'Distressing failures' led to deaths of people with a learning disability

Tuesday 24 March 2009

The Health Ombudsman's report on the six deaths featured in 'Death by indifference' has revealed 'significant and distressing failures'.

The Health and Local Government Ombudsmen today published their findings on the events surrounding the deaths of six people with a learning disability who died in NHS care.

The six people, highlighted in Mencap's 'Death by indifference' report, include Mark Cannon, who died aged 30. He was admitted to hospital with a broken leg, but died of bronchopneumonia after a catalogue of serious failings that left him in severe pain. The Health Ombudsman, Ann Abraham, concluded that he died as a consequence of public service failure. She also concluded that it was likely the death of Martin Ryan (pictured left) could have been avoided.

The Health Ombudsman's report reveals ‘significant and distressing failures' in health and social care services. People with a learning disability experienced ‘prolonged suffering and poor care', and some of these failures were for disability related reasons.

"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," said Ann Abraham. The report recommends that NHS and social care organisations in England urgently review the effectiveness of the systems and services they have in place.

Mark Goldring, Mencap's chief executive, said: "The reports confirm the findings in 'Death by indifference' of the widespread failure by health professionals to provide the proper level of care and highlight an appalling catalogue of neglect of people with a learning disability."

The Ombudsman did not, however, find service failure regarding the practice of any GP. This is despite evidence that doctors failed in their duty of care and legal responsibilities under the Disability Discrimination Act.

"Although the reports are a big step forward for people with a learning disability, it is not the end of the journey for all the families," said Mark Goldring. "We will continue to fight for justice for the families and, with them, consider referring the individual doctors who failed in their duty of care to the General Medical Council."

Find out more about the Ombudsman's report.

Read Mencap's response to the reports on each of the six cases.

Support the Death by indifference campaign.

Have your say on the Ombudsman's report.