Julie Barrow
30 Sept 2019 · Coroner Alison Mutch · Manchester (South)
A similar concern from this report was raised again 1 time later. See the linked reports.
The coroner's concerns
1. lack of best interests meeting
“despite two in-patient stays, there was no best interests meeting held to discuss her care”
2. lack of reasonable adjustments care plan
“this should be used to develop the reasonable adjustments care plan and be accessible to all staff caring for her”
3. lack of effective communication and understanding of needs
“[the deceased] was never effectively communicated with by clinicians treating her and her needs not understood.”
4. inadequate accommodation for parents
“staff at the trust expected them to sleep overnight on standard hospital bedside chairs”
5. loss of learning disability liaison role
“cuts by the Local Authority that had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people with learning disabilities within the hospital”
Linked reports
Identical hazardConfidence 0.92 · high
This report
“cuts by the Local Authority that had resulted in the loss of the learning disability liaison role, had reduced the ability of the safeguarding team to support people”
Later report
“there was no consideration or offer given to [the deceased] or her mother during her time in the Emergency Department to being introduced to a learning Disability Liaison Nurse”
Responses
2019-0325-Response-from-The-Department-of-Health-and-Social-Care.pdf ↗· Department of Health and Social Care
Stated action · June 2018
“In June 2018, NHS Improvement published Learning Disability Improvement Standards for NHS trusts in England'. The Standards are intended to help NHS trusts measure the quality of service they provide to people with learning disabilities, autism or both”