Intended for healthcare professionals


People with learning disabilities were treated “less favourably than others”

BMJ 2009; 338 doi: (Published 25 March 2009) Cite this as: BMJ 2009;338:b1261
  1. Zosia Kmietowicz
  1. 1London

    Investigations into complaints about the care of six people with learning disabilities in England has found that “significant and distressing failures” in the treatment they received from health and social care services led to the death of one and probably one other.

    A lack of leadership and failure to understand the law in relation to disability discrimination and human rights at some of the 20 bodies involved in the care of the six people led to them being treated “less favourably than others, resulting in prolonged suffering and inappropriate care,” says the health service and local government ombudsmen who carried out the investigations.

    Mencap, a charity for people with learning disabilities, asked the ombudsmen to investigate the deaths of the six people, all of whom died between 2003 and 2005 while in NHS or local authority care, on behalf of their families. The charity believed that they all died unnecessarily as a result of receiving substandard care because of their learning disabilities, which it highlighted in a report published in March 2007.

    The ombudsmen upheld complaints of poor treatment in four of the six cases. They also found that in four cases the public bodies concerned had failed to live up to principles of human rights, especially those of dignity and equality.

    The ombudsmen’s report was also critical of the way that complaints were handled by some of the three local councils, 16 NHS bodies, and the Healthcare Commission. Altogether the ombudsmen recommended payments totalling £120 000 (€130 000; $180 000) to the families whose complaints were upheld. The Healthcare Commission was also asked to apologise for mishandling complaints in four of the six cases.

    The ombudsmen’s findings “are a shocking indictment of services which profess to value individuals and to personalise services according to individual need,” the report says.

    The investigations found that Mark Cannon, who had severe learning disabilities and epilepsy, died at the age of 30 after three hospital admissions following a broken thigh bone. The ombudsmen concluded that the injury, which happened in a care home run by the London Borough of Havering, could have been avoided and that he should not have died from his injury.

    The investigation into Mr Cannon’s treatment by Barking, Havering, and Redbridge University Hospitals NHS Trust uncovered various failings, including inadequate pain relief; poor assessment, observation, and monitoring; and discharge arrangements that did not meet standards set out in national guidelines. The service failures were “at least in part for disability related reasons,” says the report.

    The ombudsmen also concluded it likely that the death of Martin Ryan, a 43 year old man with learning disabilities, Down’s syndrome, and epilepsy and who was unable to speak, could have been avoided had he not received substandard care. Mr Ryan was left unable to swallow after a stroke and was not fed for 26 days. By the time the team at Kingston Hospital realised what was happening, Mr Ryan was too weak to have a feeding tube fitted.

    Ann Abraham, health service ombudsman for England, said, “The recurrence of complaints across different agencies leads us to believe that the quality of care in the NHS and social services for people with learning disabilities is at best patchy and at worst an indictment of our society.”

    Jerry White, local government ombudsman, said that the investigations showed the need for stronger leadership throughout the health and social care professions, not just those concerned with learning disabilities.

    The ombudsmen recommend that NHS bodies and councils determine as a matter of urgency whether they have the correct systems and culture in place to protect individuals with learning disabilities from discrimination, in line with existing laws and guidance.

    They also call on the bodies responsible for regulating health and social care services to ensure that their regulatory frameworks and monitoring systems assess whether the needs of people with learning disabilities are met and to report their findings within 12 months.

    The Department of Health should report on the progress made by organisations to comply with the recommendations within 18 months, they said.

    Kathryn Hudson, deputy health services ombudsman, said that a new single complaints process for health and adult social care will come into effect on 1 April, when the new Care Quality Commission takes over the work of the Healthcare Commission, the Commission for Social Care Inspection, and the Mental Health Act Commission. Currently there are three levels of complaints: if complaints are not resolved locally they go to the Healthcare Commission before being referred to the ombudsman. However, after the Healthcare Commission is dismantled, there will be just two levels, which will speed up the process and give the public more direct contact with the ombudsmen, she said.


    Cite this as: BMJ 2009;338:b1261


    • Six Lives: The Provision of Public Services to People with Learning Disabilities is available at

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