confidential inquiry into the deaths of people with learning disabilities pauline heslop and the ci...
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Confidential Inquiry into the deaths of people with learning disabilities
Pauline Heslop and the CI teamNorah Fry Research CentreUniversity of Bristol
Aims of the CI• To detect potentially avoidable and modifiable contributory
factors in the care of a person with learning disabilities who has subsequently died
• To identify inadequate pathways of care or gaps in the treatment
• To contribute to the evidence base for best clinical and professional practice
• To provide information to guide the commissioning of services
• To establish a usable system for reporting the deaths of people with learning disabilities that can be replicated
• To improve the standard and quality of care for people with learning disabilities and ultimately their health outcomes.
How will we do this?
Notification
How will we do this?
Notification
Data collection
How will we do this?
Notification
Data collection
Talking to people
How will we do this?
Notification
Data collection
Talking to people Looking at records
Local Review Panels
Notification
Data collection
Talking to people Looking at records
• Potentially modifiable factors in relation to the death • Was the death expected?• Was the death premature?• Good practice• Learning points• Recommendations
Overview Panels• Key risk factors• Management of these• Inadequate pathways of care• Data improvements• Good practice• Learning points
How are we doing so far?
• Investigating the deaths of all people with learning disabilities in Avon and Gloucestershire
• Started investigating deaths 1st June 2010
• 50+ deaths reported and being investigated to-date
• Some amendments to the process have been made
• Experienced pool of investigators and nurses in place
• Many cases do involve potentially modifiable factors
• Some changes being made to local practice as a result of practitioners being involved in the CI process
What will happen in the future?
Submit a report to the Department of Health
Work collaboratively with the Learning Disabilities Observatory
Write an easy read report to share with people with learning disabilities
Confidential Inquiry into
the deaths of people with
learning disabilities
For further information:
Email: [email protected]
Website: www.bris.ac.uk/cipold/