Julie Taylor
24 Dec 2019 · Coroner Alison Mutch · Manchester (South)
The coroner's concerns
1. lack of reasonable adjustment care plan for learning disability
“upon her admission to hospital the Emergency Department, where she spent a prolonged period of time, and Acute Medical Unit (AMU), had not recognised the need for a reasonable adjustment care plan to help them understand her complex needs”
2. absence of best interests meeting for inpatient decisions
“No formal best interests meeting(s) was/were held whilst [the deceased] was an inpatient at the acute hospital”
3. poor inter‑agency communication for learning disability care
“need for improved communication between agencies /professionals to ensure a clear, consistent and effective plan was put in to meet the needs of those with a learning disability”
4. unavailability of local acute learning disability beds
“need was identified for an acute learning disability bed.”
5. inadequate multidisciplinary team collaboration
“limited evidence of a joint approach between the psychiatrist and learning disability team where the prescriber in that team changed the medication.”
6. insufficient acute learning disability support staff
“support that can be provided to those with a learning disability in an acute setting is not particular to the trust involved in”