NHS and council failings in six cases involving people with learning disabilities led to prolonged suffering and at least one avoidable death.
That was the verdict of an investigation by the health service and local government ombudsmen into the care given to the six people who died between 2003 and 2005.
Death by indifference
The inquiry was sparked by a 2007 report by Mencap, Death by Indifference, which argued that all six were victims of institutional discrimination against people with learning disabilities in the care they received, and their deaths were unavoidable.
Although today’s report centred on 16 NHS trusts and three local authorities in southern England, the ombudsmen were concerned at the capacity of services across the country to provide person-centred care for people with learning disabilities.
The report urged every health and social care organisation in England to conduct urgent reviews of the quality of their services in this area.
Four complaints upheld
The ombudsmen upheld complaints in four of the six cases involving seven NHS trusts and two councils in Gloucestershire, Buckinghamshire, Berkshire and London.
And they found the death of Mark Cannon, 30, in August 2003, was a consequence of “service failure” (see box right).
Agencies were severely criticised for poor leadership, communication, co-ordination between agencies, and care planning, which led to an “unacceptable” standard of care.
The ombudsmen called for compensation of £120,000 to the four families where complaints were upheld for the distress caused.
Complaints not handled well
The families complained directly to the organisations and the Healthcare Commission, but most of the complaints were not handled in a satisfactory way, the report found.
Local government ombudsman Jerry White said: “This was a major source of dissatisfaction, grievance and injustice for the families.”
White said all the authorities had access to extensive information about good practice involving people with learning disabilities, such as the Department of Health’s 2001 white paper, Valuing People.
However, many of them failed to observe the principles of fairness and respect under the Human Rights Act 1998 or provide reasonable adjustments under the Disability Discrimination Act 1995.
Mencap: Damning indictment
Mencap chief executive Mark Goldring said the ombudsmen’s report was a “damning indictment of NHS care for people with a learning disability”.
He said: “Health professionals ignored their patients’ agonising pain, they failed in a number of cases to successfully diagnose the health problem until it was too late and they ultimately contributed to the unnecessary deaths of their patients.”
However, he said the health ombudsman, Ann Abraham, should have been more critical of GPs involved in the cases, and said the charity and the individuals’ families would consider referring some of the doctors to the General Medical Council.
Independent healthcare inquiry
On the back of Mencap’s 2007 report, the government commissioned an independent inquiry on access to healthcare for people with learning disabilities, chaired by former NHS chief executive Sir Jonathan Michael.
Michael’s report, published in July 2008, said the NHS was failing to ensure equal access to care for people with learning disabilities because services were failing to make reasonable adjustments, as required by the DDA, and there was “very limited” clinical training about the client group.
In January, the government announced a “confidential inquiry” into the premature deaths of people with learning disabilities who had received NHS care, as recommended by Michael.