NHS failings in cases of three learning disabled people used as catalyst to tackle institutional care

The experiences of people who use learning disability services and their families will become the focus of inspections, the Care Quality Commission (CQC) said in a report today which highlighted the cases of three people treated badly in NHS-funded learning disability services.

The report, which makes a series of recommendations to improve care for people with learning disabilities, stemmed from an event that the CQC and Challenging Behaviour Foundation (CBF) held after discovering Lisa, who spent nine years locked away with no interaction with staff bar having meals handed to her and her hair brushed through a small hatch in a door.

The delegates at the event also discussed the preventable death of Connor Sparrowhawk and the detention for over 10 years of former Winterbourne View resident Kayleigh in assessment and treatment units. see box.

It also described how what should have been short-term placements turned into long-term institutional care with people “stranded many miles from their homes and families” for long periods. Ending inappropriate and long-term hospital placements is the goal of the government’s programme to transform care after Winterbourne View; however, a target to achieve this aim by 1 June has been missed.

Delegates at the event came up with a series of recommendations including the ones below.

They said there should be a commitment from the Royal College of Psychiatrists and and the Royal College of Nursing to uphold professional standards for care and welfare of patients in learning disability care services as part of moves to make the health and care system focused on the people that use it.

The report said data from the annual learning disability census and quarterly NHS England figures should be used to identify who is in hospital and for how long in order to reduce the number and length of long-term detentions. Additionally the revised Mental Health Act 1983 code of practice, which is due for publication in October, should set out parameters for use of long-term detention under the Act.

It also recommended that Health Education England make a plan with measurable outcomes to ensure there are enough local, multidisciplinary, community learning disability services staffed with skilled professionals.

The report said the planning of transition from children’s to adults’ services is “poor across the country” and said there should also be a national audit of child and adolescent mental health services.

It said a group of lawyers should set out the legal issues involved in the cases of the three people profiled in the report resulting in a publication on rights and responsibilities and guidance for the Crown Prosecution Services on prosecutions of patients with learning disabilities.

The report said that more independent advocacy services should be used and made available because service users do not routinely have access to good-quality advocacy.

It also recommended the creation of a national strategy for secure services for learning disabilities to ensure people get the services they need rather than ending up in ones that are more secure than they require.

The CQC and CBF will hold another meeting in September to see what progress has been made on the actions in the report.

Vivien Cooper, chief executive of the Challenging Behaviour Foundation, said: “We know how to support people well and we know the importance of valuing families as key partners. There is no excuse for getting it wrong.”

Kayleigh’s mother Wendy Fiander, said: “These three lives are just the tip of a very large iceberg. We need to ensure that our most vulnerable and voiceless people are cared for as individuals with dignity and respect. In order to achieve this we must make families integral to any plans for their future. It is abhorrent that such appalling situations continue to occur in the aftermath of Winterbourne View and together we must pledge to stop it.”

Connor’s mother Sara Ryan, said: “Three lives, and three stories that are beyond shameful. It’s time to stop talking and act to change the paucity of aspiration and provision for learning disabled people.”