Doctors could face disciplinary action by the General Medical Council following the damning conclusions of a report by the Health and Local Government Ombudsman into the deaths of six patients with learning disabilities.
One man Martin Ryan who had Down’s syndrome, epilepsy and no speech died several weeks after having a stroke. While in Kingston hospital, the 43-year-old who had lost his swallow reflex went 26 days without being fed despite constant appeals by his parents.
By the time staff realised what was happening some 18 days after admission it was too late to save him The hospital was criticised: death could have been avoided “had the care and treatment provided not fallen so far below the relevant standard”.
Mark Cannon, 30, died eight weeks after being admitted to Barking, Havering and Redbridge Hospitals NHS trust with a broken thighbone.
The report "Six lives: the provision of public services to people with learning disabilities" described Mr Cannon as clearly in distress and pain, screaming and banging his head, but he waited three days to see a pain team and developed an infection. The Ombudsmen said that his death could have been avoided and that it occurred as a consequence of “service failure and maladministration”.
Complaints were upheld against the hospital and council - he was in a care home when he was first injured.
In two of the four other cases failings in care were in part due to the fact they had learning disabilities. In the two final cases care was found to be inadequate but could not be put down to discrimination against their learning difficulties
Ann Abrahams, the Heath Ombudsman, and Jerry White, the Local Government Ombudsman, said that the investigations as a whole revealed that the care for people with learning disability in the NHS and social care is “at best patchy and at worst an indictment of our society”.
“We have not upheld all the complaints, but the very nature of our thorough and impartial investigations serves only to heighten the sense of outrage at the treatment received by most of the people involved.”
They upheld complaints against Buckinghamshire hospitals NHS trust, Gloucestershire county council, Cheltenham and Tewksbury primary care trust, Gloucestershire partnership NHS foundation trust, Kingston hospital NHS trust, London borough of Havering, Barking, Havering and Redbridge hospitals NHS trust, Royal Berkshire NHS foundation trust, and the Healthcare Commission. However, they decided the GPs involved in the cases were not to blame.
But the learning disability charity Mencap whose report initially uncovered the failures in all six cases said the Ombudsman should have been more critical of GP failings to obey disability and human rights law.
Mencap chief executive Mark Goldring said the findings were "damning". "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."
The Ombudsmen have ordered that all NHS and social care organisations in England should review urgently the effectiveness of the systems to enable them to meet the full range of needs of people with learning disabilities in their areas.
They must also examine the capacity and capability of the services they provide and/or commission for their local populations to meet the additional and often complex needs of people with learning disabilities.
Watchdogs at the Care Quality Commission, Monitor and the Equality and Human Rights Commission are also being asked to satisfy themselves that their monitoring and performance assessment procedures in terms of health and social care organisations meet the statutory and regulatory requirements in relation to the provision of services to people with learning disabilities.
They also recommend that the Department of Health should promote and support the implementation of these recommendations, monitor progress against them and publish a progress report within 18 months.