NHS England must do more to meet the needs of people with learning disabilities when they are treated in hospital, the patient safety body said.
The Health Services Safety Investigations Body (HSSIB) found that despite a commitment across the NHS to improve the experience of care for those with a learning disability, "persistent and widespread" safety risks remain.
It is estimated that approximately 2% of adults in the UK — more than 900,000 adults — have a learning disability. Health and care services are required to identify and record the specific needs of each person with a learning disability and make any "reasonable adjustments" to ensure they are cared for safely and effectively. But the HSSIB report found that current systems and processes within the NHS are "not always designed" to enable staff to deliver effective care to people with a learning disability.
Senior safety investigator Clare Crowley said: "Each person with a learning disability will have their own experiences, their own way to communicate, and will come into hospital with unique needs, which will require a tailored set of reasonable adjustments."
Care Needs Not Always Met
The report highlighted the care of a 79-year-old man with a learning disability who was admitted to a hospital unit following a referral from his GP who was concerned about the deterioration of several health problems. During his stay, his needs "were not consistently documented or met", it said.
Its wider investigation found that the biggest safety risks related to a lack of accessible information that sets out patient needs and enables staff to make reasonable adjustments, and limited support or training for staff who are not specialists in caring for patients with a learning disability.
It was "evident that forming long-term friendships, adapting communication, and having a regular routine were important to many", noting how carers stressed that routines "cannot be broken", because without them some people would be "completely lost".
Ms Crowley warned that "if needs are not met, it can cause distress and confusion for the patient and their families and carers and raises the risk of poor health outcomes and in the worst cases, harm".
Current mechanisms for sharing patient information, such as 'care passports' and alert flags on the electronic patient record, could be unreliable, with information often gathered from friends and family, the HSSIB pointed out.
Staff Did Not Always Have Time
Ms Crowley stressed that staff were "trying their best for their patients" but didn't always have the time to meet needs in the way they would like and were not always equipped with the specialist skills and knowledge needed.
The report made several recommendations for improvement, including building a specialist workforce that was appropriately resourced.
Commenting on the findings, Jackie O'Sullivan, acting chief executive of Mencap, said "systemic" barriers faced by patients with learning disabilities in having their health needs met were "appalling".
Saffron Cordery, deputy chief executive of NHS Providers, said: "Investing in training programmes would help equip hospital staff with the skills, knowledge, and confidence needed to provide effective care to patients with learning disabilities."