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Medicine omissions in learning disability secure units

HSIB legacy content

HSIB legacy content

This investigation was carried out by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Easy Read report

You can download an Easy Read version of the report 'Medicine omissions in learning disability secure units' (PDF). It doesn't include all of the original information, but it will tell you about the important parts.


This investigation explores medicines omissions (that is, patients not receiving medicines that have been prescribed to them) among patients with learning disabilities who are cared for in medium and low secure wards in mental health hospitals.

The investigation focused on:

  • 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.

The investigation used the following real event, referred to as ‘the reference event’, to examine the patient safety issues associated with omitted medicines, specifically the effects of the built environment and the communication between staff and patients.


We would like to thank Luke and his Mother, whose experiences are documented in this report. We would also like to thank the healthcare staff who engaged with the investigation for their openness and willingness to support improvements in this area of care.

Reference event

Luke was detained, through the justice system, 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.

During his time at the hospital, there were several periods when Luke was not administered the physical health medication that had been prescribed for his diabetes and high cholesterol. Luke’s medication record regularly noted that Luke refused the medication. However, Luke and his Mother disagreed with this version of events, stating that other factors led to Luke’s medication omissions.

The national investigation

Luke’s Mother referred his story to HSIB to consider the issue of omitted medicines in the care of patients with learning disabilities being cared for in mental health hospitals.

The investigation visited mental health hospitals in different areas across the country to observe work in practice, and compared older sites to new-build hospitals, reflecting on buildings guidance and the effect this has on patient and staff behaviour. The investigation has considered work that NHS England and NHS Improvement has started to review the relevant buildings guidance. The investigation has reinforced and strengthened this work through a safety recommendation.

The investigation noted the importance of staffing levels and skillsets for learning disability nurses and mental health nurses in medium and low secure units.

Across the whole of the healthcare system there is a shortage of registered learning disability nurses. This has been recognised and highlighted by NHS England and NHS Improvement, and Health Education England.

Mental health nurses are commonly used to fill rota gaps for learning disability nurses, without necessarily being given the right skillsets to do so.

Communication methods are key to ensuring that patients comply with their medication regimes. NHS England and NHS Improvement, with Health Education England, has launched the ‘All-England plan for learning disability nursing’, which aims to ‘attract, retain, develop and celebrate’ learning disability nurses.

The plan sets out a variety of short-term and long-term ambitions for learning disability nursing. The investigation was told by NHS England and NHS Improvement that all of these are subject to regular review.

NHS England and NHS Improvement told the investigation that the retention element of the All-England plan is linked to the wider nursing workforce retention strategy. The investigation heard from senior staff that this remains the most challenging element of the plan.


  • 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.