The report was commissioned by the Prime Minister and Secretary of State for Health, Jeremy Hunt, after the failure of Mid-Staffordshire NHS Trust earlier this year. 

Janine Tregelles, Chief Executive of learning disability charity Mencap, commented:

Since 2007, we have worked with close to 100 families who have lost loved ones with a learning disability, supporting them to seek justice through the NHS complaints process, the inquest system and professional regulatory bodies, like the GMC. Recent research has shown that 1,200 people with a learning disability die avoidably within the health service every year.

Families have found the complaints process slow, bureaucratic and defensive. Many have been bereaved in traumatic circumstances, yet have waited years to reach some form of justice for their loved one. This culture of delay and defensiveness means the NHS has been failing to learn lessons and take the steps needed to prevent further avoidable deaths and serious incidents.

Ann Clwyd's review makes powerful and much needed recommendations for change, which we welcome. Families have waited too long for change, we now need to see strong government leadership on delivering these changes, so that we achieve a high quality independent complaints process, with enforceable standards, and support on hand for patients and families to make their concerns known.


For more information or to arrange an interview with a Mencap spokesperson or a case study, contact the Mencap Press Office, on 020 7696 5414 or

About Mencap

There are 1.5 million people with a learning disability in the UK. Mencap works to support people with a learning disability, their families and carers by fighting to change laws, improve services and access to education, employment and leisure facilities. Mencap supports thousands of people with a learning disability to live their lives the way they want.

For advice and information about learning disability and Mencap services in your area, contact the Learning Disability Helpline on 0808 808 1111 (9am-5pm, Monday-Friday) or email