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.”