Creating Circles of Support for people with learning disabilities

Friday, 6 February 2009

Example from practice

Ted died on 27 May 2004. The death certificate stated that this was due to a
heart attack, but this was changed after the inquest to ‘aspiration’. He was 61
years old. He had a severe learning disability and virtually no speech. He had
been admitted on 5 May 2004 hospital due to problems with urine retention.
He was discharged three weeks later, despite the fact that his care staff raised
concerns about his health. The following day he collapsed and died.
Ted’s family complained to the hospital, the GP practice and subsequently to
the Healthcare Commission.
Ted developed urine retention problems and was admitted to hospital for an operation. After the operation he got out of bed and fell. It was suggested that this could have been because he had a stroke or heart attack. He was then admitted to the intensive care unit with a postoperative infection. Here, it was confirmed later that he had suffered a mild heart attack.
Ted made a good recovery and one week later he was transferred to a general medical ward. The following day, the hospital contacted the NHS residential unit where he lived and said that they wanted to discharge Ted that day. This was despite the fact that his condition had been assessed as “concerning”.
Ted had been agitated and wandering around the ward during the night. His sister said that this was unusual and in her view, a sign that he was distressed.
The senior charge nurse at Ted’s residential care home was not confident that he
was well enough to leave hospital. In particular, the care home staff were worried because Ted was not able to swallow properly and he was still bleeding when he urinated.
As Ted’s residential care home was an NHS unit, the hospital felt that it was appropriate to discharge him. A member of staff was sent to collect him. It is not clear what verbal or written instructions were given to explain Ted’s care needs.
All night, staff were concerned about his condition and Ted was watched closely. It was noted that he seemed chesty and unsteady. In the morning, the nurse in charge of the unit noted that he had a bloodshot eye, unsteady gait, chesty cough, was walking unusually fast and had blood in his urine. They called the GP the following morning and he arrived later that day.
The GP assessed Ted’s condition and said that there was no need to return him to hospital.
Ted sat down and ate a communal meal. He began to vomit and then collapsed.
The care staff called an ambulance and Ted was sent back to the hospital where he died shortly afterwards.
An inquest was held and stated that Ted had died from aspiration pneumonia and that a simultaneous heart attack would have hastened his death. The post mortem report stated that he had aspirated a large amount of food into his lungs just before he died.

• Was Ted discharged from hospital too early, given his special needs and the
fact that the residential staff expressed concern about the state of his health?
• Was it reasonable for the hospital to assume that the care home had the
skills to support him?
• Was a thorough assessment of Ted’s ability to swallow carried out by speech
and language therapists before he was discharged?
• What information was the care home given about Ted’s swallowing ability?
• Were any instructions about how to feed Ted carried out correctly?

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