Reducing Repeat A&E Attendances for People With a Learning Disability Through Proactive Admission Avoidance
Repeat A&E attendances for people with a learning disability are rarely “bad luck.” They typically indicate unmet health needs, inconsistent escalation, weak reasonable adjustments or risk management that focuses on immediate crisis rather than prevention. Strong hospital avoidance, admissions and delayed discharge is achieved when prevention and escalation are embedded into learning disability service models and pathways, supported by governance and day-to-day practice discipline.
This article sets out how providers reduce repeat A&E attendance through operational measures that can be evidenced.
What drives repeat A&E attendance
Common drivers include:
• Unrecognised pain or deterioration (constipation, dental pain, infection, epilepsy changes)
• Communication barriers leading to late escalation
• Inconsistent staff confidence and decision-making across shifts
• Lack of timely primary care access or LD nurse input
• “Safety defaulting” where hospital becomes the only recognised option
Proactive health monitoring and early escalation
Providers reduce attendance by strengthening routine monitoring and escalation:
• Structured health observation prompts aligned to the person’s baseline
• Clear thresholds for action (who to call, when, and what information to provide)
• Consistent use of health passports and reasonable adjustment plans
• Tracking patterns (e.g., repeated abdominal pain episodes) to prevent recurrence
Operational example 1: preventing attendance through constipation pathway
Context: A person attended A&E repeatedly with agitation and distress. No clear cause was documented beyond “behaviour.”
Support approach: The provider introduced a structured physical health investigation and escalation approach.
Day-to-day delivery detail: Staff implemented a bowel health monitoring tool, hydration prompts and diet adjustments, and escalated early to primary care with clear symptom summaries rather than narrative notes. The provider arranged a GP review and medication adjustment, and staff were trained to recognise pain indicators specific to the person.
Evidence of effectiveness: A&E attendances reduced significantly. Records showed fewer distress episodes, and governance review documented a clear learning loop linking health monitoring to reduced admissions.
Consistency across shifts: avoiding “rota risk”
Repeat attendance often spikes during nights/weekends when decision-making is weaker. Providers that address this use:
• Standard escalation scripts (what to report, what to ask for)
• On-call clinical/manager support for staff uncertainty
• Shift handover templates that flag emerging health concerns and actions taken
Operational example 2: reducing out-of-hours attendance through on-call decision support
Context: A person frequently attended A&E out of hours due to staff concern about seizures and risk.
Support approach: The provider strengthened on-call decision support and seizure management planning.
Day-to-day delivery detail: Staff used a seizure action plan with clear red/amber/green thresholds. The on-call manager required staff to provide a structured update (baseline, observed changes, interventions already tried, current risks) before deciding on hospital attendance. The provider ensured rescue medication competence and documented reviews after each episode.
Evidence of effectiveness: Out-of-hours attendance reduced, and when hospital attendance did occur, it was better evidenced with clear clinical rationale.
Reasonable adjustments in A&E to prevent escalation and admission
When A&E attendance is necessary, poor reasonable adjustments can push the situation toward admission. Providers should ensure:
• A&E knows the person’s adjustments in advance (quiet space, reduced waiting, familiar supporter)
• Staff attend where appropriate to support communication and de-escalation
• The hospital passport is up to date and actively used
Operational example 3: avoiding admission through adjustments and de-escalation
Context: A person attended A&E after a fall. Previous attendances escalated to admission because the person became distressed in busy environments.
Support approach: The provider implemented an A&E adjustment plan and ensured staff attendance.
Day-to-day delivery detail: The provider alerted A&E in advance and requested a quieter space. Staff brought familiar sensory items, used the person’s communication prompts, and supported compliance with assessment steps. The provider documented what worked and updated the adjustment plan for future attendances.
Evidence of effectiveness: The person was assessed and discharged same day without restraint, sedation or admission. Records showed reduced distress and clearer clinical documentation.
Governance: turning attendance data into prevention
Providers should evidence that A&E attendance is reviewed, not simply recorded. Strong governance includes:
• Monthly review of attendance reasons and trends
• Identifying preventable causes and implementing action plans
• Multi-agency discussion where repeat attendance persists
• Senior oversight where attendance suggests systemic failure
Commissioner expectation
Commissioners expect providers to reduce avoidable A&E attendance through proactive health monitoring, clear escalation pathways, and evidence that system working is preventing repeat crisis.
Regulator / Inspector expectation (CQC)
CQC expects people to receive safe, person-centred care that anticipates and prevents harm where possible, with risk managed proportionately and learning applied to reduce repeat incidents and avoidable hospital use.
Conclusion
Repeat A&E attendance is a quality signal. Providers that build prevention into daily practice, support staff decision-making and use governance to drive improvement can demonstrate reduced admission risk and stronger system credibility.