Welcome to the latest edition of my blog series, Prioritising Patient Safety.
It's been a year since I first started writing these blogs. They have been well received with positive feedback, and I want to thank you for your continued interest and support.
Each month, we publish between 70 to 100 of our casework decisions as a way to share learning that will help organisations improve their service and prevent mistakes happening again.
Through this blog, I try to highlight some of the cases we see to share good practice and findings from our casework more widely. I hope this helps colleagues across the NHS use the power of complaints to improve patient safety. I also provide a round-up of wider NHS patient safety developments.
In this edition, I will:
- share two cases involving patients with disabilities and the improvements one Trust has made
- highlight key themes emerging from our casework
- provide updates on external patient safety work from NHS Resolution, the Freedom to Speak Up Guardian and HSSIB.
Learning from patient experience: people with learning disabilities
We are sadly seeing an increasing number of cases relating to care and treatment provided to people with learning disabilities. Recent reports have highlighted that adults in England with learning disabilities die on average 20 years earlier compared to the rest of the population. Two recent cases we have investigated show some of the challenges facing these patients and their families.
Chris's story
Chris was in his 30s with significant physical and learning disabilities. He was admitted to the emergency department (ED) feeling generally unwell. He was initially thought to have a chest infection. Chris was unable to articulate for himself what was wrong with him. His family and carers were there for him to do this. His family and carers were concerned about his excessive belching and abdominal discomfort and expressed this to the clinicians caring for Chris.
Chris had a chest x-ray. The quality was not good due to his physical disabilities but clinicians used the results to diagnose pneumonia. He was treated for possible sepsis and started on the sepsis pathway but there was a delay in starting treatment. Although he had an initial response to antibiotics, Chris continued to be in pain. He vomited, continued to belch excessively and had ongoing abdominal pain.
As Chris's condition continued to deteriorate, it was decided he needed further investigation including a CT scan. By the time this was done, Chris had suffered a stomach perforation secondary to a volvulus (twisted stomach). Sadly, Chris was too unwell by this point and he died.
Our investigation found that there was a missed opportunity to manage and investigate Chris’s symptoms differently given how he presented in ED and the history his family gave on his behalf. It also found that the pain relief Chris was given as he was dying was inadequate.
The Trust's response
We organised a meeting with the Trust to discuss our findings and asked that the Trust's Patient Safety Specialist attended. This was a very positive meeting, and it was clear the Trust had taken action as a result of this complaint.
The Trust shared with us some significant changes it had made following the complaint. These included:
- dedicated 15 hours per month for a learning disability nurse in the ED
- training for all ED staff on learning disabilities (Oliver McGowan training)
- learning disability champions in the ED.
Andy's story
Andy, in his mid-40s, was disabled and lived in supported care. He had a urinary catheter and frequently developed urinary tract infections (UTIs) which usually required treatment with intravenous (IV) antibiotics.
Andy was admitted to hospital by his GP with a UTI. The GP had seen the urine test results and confirmed Andy required IV antibiotics. However, once Andy arrived at hospital, the GP's request was ignored. Instead, clinical staff decided to prescribe Andy on oral antibiotics — the choice of which were readily available from a community pharmacy with a GP prescription but not at the hospital pharmacy.
Andy could not articulate his needs independently. His mum told clinical staff that whenever Andy was admitted to hospital, he needed IV antibiotics. She was ignored. Andy's mum assumed he was receiving the oral antibiotics for his infection. He wasn't. Andy did not receive any treatment for the UTI he was admitted with for over 30 hours.
Sadly, Andy’s condition worsened and he was discharged back to his care home, where he died.
Our investigation found that Andy's death was avoidable. Unfortunately, in the Trust's initial response to Andy’s mum, they made no reference to the delay in giving him antibiotics and the impact this had. We are still working with the Trust to look at what they can do to prevent this happening again to others.
'Shambles' as man dies from sepsis after 34-hour medication delay - BBC News
Key themes from our casework
These cases, and others like them, have helped us identify some recurring themes:
- Care for vulnerable adults: People with significant learning disabilities face additional barriers to getting timely and appropriate treatment.
- Communication with families and carers: Despite trying to advocate for their loved ones, families are too often ignored by clinical staff.
- Commissioning of learning disability services: In Chris's case, learning disability services were not commissioned to provide care over the weekend. He was referred to them on the Friday when admitted but the referral was picked up on the Monday — the day after he died.
- Candour: In Andy's case, the complaint response made no reference to the delay in receiving appropriate antibiotics, disregarding the Duty of Candour to be open and honest.
Unfortunately, we are seeing several cases similar to the ones I've described. I would like to encourage Trusts and other organisations to share any examples of good practice with us that we may be able to share more widely.
What's new in the world of patient safety
Alongside our casework, we continue to contribute to wider patient safety improvements across the NHS and like to publicise work other organisations are doing:
- NHS Resolution has published a thematic review on delayed diagnosis of cancer in general practice. They are also running a webinar on 5 February 2026.
- Freedom to Speak Up Guardian: We were thrilled to be asked to participate in Freedom to Speak Up Week. You can watch our Lunch and Learn webinar, 'The importance of candour and action', on YouTube.
- HSSIB has published a report on patient care in temporary care environments, which is worth reviewing.
- Patient safety update from the NHS National Patient Safety Team.