Whittington Hospital forgot policy that may have saved life of patient with learning disability

The hospital that failed Gerald Yilmaz brought in special procedures three years ago that may have saved his life – if doctors had not forgotten about them.

The Whittington Hospital’s A&E department introduced a ‘learning disability pathway’ in May 2010, which was designed to tackle the widespread misdiagnosis of people with learning impairments.

The five-page policy, seen by the Ham&High this week, outlined special checks that should be made during initial assessment of a patient.

However, by the time Mr Yilmaz arrived in July last year, it had fallen into disuse.

Gerald’s brother Muhammed said: “When we found out that the policy existed, we were amazed. We have been given no valid explanation for why it was dropped even now.

“I think it would have improved the probability of him surviving if it was followed.”

The pathway tells nurses to consider a number of key factors, including whether the person could have a serious condition “that may be diagnostically overshadowed by their learning disability”.

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It also stresses the importance of listening to carers or family, saying “they may be able to give a very clear and accurate report of changes in the person”.

The lead consultant in the Whittington’s emergency department, Dr Duncan Carmichael, has admitted that he had no idea the policy existed until Mr Yilmaz’s case brought it to light. He said it was forgotten partly because of a high turnover of staff.

As part of a wide-ranging action plan drawn up in response to Mr Yilmaz’s case, the Whittington A&E department has pledged to re-implement it. It will also provide training to all staff and has appointed a new consultant who will act as a learning disabilities champion.

Dr Richard Jennings, the Whittington’s director of integrated care and acute medicine, said: “We recognise that we failed Gerald and are extremely sorry for that. This tragedy has shown we had gaps in our provision and we need to fill and strengthen these gaps.

“We’re very committed to our patients with learning disabilities getting the same quality of care as people without learning disabilities.”

The family is concerned new measures will once again be allowed to slip.

However, Dr Jennings insisted: “We will ensure it doesn’t happen again with an upgraded level of attention.

“Learning disability is going to have a higher profile in the trust than it had before.”