Latest mortality review report finds 'pace with which reviews are conducted needs to increase'

The third annual report of the Learning Disability Mortality Review Programme published in May 2019 provides an update on the learning emerging from this area of work. It gains more significance given the recent Health Service Journal coverage on the amending of LeDeR reports.

This NHS England and NHS Improvement report is the first report on work to translate learning into action. It provides examples of local changes that have been made to services so far (see: Annex 4 at pages 28 – 34).

They are concerned that the latest LeDeR report cites deaths reviewed where there were concerns about the quality of care and an average age of death 23 years younger than the general population for men and 27 years younger for women.

NHS E/I have confirmed that they will provide funding (£12m) to clinical commissioning groups to support them to complete outstanding reviews / ensure they are completed within six months of notification. There will also be investment to secure the long term future of the LeDeR programme.

An action plan has been developed to ensure prompt and effective action is taken to address the learning identified about factors that contribute to premature mortality (see: Annex 3 at pages 21 – 27).

A learning into action collaborative has been set up to better coordinate national responses.   

They emphasise that it is vital that work is shared across all services (including A&E services and outpatients), if changes are to be made that will save people’s lives (and not just within the learning disability sector).

The report covers sepsis, constipation, dysphagia and cancer.

With regard to the Mental Capacity Act, the latest report notes that the need for better understanding and appreciation of the MCA has already been highlighted. Problems with the level of knowledge about the MCA amongst professionals and concerns about capacity assessments not being undertaken and best interests procedures not being followed are noted.

Respond, the learning disability charity, have been commissioned to work with a group of bereaved family carers to develop resources to enhance the experiences of families involved in LeDeR reviews.

We have a large team who can assist with training on the MCA or risk management – do get in touch if you require support.

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