Serious case review

In respect of X (deceased)
(Died 6 September 2006)
30 November 2009
X had Epilepsy and Autism Spectrum Disorder (ASD). His family home was in
Nottingham, but his parents took the decision that he would be better cared for in
specialist accommodation. Accordingly, during 1996 he became resident at a
specialist residential unit in Lincolnshire.
Following several seizures in 2006 his usual prescribed medication (Epilim) was supplemented by Keppra. Keppra should have been administered twice each day at 9am and 9pm. On Saturday 2 September 2006 night staff completed an entry in a handover/communication book indicating that X was about to run out of Keppra. No immediate steps were taken to obtain further supplies and records show that at 2100 on Sunday 3 September 2006 X had his last dose of Keppra. At 0910 on Wednesday 6 September 2006 he was found dead in bed. By this time he had missed four doses of Keppra and had been due a fifth at 0900 that day. An inquest jury later concluded that the failure to provide Keppra had materially contributed to his death. The jury also decided that systemic failures in relation to stock keeping, record keeping, and a lack of sufficient training, communication and vigilance by staff to follow policy and procedures had all contributed to the death.

On 15 May 2008, the Lincolnshire Safeguarding Adults Board agreed that an
independently chaired Serious Case Review should be commissioned.
The review terms of reference were:
To examine the circumstances leading up to the death of X with a view to establishing: Whether there are lessons to be learned about the way in which professionals and others involved in the case worked together to protect X. Whether policies and procedures applying to the placing and host Adult Social Services authorities were correctly followed. Whether arrangements for Adult Protection Case Conferences involving a number of placing and a host authority require review. Based on the findings of the inquest and the result of the Serious Case Review, identify individual and systemic issues which may have contributed to treatment of X falling short of expected standards and make recommendations to inform action plans aimed at overcoming these. FINDINGS
Policy and Procedures at the Residential Unit

The serious case review panel were provided with extensive documentation by the
management of the unit and also took account of evidence provided at the Coroners
Inquest. Having considered information from these sources the panel identified
failings in relation to staff qualifications, management, supervision and training. It
was also clear that communication between management and across staff teams was
poor or not appropriately responded to. This resulted in staff closely involved in the
care of X failing to correctly follow policy and procedures and in turn brought about
the lack of an adequate and safe service to X (Recommendations 1-5).
Lessons to be learned about the way in which professionals and others involved
in the case worked together to protect X

The review panel found that professionals and others did not always work well
together to protect X.
Problems were identified in the regulatory system governing the operation of the unit.
Resources applied to the inspection and monitoring of activity were not sufficient to
be able to rely on the findings of Commission for Social Care Inspection (now CQC)
and local authority quality assurance processes. Examples of this include failures to
discover that National Minimum Standards were not adhered to or that Department of
Health Circular (LAC 93(7) had not been followed by placing and host authorities. In
fact, the review panel reached the conclusion that across the country LAC 93(7) is
almost routinely ignored. Joint yearly reviews of the suitability of X’s treatment at
the unit had not been conducted each year by the placing and host authorities.
The review panel came to the view that the use of the terms ‘Requirement’ and
‘Recommendations’ within CQC Inspection Reports may be misleading to the general
public. CQC inspection reports are available to the public and are a valuable source
of information when seeking a suitable and safe care home in which to house loved
ones. It is therefore critical that inspection reports and other monitoring activity
provide accurate information on which to base such decisions (Recommendations 6 -

Events after 6 September 2006

At the time of the death there were three residents from within Lincolnshire at the unit
and because the police investigation was given precedence these service users were
not promptly risk assessed. Service users from outside Lincolnshire were not risk
assessed because placing authorities and self funding residents (total about 30) were
not formally informed of events until other local authorities were contacted inviting
attendance at an adult protection strategy conference in May 2007. Although criminal
investigations should be given precedence there is no reason why information should
not be shared to safeguard vulnerable adults and a multi agency investigation for this
purpose commenced at an early date.
Seven representatives of local authorities outside Lincolnshire attended the May 2007
meeting and eight sent apologies. At the later case conference meeting one
representative from another authority was present but nine others did not respond to
The parents of X have indicated that they were not contacted to discuss process and
timescales or made aware of developments until they were contacted and asked to
contribute views to the serious case review. This served to aggravate an already
distressing situation and is not acceptable.
When the Serious Case Review commenced, letters were sent to all placing
authorities asking for comments on their placements at the unit (to include a negative
response). Very few responses were received. It is in the interests of all local
authorities placing service users in other areas to cooperate with serious case reviews.
If thorough reviews are not carried out other vulnerable adults are likely to be
needlessly placed in danger.
The Department of Health is currently conducting a review of ‘No Secrets’. Part of
that review is looking at whether participation in adult safeguarding serious case
reviews should be made mandatory. (Recommendations 14-20).

