Skills gap blamed for learning disability deaths

15 June 2010 | By Ben Clover, Graham Clews

Gaps in nurses’ knowledge often contribute to “all too common” deaths of patients with learning disabilities, the Royal College of Nursing has said.

Michael Brown, RCN learning disability forum chair and a nurse consultant with NHS Lothian, said most nurses working on acute wards had little experience of treating patients who were severely cognitively impaired and almost no education in the field, as well as a lack of time.

“There has been a whole catalogue of deaths and incidents, and it makes you question how serious we are about the care of the most vulnerable people,” he said.

Mr Brown was speaking after the Basildon and Thurrock University Hospitals Foundation Trust was fined £50,000 after the death of Kyle Flack, who was asphyxiated when his head became trapped between his hospital bed and bedrail.

Mr Flack, who was blind, deaf, quadriplegic and had cerebral palsy, as well as having learning disabilities, was found lying with his head wedged between the rails twice on the night he died.

Both times he was repositioned by nurses before he finally died.

The trust was criticised by the Health and Safety Executive, which investigated Mr Flack’s death.

It has since appointed a nurse adviser for learning disabilities, held a nurse training day run by people with learning difficulties, and introduced protocols including a formal risk assessment tool for bedside rails.

The Care Quality Commission looked at the quality of care for patients with learning difficulties at Basildon and concluded it needed to improve staff training, communication with patients and patient safety risk assessment.

The findings follow alarming research from the National Patient safety Agency that found mental health nurses were untrained or inexperienced in dealing with heart attacks and choking incidents.

The research is detailed in this week’s Nursing Times and was ordered after a death in April 2008 at a mental health facility where staff were unable to clear vomit from a patient’s airway and instead gave heart massage for 20 minutes.

A review of 599 similar incidents in mental health or learning disability settings in the two preceding years found three cases where patients had choked to death on food and 22 had suffered moderate or severe harm “where staff did not always seem to have the skills to deliver effective first aid.”

Readers' comments (19)

carol stone | 15-Jun-2010 2:41 pm
This is an all too common thread & one which relates purely to the changes needed in nurse training.

Nurse training needs a step back whereby you undergo general nurse training for 3 years then follow your chosen branch for 18 months. The Common Foundation does not prepare nor equip any student nurse who then follows the Adult branch to care effectively for LD/MH patients, nor does it prepare students following LD or MH branches with the skills and knowledge required in general nursing.
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mike | 16-Jun-2010 0:19 am
I'm sorry but isn't this the reason we have seperate branches?

I am an adult Nurse, I am good at what I do and I am responsible for the medical care of a wide range of illnesses and injuries in adults. I admit my knowledge in Childrens and Mental Health Nursing is basic, but why should it be anything but? I am a specialist in my area, just as they are specialists in theirs. We cannot be expected to know everything, even though I think that expectation is made on us sometimes.

If we are to have these specialties, where Nurses are branched off into seperate groups (which I believe is a good thing), then wouln't a better system - instead of blaming general nurses - be to make sure that general wards who recieve patients with mental health patients, have access to mental health Nurses?

I mean on any given ward or general area, we will recieve patients with anything from schizophrenia to senility, bipolar disorder to autism, etc etc etc, yet where the bloody hell are the mental health Nurses? You can be damn sure if a mental health ward had any medical concerns they'd be shipped off as soon as!
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tich x | 16-Jun-2010 1:03 am
how long is t6he nurse training supposed to be in the end. we cant keep on suggesting the restructuring of the course following an incident. i qualified almost 3yrs ago & am happy with the course.

i agree with everything mike states above & totally disagree with carol. i ork in a busy respiratory ward & look after many Ca patients as well. i am very good too as mike put it at what i do. however even though i am a 'good nurse' it doesnt mean i have a clue about surgical nursing, or much expertise in gastro or coronary care. bi will stillneed a bit of time if i were to move to these wards. several of my friends work in mental health but havent got a clue when i talk adult nursing. its just not their forte.

