Ombudsman's reports damning indictment of NHS says Mencap

Tuesday 24 March 2009

Mencap's response to Six Lives: the provision of public services to people with learning disabilities

- the Health Ombudsman and Local Government Ombudsman's report into the six deaths identified by Mencap's Death by Indifference report

Mark Goldring, chief executive of learning disability charity Mencap, said:

"The Ombudsman's reports are a damning indictment of NHS care for people with a learning disability. They confirm the findings in Mencap's Death by Indifference report 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.

"There is clear evidence in the Ombudsman's reports that several doctors failed in their duty of care and in their legal responsibility under the Disability Discrimination Act. Health professionals ignored their patient's 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.

"Mencap believes the Ombudsman should have been more critical of the failure of GPs to obey disability and human rights law. We cannot agree with the Ombudsman's conclusions that some of the actions taken were acceptable because other doctors would have acted in the same way. We welcome her overall findings in respect of the message to all health professionals that the rights of people with a learning disability must be respected, including their right to good quality health care. We would, however, have liked to see individuals held accountable where they have not met required standards.

 "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. 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."

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Notes to editors

Mencap's Death by Indifference report

The report contained evidence that people with a learning disability were dying unnecessarily due to institutional discrimination in the NHS. Death by Indifference contained six cases where people had died unnecessarily due to widespread ignorance and neglect within the NHS.

For copies of Mencap's Death by indifference report visit: www.mencap.org.uk/deathbyindifference

• Martin Ryan, aged 43, went without food for 26 days whilst he was in hospital following a stroke. By the time staff realised what was happening, he was too weak to be helped. Martin died on 21 December 2005. He had a severe learning disability and no speech.

• Doctors told Emma Kemp, aged 26, that she had a 50:50 chance of survival, but decided not to treat her as they believed she would not cooperate with treatment. Emma, died of cancer on 25 July 2004. She had a severe learning disability, which meant that she sometimes exhibited challenging behaviour and had difficulty in communicating how she felt when she was upset or scared.

• Mark Cannon, aged 30, died eight and a half weeks after being admitted to hospital with a broken leg (femur). He was clearly distressed and in pain, screaming and banging his head, but he had to wait three days to see the pain team. Mark died on 29 August 2003.

• Ted Hughes, aged 61, was discharged three weeks after being admitted to hospital for a minor operation, despite his condition having been assessed as 'concerning' because staff didn't want to meet his extra needs. He collapsed and died the following day on 27 May 2004. He had a severe learning disability and had virtually no speech.

• A hospice consultant recommended that 20 year old Tom Wakefield's pain was investigated by a gastroenterologist over a year before he died. No action was taken until it was far too late. Tom's expressions of pain weren't listened to and he died on 25 May 2004. He had profound and multiple learning disabilities.

• Warren Cox, aged 30, died following perforation of the appendix. His mother and father repeatedly asked whether Warren had appendicitis or a blocked bowel when doctors visited Warren. They were told Warren had a virus. Warren died on 25 September 2004. He had a severe learning disability and very little speech, but he could make himself understood to his family.

Mencap

• Mencap works with people with a learning disability and their families and carers.
• 1.5 million people in the UK have a learning disability.
• A learning disability is caused by the way the brain develops before, during or shortly after birth. It is always lifelong.
• Learning disability affects someone's intellectual and social development all their life. People with a learning disability find it harder than others to learn, understand and communicate.
• People with a learning disability don't get an equal chance in life. Mencap fights to change laws and services and to provide better access to education, employment and leisure facilities, supporting thousands of people with a learning disability to live their lives the way they want.
• It is not a mental illness and should not be confused with mental health issues. It is not dyslexia or aspergers syndrome.
• It used to be called mental handicap but we don't use this term anymore because most people with a learning disability find it offensive.
• For information about learning disability issues please call the Learning Disability Helpline (England) on 0808 808 1111
• For online press information, go to www.mencap.org.uk/press