HSIB: Medicine omissions in learning disability secure units (23 June 2022)

Summary

This Healthcare Safety Investigation Branch (HSIB) investigation explores medicines omission among patients with learning disabilities who are cared for in medium and low secure wards in mental health hospitals. A medicine omission is when a patient doesn't receive medicines that have been prescribed to them, and the investigation focused on a number of factors that could contribute to omission:

• the environment in which medicines administration takes place
• the availability and use of learning disability nurses in these environments
• the skills required for nurses to help patients with learning disabilities be involved in choices about their medicines.

For it's reference event, the investigation looked at the case of Luke, who was detained in a medium secure ward of a mental health hospital. He spent 21 months on the ward before moving into a low secure ward at the same hospital, where he stayed for a further 11 months. Both wards were specifically designated for patients with learning disabilities. While at the hospital, there were a number of periods when Luke was not given the physical health medication he had been prescribed for his diabetes and high cholesterol. Although Luke’s medication record regularly noted that Luke refused the medication, Luke and his Mother disagreed with this version of events, stating that other factors led to Luke’s medicine omissions.

Content

Findings

• The design, layout and décor of wards affected the behaviour of patients and the ‘atmosphere’ on wards.
• Wards that resembled a living space, rather than a clinical environment, were considered by the investigation to have a calmer, happier atmosphere.
• Current guidance on ward design and layout did not reflect current clinical thinking in relation to medicine administration areas.
• The number of learning disability nurses recruited by the NHS each year is currently matched by the number of learning disability nurses leaving the NHS each year.
• NHS England and NHS Improvement has found the retention aspect of its All-England plan for learning disability nursing (attract, retain, develop, and celebrate) harder to implement than the other three aspects.
• In the sites visited by the investigation it was common for registered mental health nurses to fill rota gaps for learning disability nurses.
• The competencies and skills of learning disability nurses and mental health nurses differ when considering how patients are engaged in taking medication. This was rarely considered when using mental health nurses to fill learning disability nurse staffing vacancies.
• Electronic prescribing and medicines administration (ePMA) systems observed by the investigation were not interoperable with electronic patient records systems.
• In the observation sites the investigation visited, medicines omissions were not automatically alerted to the prescribing or Responsible Clinician (the clinician with overall responsibility for a patient being treated under the Mental Health Act).
• The number and descriptions of reasons for medicines omissions varied across ePMA systems and between hospitals.

Safety recommendations

• HSIB recommends that NHS England and NHS Improvement reviews and updates all health building guidance relating to learning disability secure units to reflect current clinical guidance on ensuring the design and layout provides a suitable environment for patients and staff.
• HSIB recommends that NHS England and NHS Improvement develops the ongoing work to improve the retention of learning disability nurses, in line with the intent of the All-England plan for learning disability nursing.

Safety observations

• It may be beneficial if electronic prescribing and medicines administration (ePMA) systems were interoperable with electronic patient records (EPR) systems to allow details of medicines omissions to be alerted to staff automatically from the ePMA system to the EPR system.
• It may be beneficial if user menus on electronic prescribing and medicines administration (ePMA) systems provided clear differences and reasoning for the categories used to record medicines omissions.
• It may be beneficial if organisations that use mental health nurses to cover shortages of registered learning disability nurses review their clinical model and conduct a training needs analysis. The aim of this would be to identify skills or training requirements, to make sure mental health nurses have the relevant communication methods and strategies to assist patients with learning disabilities in taking their medication.