Safety watchdog finds shortage of learning disability nurses risks medicine omissions

The Health and Care Act 2022 establishes the Health Services Safety Investigations Body as a fully independent non-departmental public body of the Department of Health and Social Care in England.

The Healthcare Safety Investigation Branch will commence a year-long transition as a shadow Arms Length Body, during which they will have a chair, non-executives and executive team appointed for the HSSIB. They expect to begin operating as HSSIB in April 2023.

Against this background, the Healthcare Safety Investigation Branch recently published a report, which concludes that some patients with learning disabilities in mental health hospitals are not receiving medicines that are prescribed to them in respect of their physical health issues.

HSIB have made two recommendations to NHS England and NHS Improvement to improve patient safety in relation to medicine omissions, by changing mental health ward environments and retaining learning disability nurses.

The context

The investigation began following notification in 2019 by the mother of a “long stay” mental health patient with learning disabilities named Luke. Luke had, during several periods, not been administered the physical health medication prescribed for his diabetes and high cholesterol. The Terms of Reference are set out at paragraph 3.3.1.

HSIB visited mental health hospitals across the country to observe work in practice and reflect on how environment affects patient and staff behaviour.

It had been regularly documented on his medication chart that Luke had “refused” medication but he and his mother told the investigation there were other reasons. 

The investigation noted confusion amongst staff in terms of categories to select to record an omitted medication, that there was no option to record the fact the patient was sleeping, staff did not apply any latitude in respect of forecasted times to administer meds, clinical notes did not accurately report omissions and the “Staying Healthy” section of the notes did not reference them either.

From a risk management perspective, there was no guidance or protocol on escalation of instances of omitted medication and no alerts were created in the system. There ended up being a disconnect between what the prescribers thought was happening and what the administering nurses were actually doing

It was thought that being able to refuse medication gave patients a sense of reasserting some control given they could not refuse under the MHA. The investigation observed that choice of language is especially important in wards who treat people with communication or cognitive needs.

Analysis showed that no recordings of MCA assessments were witnessed during the investigation either and that there was a gap between the aims of hospital community LD settings and LD secure units because where self -administration was encouraged medicines omissions were reduced.

Key findings

  • The design, layout and decoration of wards affected ‘atmosphere’ and the behaviour of patients
  • Wards resembling a living space were considered to have a calmer, happier atmosphere
  • The current guidance regarding ward design / layout did not reflect current clinical thinking regarding medicine administration areas
  • The number of learning disability nurses recruited by the NHS annually was equal to those leaving the NHS annually
  • NHS England and NHS Improvement has found the retention aspect of its plan for learning disability nursing the most difficult to implement
  • It was common for registered mental health nurses to fill rota gaps for learning disability nurses, despite the difference in competencies and skills of learning disability nurses and mental health nurses when considering how patients are engaged in taking medication
  • Electronic prescribing and medicines administration systems observed by the investigation were not interoperable with electronic patient records systems
  • Medicine omissions were not automatically alerted to the prescribing or Responsible Clinician
  • The number and descriptions of reasons for medicines omissions varied across electronic prescribing and medicines administration systems and between hospitals


  • NHS England and NHS Improvement should:
    • Review and update all health building guidance relating to learning disability secure units to reflect current clinical guidance on ensuring the design and layout provides a suitable environment for patients and staff
    • Develop the ongoing work to improve the retention of learning disability nurses, in line with the intent of the All-England plan for learning disability nursing


  • It may be beneficial if:
    • Electronic prescribing and medicines administration systems were interoperable with electronic patient records systems to allow details of medicines omissions to be alerted to staff automatically
    • User menus on electronic prescribing and medicines administration systems provided clear differences and reasoning for the categories used to record medicines omissions
    • Organisations that use mental health nurses to cover shortages of registered learning disability nurses reviewed their clinical model and conducted a training needs analysis, to ensure mental health nurses have the necessary communication methods / strategies to assist patient with learning disabilities to take their medication

HSIB’s findings are intended to improve patient safety in respect of medicine omissions and will be of note to those who work in mental healthcare. The report highlights the significant impact that environment and atmosphere can have on patient behaviour. It also iterates the importance of retaining learning disability nurses, to ensure appropriate staffing levels and skill sets of individuals working with patients with learning disabilities.

If your organisation requires advice in respect of mental health patient issues, please do get in touch with our friendly team of experts.

Our content explained

Every piece of content we create is correct on the date it’s published but please don’t rely on it as legal advice. If you’d like to speak to us about your own legal requirements, please contact one of our expert lawyers.

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