i have looked after LD patients needing one to one care but the site managers always ended up moving the extra member of staff to other under-staffed wards. rather than lack of knowledge this case looks like lack of manpower to me.
however the mandatory difibrillation training in my trust cover virtually all emergencies such including choking, drowning & the heart attacks.
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K WHENT | 16-Jun-2010 9:51 am
i would like to respond to Mike- mental health patients who become unwell are not just "shipped off"
we have to provide physical care until a point where it becomes unsafe for the patient and others around them. I have run IVI's on the ward but only when the patient can be isolated and enough staff are competent to manage the IVI- the risk come in when a paranoid schizophrenic thinks you are harming his friends- mis interpreting what is actually happening. When i trained i had a 8 week placement in a medical ward- this gave me sound basis of physical care but this has then been topped up with joint working when difficulties occurr.
instead of asking where the "bloody mental health nurses are" it would be better to put this energy into building relationships with them so they are only a phone call away for advice.

if this worked both ways we would all have the knowledge required- all be it on a need to know, as and when basis.
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mike | 16-Jun-2010 11:20 am
K Whent, I see your point and I did not mean to sound so disparaging. The problem as we see it (after working on wards and A&E) is that patients with a wide range of mental health problems do present to us; you may have given them very good care before they did I don't know, the problem is when they do present, that is where your input often ends. So it does seem to us as if they are just 'shipped off'. You required medical attention, so you sent them to us and asked for adult Nurse care, fair enough, but we cannot do the same or ask for MH staff when we have to treat MH patients. We often do not have the levels of staff to give numerous mental health patients the attention we need, nor do we have the specialist knowledge you do beyond the basics. Yet trying to get support from mental health services is not always easy, yes we can sometimes get through to ask for advice, but there is no physical presence there to give specialist care, and we can and do give them the medical care they need. But this is often not in an ideal envioronment or conditions, leaving staff and patients stressed.

What annoys me the most about this article however is the fact that it is blaming Nurses once again for things that go wrong.
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mike | 16-Jun-2010 11:22 am
Sorry that should have read the attention they need.
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Anonymous | 16-Jun-2010 12:43 pm
Sorry, but if any nurse, of any speciality, finds a patient with their head stuck in the bed-rails once, let alone twice in one shift, it is not any sort of 'training' that is needed but a large dose of common sense to see that patient needs bumpers fitted and extra checking to keep them safe.
For goodness sake, it is not rocket science is it?
Can't people think for themselves without having a 'tool' to follow as if we are brainless robots?
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mike | 16-Jun-2010 5:19 pm
Anonymous | 16-Jun-2010 12:43 pm, I think you are missing the point slightly here.

Of course the vast majority of adult Nurses have the basic knowledge to deal with basic MH and LD patients, and I like to think we all would have common sense in that situation.

What I am saying is that none of us have the training or specialist knowledge to deal with the vast amounts of MH and LD patients that are on the wards daily, and nor should we be expected to. If adult Nurses are expected to treat MH and LD patients, then maybe MH Nurses should be on the wards with those patients whilst we treat them medically. That would create not only the staff and resources needed to deal with what are often highly demanding patients time and attention wise, but also bring the specialist knowledge that is required to treat them holistically.
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mike | 16-Jun-2010 5:25 pm
Sorry hit submit when I didn't mean to then.

As I was saying, I think it is completely wrong to blame Adult Nurses for a lack of knowledge and training, when we should not be expected to have that specialist knowledge.

I would not expect a mental health or LD Nurse to have in depth knowledge of emergency trauma or how to treat COPD or spot the signs of renal failure, etc. In the same way, would a medical Doctor be expected to have the same specialist knowledge as a Psychologist? They are both Doctors after all? We have different specialisms for a reason.
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Anonymous | 17-Jun-2010 7:56 pm
But how many more acute trusts are holding off employing Learning Disability liaison Nurses/or LD advisors due to finanacial restraints? When the patient has a learning disability.General nurses need the support and guidance of LD nurses in acute general hospitals - as do acute mental health nurses - The LD nurse role is to support and enable the individual with a learning disability to access mainstream health services - and then support mainstream professonals to provide the best outcome for that individual.
The old adage of if you don't use it you will lose it - LD nurses are a minority Support the need for them in your local acute trusts and use those LD nurses who are still working in community teams to support acute staff and support patients in your care.
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mike | 17-Jun-2010 11:01 pm
Anonymous | 17-Jun-2010 7:56 pm, now there you have a good point. Trusts are not employing enough Nurses across the board, and I believe should be brought to task for this legally.

