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Charity criticises care which led to the avoidable death of a man with a learning disability
Wednesday 28 September 2011
Welsh Ombudsman uphold complaints about neglect and poor care that lead to the death of a man with a learning disability in a Swansea hospital
Mencap Cymru has denounced the treatment of a man with a learning disability at a Welsh Hospital, who received what it believes was neglect and a poor package of care, contributing to his death in 2009. A report published today by the Public Service Ombudsman for Wales upholds many of the complaints lodged by the man’s family, and points to “clinical inadequacy” made by hospital staff after they failed to give due consideration to his learning disability.
Paul Ridd from Baglan was a well-loved man described as “...a gentle giant with a smile for everyone.” He was 53 when he died from respiratory failure at Morriston Hospital, Swansea, in January 2009. He had contracted pneumonia at hospital, and the pathologist reported that he was “struck…. by the extent of secretions” adding that they “were filling the airway up to the level of the vocal cords”. Devastated by the infrequency and standard of care Paul received and convinced that he hadn’t been given the chance he deserved, his brother and sister, supported by Mencap Cymru, complained to Abertawe Bro Morgannwg health board before taking their case to the ombudsman.
Paul had been taken to hospital three weeks earlier with abdominal pains, and received an operation on part of his bowel. During his time in the intensive treatment unit (ITU), he developed pneumonia. After a short period in the high dependency unit, however, he was moved to a general medical ward, where his condition deteriorated dramatically. The ombudsman’s report concludes that “…the NHS failed him” and that he is concerned that “…the dire level of nursing care to which Paul was subjected to on the ward could happen in the 21st century.”
Wayne Crocker, Mencap Cymru’s director said:
It’s a disgrace that someone can go into a hospital - a place where they should be looked after - and see their chances of survival reduced because they have a learning disability. Whether it’s intentional or not, failing to meet their specific needs counts as institutional discrimination and this tragedy should act as a wake up call for all health-providers in Wales. Currently, people with a learning disability get sub-standard healthcare compared to those without – it’s as simple as that.
When we lose a loved one, we all need time to grieve, but for families like Paul’s, this can prove difficult when so many unanswered questions remain about how and why they passed away. We welcome the ombudsman’s findings, and hope they will go some way to help the family to come to terms with their loss. Paul was a kind–hearted person and a loving brother, and he deserved better than this.
The ombudsman’s report supports many of the family’s claims *:
- Inadequate reporting of information, which meant that a process known as suctioning (where secretions are removed from the airways) was not properly continued once Paul had moved to the ward.
- Failure on the part of nurses and a clinician to respond to repeated calls for assistance when the family and manager of the residential service where Paul lived (who were with him around the clock) expressed mounting concerns about the pain and distress he was in.
- Failure to meet Paul’s needs under the Disability Discrimination Act.
- Failure to meet Paul’s needs under the Mental Capacity Act.
The ombudsman concludes that Paul’s chances of survival could have been improved had more attention been given to his learning disability. Crucially, hospital staff should have responded to the pleas from the service manager to come to his assistance. The manager knew Paul and how he communicated very well, and could tell that his condition was getting worse. Paul could also have benefitted from a longer transitional period between moving from the ITU and the ward, so that changes in his condition could be better observed.
Furthermore, the report suggests that more could have been done for Paul had his family been consulted and involved in decisions around his care, and had a learning disability liaison nurse from the hospital trust been asked to input.
Mencap Cymru is calling for:
- The Welsh Government to put measures in place so that the numbers of secondary healthcare staff receiving learning disability awareness training are monitored effectively.**
- Hospitals to make better use of learning disability liaison nurses to help patients like Paul.
- Healthcare staff to consult with and listen to families and carers of people with a learning disability when they are in hospital.
Wayne Crocker added:
This is yet another example of a failure by health professionals to provide the proper level of care for patients with a learning disability, since Mencap Cymru published it’s Death by Indifference report in 2007. The ombudsman has made it clear that he hopes to see no further cases like this in the future, and it’s encouraging to see that the health board has already taken some positive steps. These include a traffic light system**** to highlight important information about individuals, and an action plan to improve provision.
Learning disability awareness training is crucial. For example, someone with a learning disability may show what is perceived as challenging behaviour, but someone who knows them may recognise this as a sign of distress. If health professionals act in accordance with the Equality Act and the Mental Capacity Act, they would know that they have a duty to make reasonable adjustments for patients like Paul and involve their families and a learning disability liason nurse. This didn’t happen here.
For further information, or to arrange an interview with a Mencap Cymru spokesperson please contact Rhodri Davies, external affairs manager on 029 20 747 588 ext. 212, 07909 525 531 or email firstname.lastname@example.org.
To speak to Paul Ridd’s brother and sister, or for comment from the Public Service Ombudsman for Wales’ office, please contact Sarah Hudson, Policy and Communications Manager on 01656 641 153.
Notes to editors
Some of the key recommendations for Abertawe Bro Morgannwg Health Board in the ombudsman’s report include:
- Within four months, setting out a comprehensive programme of learning disability awareness training for nursing and clinical staff.
- Within four months, presenting the report at a health board meeting, and discussing how hospitals meet the Equality Act in relation to people with a learning disability.
- *Although the ombudsman’s investigation looked at clinical mistakes, it also refers to some errors made by nursing staff, such as failing to accurately record observations of Paul’s condition. An investigation into nursing errors was already carried out, however, by the Protection of Vulnerable Adults Panel (POVA), led by the health board’s Head of Nursing, which also upheld many of the family’s complaints.
- **The Welsh Government has recognised that people with a learning disability are often at an increased risk of becoming unwell, and in 2005 Wales became the first country in the UK to introduce annual health checks for people with a learning disability to help improve their long-term well-being.
- *** Mencap’s Death by Indifference report contained evidence that people with a learning disability were dying unnecessarily due to institutional discrimination in the NHS. Death by Indifference contained six cases where people with a learning disability had died unnecessarily due to widespread ignorance and neglect within the NHS.
- ****This involves creating a document for each patient with a learning disability with key information in red, such as medication; useful information in amber, such as preferred communication method; and in green, details which would improve the patients stay, such as food choices.
- About Mencap Cymru
There are around 60,000 people with a learning disability in Wales. Mencap Cymru services provide support so that people with a learning disability can live as independently as they want. These services include supporting people with a learning disability to train for and find employment, and domiciliary services and short-term breaks for parents and carers.
Mencap Cymru also provides campaigning and political training for people with a learning disability from school age to retirement. It has over 5000 members through a network of groups across Wales, and a growing number of school and community groups.
- About learning disability
A learning disability is caused by the way the brain develops before, during or shortly after birth. It is always lifelong and affects someone's intellectual and social development. It used to be called mental handicap but this term is outdated and offensive. Learning disability is NOT a mental illness.
The term learning difficulty is often used interchangeably with learning disability.