Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI...
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![Page 1: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/1.jpg)
Confidential Inquiry into the deaths of people with learning disabilities
Pauline Heslop and the CI teamNorah Fry Research CentreUniversity of Bristol
![Page 2: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/2.jpg)
Aims of the CI• To detect potentially avoidable and modifiable contributory
factors in the care of a person with learning disabilities who has subsequently died
• To identify inadequate pathways of care or gaps in the treatment
• To contribute to the evidence base for best clinical and professional practice
• To provide information to guide the commissioning of services
• To establish a usable system for reporting the deaths of people with learning disabilities that can be replicated
• To improve the standard and quality of care for people with learning disabilities and ultimately their health outcomes.
![Page 3: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/3.jpg)
How will we do this?
Notification
![Page 4: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/4.jpg)
How will we do this?
Notification
Data collection
![Page 5: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/5.jpg)
How will we do this?
Notification
Data collection
Talking to people
![Page 6: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/6.jpg)
How will we do this?
Notification
Data collection
Talking to people Looking at records
![Page 7: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/7.jpg)
Local Review Panels
Notification
Data collection
Talking to people Looking at records
• Potentially modifiable factors in relation to the death • Was the death expected?• Was the death premature?• Good practice• Learning points• Recommendations
![Page 8: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/8.jpg)
Overview Panels• Key risk factors• Management of these• Inadequate pathways of care• Data improvements• Good practice• Learning points
![Page 9: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/9.jpg)
How are we doing so far?
• Investigating the deaths of all people with learning disabilities in Avon and Gloucestershire
• Started investigating deaths 1st June 2010
• 50+ deaths reported and being investigated to-date
• Some amendments to the process have been made
• Experienced pool of investigators and nurses in place
• Many cases do involve potentially modifiable factors
• Some changes being made to local practice as a result of practitioners being involved in the CI process
![Page 10: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/10.jpg)
What will happen in the future?
Submit a report to the Department of Health
Work collaboratively with the Learning Disabilities Observatory
Write an easy read report to share with people with learning disabilities
![Page 11: Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol.](https://reader030.fdocuments.us/reader030/viewer/2022032803/56649e1f5503460f94b0aaf7/html5/thumbnails/11.jpg)
Confidential Inquiry into
the deaths of people with
learning disabilities
For further information:
Email: [email protected]
Website: www.bris.ac.uk/cipold/