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Learning from Lives and Deaths - People with a Learning Disability and autistic people (LeDeR) - A Dudley Case study

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The Dudley Safeguarding Adults Board recently discussed Roger who was 68 years old when he died, his learning disability was recorded as Downs Syndrome, and he appeared to have led a happy and healthy life.

During his last 6 months of his life he did not present with any serious illnesses, the LeDeR review looked at his interactions with partners and professionals around his health. Learning and good practice that came out of the review was:

1. The learning disability annual health check were completed yearly, but due to Covid restrictions, his last health check was completed over the telephone with his carer. The recommendation is that an annual health check should be completed face to face, ensuring that cardiac assessment can be completed as per the Royal College of General Practitioners – Syndrome Specific defects.

2. Roger could have accessed proactive dementia screening from the age of 30, but there is no evidence if this had happened. The recommendation is to promote the Dementia Screening pathway across Dudley.

3. There is evidence that paramedics followed procedure in regard to CPR and made every attempt and effort to resuscitate

4. Lack of follow up from LA following an assessment for aids and adaptations. The recommendation LA rep at panel to share the Rogers case study with Adult Social Care.

The case study is available on our Further Information page.


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