But I have to say though, it is actually quite difficult to use the services of LD Nurses and getting hold of the MH liason is a nightmare sometimes, I would love to use them more, but often cannot.
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judith willis | 18-Jun-2010 7:59 pm
Yes anonymous 12.43 and could not agree with you more.

This was a physical recurring problem that should have been addressed. Any nurse, whether general, paediatric, learning difficulties or mental health, should have intervened for the safety of the patient.

As you stated, not rocket science, but plain common sense...
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Anonymous | 18-Jun-2010 8:05 pm
A lesson to be learnt on both sides then. Sometimes I feel I am touting my trade when going around my local acute Trust sharing info & putting up information posters about how to contact me for info/advice etc Offering teaching to staff. Even so my referrals are still coming from primary care rather than the acute trust & often I have to chase after the discharge team to enable a coordinated discharge for patients with learning disabilities. I don't know what the answer is - all I know is that I beleive do our best both as individual general & LD nurses but sadly due to lack of support from the top our best often is not good enough
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Anonymous | 18-Jun-2010 8:15 pm
And judith I do agree with you that it was a physical reccurring that should have been addressed ...........An an error that cost Mr Flack his life but an error it seems within that particular ward that could have occurred to many a patient and not just one who had a learning disability due to the lack of safe systems and risk management plans. But for those vulnerable patients with learning disabilities we don't seem to be learning our lessons Remember Death by Indifference.................... and the many other reports that have told of our failings both within the acute hospital and LD trusts
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karen davies | 19-Jun-2010 7:25 pm
I would just like to say that as Community LD Nurse, if any of our patients are admitted to hospital our Health Facilitation Team(HFT) are informed their role is to liase with the ward,complete a patient hosp book so all staff know about the patient and whome they should contact, it is then the role of the C/N to keep in contact with staff, if there is no no C/N involved then the (HFT) Will stay involved these are also qualified LD nurses.
I cannot comment on MH Nurses but as an LD Nurse it works well for our Trust.
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mike | 21-Jun-2010 8:52 am
Karen, I think that is great, but that simply does not happen in my trust. As I said earlier, it does seem, for both LD and MH patients, that they are just shipped off to our wards so we can provide medical care, with no advice, input, or more importantly extra staff resources to help care for them.
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Anonymous | 21-Jun-2010 8:28 pm
Why beat about the bush - name and shame those trusts who do not have good liaison services with learning disability teams - but lets also name and praise those trusts like those for whom karen works
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tich x | 22-Jun-2010 0:44 am
i agree more and more with mike's comments. at times its only theoretical that u have that input/support from LD & MH teams. if you are lucky you get a phone call enquiring about diagnosis and a bit of information on patients usual/normal routine. the support then dries. its like saying you need 6 nurses on a shift but then most of the time only 4 or 5 are expected to carry out these duties. why cant these support teams make an effort to visit patients known to them even for a minute or two in hospital without being asked.

in my trust if for instance a patient need to be seen by psychiatric team, the senior drs make the decision, then write a referral, then patient gets a visit from a junior psychiatric dr, then snr one.... well i have lost track whether this will take 3, 4, or 5 days.
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Lisa Oluyinka | 24-Jun-2010 3:43 pm
We can continue to argue this till the next election and nothing would be done. There is a 54% chances that a person with LD would be admitted into a general ward than the rest of the population. Employ more LD qualified nurses on general wards and not just as liason nurses only, And they would be able to give the appropriate care needed. Simple.
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