Recommendation 1
The unit’s management should ensure that senior on site management take
responsibility for ensuring that middle level management and more junior staff
perform their roles in line with company policy and procedures. The fact that
this responsibility cannot be passed to others should be made clear to those

Recommendation 2
The unit’s management should ensure that managers and other supervisors at all
levels have suitable qualifications linked to the key tasks expected of them.
Recommendation 3

Newly appointed managers and other supervisors should be provided with
suitable mentoring and personal development plans and performance should
then be monitored to provide evidence of achievement.

1 No Secrets: guidance on developing and implementing multi-agency policies and procedures to protect vulnerable adults from abuse (London: DH2000). Recommendation 4
The unit’s management should ensure that all staff receive the required levels of
supervision and that issues raised are responded to in an appropriate manner
and decisions on any required changes recorded. If management decide that no
action is necessary in relation to issues raised staff should be informed of the
decision and its rationale.

Recommendation 5
The unit’s management should ensure that all staff employed in a capacity where
they are likely to be involved in the administration of anticonvulsant and other
prescribed medication are aware of the purpose of the medication and the
importance of administering it to service users in line with medical advice.

Recommendation 6
The DH may wish to consider reinforcing the contents of Local Authority
Circular 93(7) and place increased emphasis on compliance with its contents, in
particular that the duty of placing local authorities to inform host authorities of
placements, must be complied with.

Recommendation 7
Lincolnshire County Council Adult Social Care Department should consider
whether the staffing and terms of reference of the Quality Assurance Team
should be reviewed, so that in future similar problems to those revealed at the
unit would be more likely to be identified and tragedies such as the death of X
Recommendation 8
Nottingham City Council Adult Social Care Services should ensure that when
service users are placed in other Local Authority Areas, correct procedures are
followed and the host authority informed of the placement.
Recommendation 9
Nottingham City Council Adult Social Care Services should ensure that yearly
reviews of placements within other authorities take place and that information
from the host authority forms a part of the review of care arrangements.
Recommendation 10
Lincolnshire County Council Adult Social Care Department should consider
how to ensure that proper information exchange takes is achieved between host
and placing authorities to assist good and thorough care reviews at the unit and
other similar care settings.

Recommendation 11

The Care Quality Commission should seek consultations and review whether it is
possible to remove the different approaches to resolving issues arising from the
use of the terms Requirements/Recommendations in Inspection Reports.
Recommendation 12

The DH may wish to consider whether National Minimum Standards should
become legally enforceable.
Recommendation 13
The Care Quality Commission may wish to consider providing sufficient
resources to conduct detailed inspections of care provider settings. Alternatively
it should be made clear on inspection reports and the Commission’s website that
inspection reports provide a limited rather than detailed view on performance.

Recommendation 14
Lincolnshire Safeguarding Adults Board should ensure that in the event of a
serious incident within a care setting multi agency procedures are promptly
instigated with a focus on investigating adult safeguarding concerns and
safeguarding other service users.
Recommendation 15

Lincolnshire County Council Adult Social Care Department should ensure that
where a serious incident within a residential care setting occurs, placing
authorities are formally informed at an early date. A thorough assessment of
risk should include the desirability or otherwise of also informing the
families/carers of service users.

Recommendation 16

Lincolnshire County Council Adult Social Care Department and Nottingham
City Council Adult Social Care Services should ensure that if service users suffer
death or serious injury their families/carers should be contacted at an early
stage, fully informed of the circumstances, provided with a named contact and
thereafter kept up to date with ongoing developments.
Recommendation 17

The DH may wish to consider circulating advice to Local Authorities reinforcing
a duty to contribute to Adult Safeguarding Investigations and Case Conferences
held outside their areas, but involving residents placed by them in that area.

Recommendation 18
Lincolnshire Safeguarding Adults Board should review its multi agency
procedures to ensure that POVA list notifications are made as soon as
practicable after a serious incident
Recommendation 19
Lincolnshire Safeguarding Adults Board should ensure that decisions on
whether to conduct a Serious Case Review are taken swiftly, if necessary outside
its usual quarterly meeting cycle. Any review should be started promptly and
steps taken to secure cooperation and information gathering from involved

Recommendation 20

The Department of Health should consider whether the events described in this
review require that legislation should enforce participation in serious case
reviews by those holding relevant information.
On 18 June 2009 the Lincolnshire Safeguarding Adults Board accepted the above
recommendations. The Board also agreed to bring the review report to the attention of
the Department of Health and the Care Quality Commission so that recommendations
relating to national policy might be considered at the appropriate level.
An Action Plan was agreed and this will be reviewed to ensure recommendations are
reviewed and implemented.
Finally I take this opportunity to thank review panel members and others contributing
to this review. In particular I record my thanks to X’s parents who despite their great
feeling of loss have treated me with every courtesy and provided detailed information
to assist the review process. I formally express my condolences for the loss of a much
loved son and the hope that this review might help bring some form of closure, in the
knowledge that its recommendations may help avert similar tragedies.
Roger Vickers
Independent Adult Safeguarding Consultant
Serious Case Review Panel Chair


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