Cumbria Safeguarding Adults Board (CSAB) have released a report today into the death of Judy Benn, who died of twisted bowel in the Cumberland Infirmary in April 2014.
Judy Benn had a learning disability and required 24 hour care in a supported home environment during her life. In addition to this, Judy had lifelong history of bowel problems including chronic constipation.
Judy was unable to verbally communicate although she could make her feelings clear to those who knew her through her own pattern of communication.
This included rubbing her stomach or pointing to her teeth when she was in pain and clapping to say ‘no’. Due to her condition, she was assessed to lack capacity to consent to medical treatment herself.
A coroner’s inquest concluded there was no blame attached to an individual or organisation for Judy’s death; however they did note that Judy had died of a treatable condition.
The review highlighted that Judy’s communication issues and learning disability played a key part in her not being admitted to hospital earlier, which subsequently lead to her untimely and avoidable death.
Jeanette McDiarmid, Independent Chair of the Cumbria Safeguarding Adults Board, said:
“On behalf of the Board, I firstly want to apologise to Judy’s family for the delay in publishing this report and I fully understand the added trauma this will have placed on the family.”
“This is a tragic set of circumstances and highlights that professionals must do more to understand the care and support needs of individuals with a learning disability and ensure that these needs are prioritised during any health assessment.”
A Safeguarding Adults Review has been carried out to identify lessons to be learned from the case in respect of how professionals and organisations work together, and how the findings of this report can improve practice in the future.
Jeanette went on to say: “Cumbria Safeguarding Adults Board and individual board members have fully accepted the recommendations within the report and safeguarding partners have made significant changes to practices and procedures for adults with a learning disability since Judy’s death.”
Following the review, the CSAB have stipulated the introduction of more robust and effective methods to co-ordinate and disseminate healthcare information across practitioners and medical settings; as well as additional training of medical staff both in hospital and the community. This includes a programme of audit and inspection across services specifically focused on the care of individuals with a learning disability.
David Blacklock, CEO of People First, said: “We were very pleased to be asked to carry out this independent review and would like to thank the Benn family for their cooperation throughout this extremely difficult process. It was a privilege to get to know about Judy’s life and we feel this report is unique in that you get a real sense of who she was.”
“We are disappointed in the delay in publishing this report and the added uncertainty that will have placed on the family. The report has identified a number of lessons that must be learnt to prevent something like this from ever happening again, and that more information and training must be made available to health professionals and services in the community. We are confident the changes outlined will help to ensure the needs of people with learning difficulties are managed more effectively in the future.”
Judy’s family have worked closely with the CSAB throughout the process and had this to say on the report:
“The publication of the report and joint agency action plans will ensure that there is a greater emphasis towards the promotion of the health and wellbeing of people with a learning disability. It is our hope as a family that this report will help work toward a positive future legacy from Judy’s premature death.”
Read the full report here: