Calls have been made for an overhaul of the support structures for adults with learning disabilities in Suffolk, after serious case reviews (SCRs) into the deaths of two people highlighted a raft of failures in healthcare.

The reviews were into the deaths of James, a 33-year-old man with a learning disability who had lifelong problems with constipation, and Amy, a 52-year-old woman with learning disabilities and known bowel problems. James died in hospital on November 17, 2012 and Amy died in hospital on May 7, 2013. The names of both have been changed to preserve anonymity.

It was found in the review that the only person regularly checking James’ health was a psychiatrist, with only passing reference to his physical needs. Staff at the supported living development he lived at were also found to have had no training in monitoring the bowel health of people with learning disabilities. 

Meanwhile, the review found that the significance of Amy’s bowel problems was lost when the care home she was living in transferred from the NHS to a social care provider.

The reports made 15 recommendations, led by a call for clear structures to be put in place for the future protection of adults with learning disabilities in Suffolk.

Other recommendations made by the reports include ensuring adults with learning disabilities and complex support needs have a named care coordinator and that their health and social care needs are jointly reviewed on at least an annual basis. In addition, it called for care coordination to be supported by record keeping and information sharing across professionals and services, and to ensure people’s families or representatives are regularly consulted.

Additionally, the reviews called for NHS England, GP practices, Ipswich and Suffolk Clinical Commissioning Group, the Norfolk and Suffolk NHS Foundation Trust and Suffolk County Council draft and communicate a multi-agency protocol for identifying and agreeing changes to roles and responsibilities across the health and social care services that arise from changes to a contract or a change in provider.

“The publication of [the] independent reports examines the very sad death of two vulnerable adults with learning disabilities.” said Tim Beach, independent chair of the Safeguarding Adults Board in Suffolk. “The reports have led to the identification of recommendations that have been made as part of the reviews that will address highlighted concerns.

“Further to this, while it is clear that no amount of future change can ever alleviate the loss of a loved one, the progress the Board has made in working with the independent authors of both reviews will serve to prevent similar circumstances from occurring in Suffolk in the future.

“As a Board we need to be assured that adults with learning disabilities and complex support needs have a future named care co-ordinator and that their health and social care needs are jointly reviewed on at least an annual basis. Such reviews should always consider whether an assessment for continuing health care is required.

“Further to this, we need to be assured that named care coordinators work within structures that facilitate professional interdependence. There needs to be recognition of the value of complementary professional skills and collaboration with people’s families or representatives.”