James Maughland

Hospitals (other than psychiatric hospitals) should review how they deal with the admission of patients with learning disability or mental illness and devise a protocol for identifying such patients and to ensure that there is proper communication with them not only on admission but throughout their stay in such hospitals.

Where there is a patient in a general hospital who is learning disabled or suffering from mental illness, doctors and nurses should take care to pay attention to close family members of the patient who may be the only effective mouthpiece for the patient. In such cases the fact that communication is coming from a family member should be noted in both the medical and nursing notes in such a way that anyone looking at the notes would be aware that was the case and that information regarding the patient may not be coming from the patient himself.

What is said by family members on behalf of the patient should be carefully recorded in notes in such a way as to make it clear to anyone reading the notes in future that the information may have been obtained otherwise than from the patient direct.

Patients with learning disability or mental illness who require to be treated in a general hospital should, where possible, be treated in open or general wards and not side rooms. This would minimise the risk of the patient, especially one who will not or cannot communicate effectively, being isolated and would reduce the risk of matters which an otherwise well patient might be able to draw to the attention of nursing staff being missed or ignored.

Where such a patient is admitted to a general hospital more care should be taken to make sure that everyone who might be involved with his or her care is fully aware of how the patient's learning disability or mental illness presents and of any specific problems which may be encountered as a result of such disability, illness or presentation.

Where there is a difficulty in communication with such a patient, steps should be taken as early as possible on admission to note such difficulty in a prominent place in the medical and nursing notes. Thereafter steps should be taken to ensure that the patient has access to appropriate advocacy services especially where there is no close relative who can act as advocate.

Consideration should be given to the feasibility of specialist nurses (with appropriate training in learning disability and/or mental illness) being available in general hospitals to assist with patients who have a learning disability or a mental illness. This would be more important where the patient has no close relative or friend to assist in communication with medical or nursing staff. I understand that this may be an area which the Scottish Executive has addressed in its considerations. If it is then I would urge that it be treated with a degree of urgency.

Where doctors or nurses become aware that nutrition is an issue in relation to a patient steps should be taken at the earliest stage to involve a dietician and to ensure that the patient receives an adequate diet.

A protocol needs to be developed whereby nutritional issues are identified and acted upon at an early stage of admission to hospital. Someone, be that a doctor or nurse, should be given specific responsibility for monitoring a patient's nutritional status, making a proper record of same and drawing it to the attention of those responsible for treatment. Given some of the comments I make later regarding the difficulties with the nursing notes it would do no harm to identify a form of note dedicated solely to nutrition and designate an appropriate person to maintain that note and accept general responsibility for ensuring that sufficient nutrition is achieved.

A study should be undertaken with a view to developing a standard system for the keeping of medical and nursing notes in general hospitals.

Whatever the case it seems to me that there is a strong argument for the system to be looked at with a view to producing a coherent and easily managed system of nursing notes.

Where possible, entries in nursing notes, particularly in the type of notes used at Liff Hospital, should contain the time the note is made and not simply a reference to the date or morning, afternoon or evening.

It appeared from the evidence that there is something approaching a culture among doctors of not looking at nursing notes. If that is a culture then steps should be taken to eradicate the culture.

In the interests of both patient care and risk management, appropriate and sufficient resources should be made available to allow all notes to be promptly and properly filed and thereafter kept in an easily accessible form so that they comprise an accurate, chronological and fully detailed record of all matters relating to the patient.

I suggest that, if it has not already been done, attention be given to the provision of such items as neck collars in Liff Hospital and other such establishments where falls are likely to happen. It follows from this that there would also require to be appropriate training of nursing staff.

It was also a matter of some surprise that, having heard from an expert witness brought in by the NHS Trust about the benefits of a hospital having a falls protocol, that there was no evidence to suggest that any such protocol has ever been considered far less established at Liff. If it has not been done then it should be and, standing what was heard about the number of unseen falls, it should be done with a degree of urgency.

Where incidents occur which necessitate the completion of an Incident Report form (IR1) and supporting witness statement(s) and a doctor is called to see the patient following such incident, steps should be taken as quickly as possible after the incident to have the doctor see and initial the Incident Report form and any relative statements.

A system should be devised which allows patients or relatives to make complaints or observations regarding any aspect of treatment in a manner that is both transparent and easily understood.

There should be a system on a ward which is capable of registering all complaints of whatever nature and which explains clearly how complaints are to be dealt with, to whom they should be directed and from whom a response is likely to be received.

Where a patient is found to have acquired an MRSA there should be clear and easily understood guidelines and advice for the patient and any visitors in relation to precautions which may require to be taken, hygiene and any other relevant matters regarding prevention or treatment of infection.

Further, where a MRSA is found that fact should be flagged up in the medical notes rather more clearly than it was here.

Consideration should be given to the possibility of training nursing staff in appropriate wards in general hospitals in the care and management of patients with learning disability or mental illness.

The primary legislation covering Fatal Accident Inquiries is clear in its terms and it may be appropriate that guidelines be prepared covering cases where an Inquiry "might" be held as opposed to cases where it "must" be held. Consideration should also be given to procedures.

I would urge that some consideration be given to regulating the evidence and procedure in Fatal Accident Inquiries. Fair notice of criticism which is likely to be made would be a start. There would have to be a corresponding obligation on all parties, particularly the Crown, to disclose all evidence and likely productions at an early stage. Careful consideration should be given before allowing any late lodging of expert reports as witnesses who have already given evidence will not have had the opportunity to comment on such reports.

If a Fatal Accident Inquiry is to be held then notice of such Inquiry should be given at an earlier stage than at present.

Inquiries should, where possible, proceed on a day to day basis to a conclusion. Accordingly, once there is a realistic estimate of the time required, there should be allocated sufficient court resource to enable the Inquiry to proceed continuously.

If Fatal Accident Inquiries are to be held they should be accorded sufficient priority within the system to enable them to be held a reasonable time after death.