A guide to best practice dementia care: lessons learnt from a serious case review

This reflective paper discussed a clinical scenario and compares best practice guidelines with published literature against a backdrop of evidence taken from a serious case review (SCR). Mrs B (pseudonym) was a 94 year old lady with dementia and blinds, plus several other co-morbidties, including a previous stroke, She lived in a care home and had a history of falling. The last fall was fatal, due to aspiration pneumonia and fractured vertebrae of the neck. A serious case review process highlighted a number of failures in interdisciplinary working practice which contributed ultimately to Mrs B's avoidable death. The article discusses how applying evidence based best practice could have led to better care outcomes. A series of severn recommendations and lessons learned are presented for multi-agency approach to best practice in dementia care