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Safe and Wellbeing Reviews: Thematic Review and Lessons Learned


On 21st February, the government published its report entitled Safe and Wellbeing Reviews: Thematic Review and Lessons Learned. The review is part of the NHS response to the safeguarding adults review concerning the deaths of Joanna, Jon and Ben at Cawston Park. Detailed powerpoints about their cases can be downloaded from the Edge website


This national review was to check the safety and wellbeing of all people with a learning disability and autistic people who are being cared for in a mental health inpatient setting. One significant area of concern is the number of people inappropriately in hospital when they should be in the community with support. The report explains:


"Across England, 59% of individuals were regarded as having care and treatment needs that could only reasonably be delivered in hospital. This varied by region, with South West having the lowest proportion of individuals (47%) and London having the highest proportion of individuals (73%) who were regarded as having care that could only reasonably be delivered in hospital. Notwithstanding the data limitations as highlighted below, the key conclusion from these figures is that, at the point of the SWR, 41% of patients had needs that could be met in the community with appropriate support."


Other concerns included inappropriate medication being given to people and physical healthcare concerns such as: "people with a high body mass and significant weight gain following being admitted to hospital, including instances where this led to people

developing diabetes."



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