Deaths of two vulnerable adults in Suffolk expose failings in care

Richard Handley

Richard Handley - Credit: Archant

Health chiefs have promised to learn lessons from a review into the deaths of two vulnerable adults which exposed a catalogue of failures surrounding their care.

An overhaul of support for adults with learning disabilities has been called for following the deaths of a 33-year-old man and a 52-year-old woman within six months at Ipswich Hospital.

Although referred to by aliases 'James' and 'Amy', the family of the man have shared his identity, along with their shock at his 'sudden and unexpected' death.

Richard Handley's relatives said they were 'deeply saddened' by the treatment he received from all service providers involved in his care.

Mr Handley, who had Down's syndrome and lifelong problems with constipation, died three days after being admitted to hospital from

Bond Meadows – a supported living scheme run by United Response, in Lowestoft.

A review by the Suffolk Safeguarding Adults Board found his health had been regularly checked only by a psychiatrist, with just passing reference to his physical needs.

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It said staff at Bond Meadows – also referred to by an alias in the report – had received no training in monitoring the bowel health of people with learning disabilities.

The review highlighted a change in status at Bond Meadows from residential care to supported living in 2010, when performance indicators were designed to reward councils providing independent living – seen as less of a financial burden than residential care.

In Amy's case, the review said the significance of her bowel problems was lost when responsibility for the home she was living in – referred to in the review as 'Crane Court' – changed from the NHS to a social care provider.

It was run by the Papworth Trust until November 2011, when it was taken over by Suffolk County Council, and then the divested social enterprise Leading Lives from July 2012.

Tim Beach, chairman of the safeguarding board, said: 'These are two very sad deaths and, as throughout this whole process, our thoughts are with the families who have lost loved ones.'

Mr Beach said that progress made in working with the independent authors of both reviews would serve to prevent similar circumstances from occurring in Suffolk in the future.

The report sets out 15 recommendations, including the need for care coordination to be supported by record keeping and information sharing, and for people's families or representatives to be regularly consulted.

Norfolk and Suffolk NHS Foundation Trust was commissioned to provide psychiatric care to Mr Handley and add extra support for Amy.

Jane Sayer, director of nursing, quality and patient safety, said: 'We have acknowledged the findings and recommendations of the serious case reviews into the circumstances of their deaths.

'Our trust has acted upon the lessons presented in the reviews and has taken steps to raise awareness of the importance of sharing and gathering information to provide effective and safe care, through training, consultations and operational safeguarding groups.'

Suffolk County Council's director for adult and community services, Anna McCreadie, said: 'Our thoughts are with the families and friends of James and Amy at this time. The loss of any loved one has a major impact on the people around them.

'I know that every agency involved in the care of James and Amy takes its role extremely seriously and will be working together to follow up and embed the recommendations of the reports, if they have not done so already.

'If anybody has concerns relating to the care of a loved one, I would urge them to contact our Customer First team to discuss the matter in the first instance.'

Nick Hulme, chief executive of Ipswich Hospital, said: 'I would like to offer sincere apologies to the families of James and Amy. We could and should have done more for them, particularly in the way we involved their family members in their care. I am extremely sorry that we let them down. I want to give my personal assurance that we have learned from these tragedies and improved care and support for people with learning disabilities.'

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