the NCEPOD reports in meeting the requirements of Clinical Negligence Scheme for Trusts (CNST) standards.

The Independent Inquiry into Access to Healthcare for People with Learning Disabilities reported in July 2008. Based on a public consultation, a review of research and evidence and the views of witnesses and stakeholders, the Michael Inquiry concluded that there are risks inherent in the care system for people with learning disabilities and that they are largely due to a failure to make ‘reasonable adjustments’ to services, as required under the Disability Discrimination Act. The Inquiry found evidence of a significant level of avoidable suffering due to untreated ill‐health, and a high likelihood that avoidable deaths are occurring. Although the report highlights examples of good practice there are some appalling examples of discrimination, abuse and neglect. The article makes ten essential recommendations for urgent change across the whole health system and the Inquiry team report contains practical illustrations of how to implement them.

The purpose of this paper is to use the findings of the Confidential Inquiry into Premature Deaths of People with Learning Disabilities, to estimate the likely annual number of deaths of people with learning disabilities in England that would be amenable to healthcare, or both amenable and preventable.

The study uses two scaling approaches, one based on age profiles of the population of the study area and of the country, the other on General Practice Quality and Outcome Framework (QOF) learning disability register statistics.

National estimates of the annual number of deaths either amenable to healthcare or both amenable and preventable were 1,413 using the age‐based scaling approach and 1,238 using the QOF‐based approach. The two estimates are reasonably close, and represent about three and a half people a day or 25 a week.

The likely accuracy of the estimates depends on how representative of the country the study area is. There are reasons for thinking that people with learning disability are, if anything, likely to be more accurately recognised and better treated there. Both influences would have the effect of reducing national estimates using the authors’ methods. This suggests they should be seen as a minimum.

Over the last 20 years surgery has undergone significant change in the UK and emergency admissions are now beginning to exceed elective cases. There has also been consultant expansion allowing a consultant‐led emergency service. The Confidential Enquiry for Peri‐operative Deaths (CEPOD) also recommended that an emergency theatre is available 24‐hours a day. This study was undertaken to identify the current consultant management of acute surgical admissions, to investigate the impact of consultant expansion on the management of acute surgical admissions and to assess the development of CEPOD theatres throughout Wales. A telephone survey was conducted in February 2001 and repeated in February 2002. The provision of a CEPOD theatre has markedly improved throughout Wales in the last year. A consultant‐led emergency service is still only provided by 29 per cent of hospitals and this was achieved mostly by consultant expansion. In most hospitals the working pattern has been unable to change to reflect the increase in emergency work.