Inadequate hospital care for learning disabled
Failures in basic care, pain assessment, missed examinations, and escalation for learning-disabled adults in hospitals.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
2 inquiry recs
25 PFD reports
33 committee recs
15 HSSIB recs
57 CQC actions
4 PPO recs
30 IMB recs
9 IMB reports
1 Scottish FAI
1 DHR rec
43 PHSO decisions
32 LGO/SPSO decisions
3 CQC enforcement actions
4 LeDeR reports
1 MNSI report
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(2)
R29 — Patient weighing equipment
Recommendation: Health Boards should ensure that there is appropriate equipment in each ward to weigh all patients. Patients should be weighed on admission and at least weekly thereafter and weights recorded. Faulty equipment should be repaired or replaced timeously and a …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
17 — Improve Furness General Hospital delivery suite
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify options, with a view to implementation as soon as practicable, to improve the physical environment of the delivery suite at Furness General Hospital, including particularly access to operating theatres, …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Unknown
Prevention of Future Deaths reports(25)
Mohammed Chaudhury
Concerns: The coroner identified concerns regarding the development and deterioration of pressure sores due to inadequate nursing care, including a failure to turn patients regularly, missing care plans, and inconsistent Waterlow scoring. Additionally, nursing rotas were unavailable, understaffing was reported, and the safety of current staffing levels for high-dependency patients could not be confirmed.
Overdue
Norma Sheppard
Concerns: The coroner noted considerable confusion regarding Mrs Sheppard’s discharge terms, with the written discharge letter indicating continued subcutaneous fluids while the understanding upon discharge was that she would not receive them. This discrepancy created difficulties in finding a suitable care home.
Overdue
Janet Blackman
Concerns: The coroner noted psychiatric units struggle to provide physical health care and that deep vein thrombosis (DVT) prophylaxis policies were not consistently applied to patients in these units. The report suggests developing a system for integrated physical and mental health care delivery.
Overdue
Jessica Birkhead
Concerns: The coroner noted that mainstream adult services offered to an individual with intellectual disabilities were perceived as unequipped for their specific needs, suggesting a review of appropriate support pathways for similar future cases.
Response (Northern Eastern and Western Devon Clinical Commissioning Group): • The CCG has commissioned services, including primary care nurses and acute care liaison nurses, to support access to mainstream services for people with learning disabilities. • The CCG will … (AI summary)
Response (The Seaton and Colyton Medical Practice): • The practice held an informal Significant Event Audit Meeting following the death. • The practice will hold a formal Significant Event Audit Meeting to discuss the case. • The … (AI summary)
Responded
Dorothy Webb
Concerns: The coroner noted a missed opportunity by a Radiologist to assess a scan, which might have led to further investigation of a mass. There was also a failure to identify a fracture from an x-ray, preventing timely awareness by the patient and family.
Response: • The Trust established a system for monitoring individual Consultant Radiologists' error and discrepancy rates. • Additional training was provided to all reporters regarding the order of image presentation in … (AI summary)
Responded
Julie Barrow
Concerns: The coroner identified insufficient care planning and communication for a patient with disabilities, including no reasonable adjustments care plan despite her needs passport. Other concerns included poor parental accommodation and reduced safeguarding support.
Response (The Department of Health and Social Care): • The Department published Learning Disability Improvement Standards for NHS trusts, which are part of the NHS Standard Contract and will apply to all NHS-funded care by 2023/24. • The … (AI summary)
Responded
Julie Taylor
Concerns: The coroner noted the absence of reasonable adjustment care plans in emergency settings and a lack of formal best interests meetings for key decisions. Concerns were also raised about insufficient inter-agency communication and the limited availability of acute learning disability beds.
Response (Greater Manchester Health and social Care Partnership): • Stockport NHS Foundation Trust confirmed that all adult inpatients must have a Reasonable Adjustment Care Plan, supported by an electronic flagging system and daily emails to senior nurses. • … (AI summary)
Response (the Department of Health and Social Care): • The Department stated that Learning Disability Improvement Standards were published in 2018 and are part of the NHS Standard Contract for 2020/21. • The Department confirmed that Ms Taylor’s … (AI summary)
Responded
William McKibbin
Concerns: The coroner identified insufficient 'tick-box' checks for bed safety in nursing documentation, alongside a lack of guidance for clinical incident investigations. Concerns also included a lack of organisational candour and gaps in inter-hospital information sharing.
Response (NHS England): • NHS England and NHS Improvement is promoting and encouraging NHS employers to complete free online Just and Learning Culture training. • NHS England and NHS Improvement is promoting and … (AI summary)
Response (Manchester University NHS Foundation Trust): • The Trust updated its Falls Investigation Template, Falls Policy, and Intentional Rounding documentation to include additional safety checks for bed brakes and bed rails. • A "First Responder" document … (AI summary)
Response (CQC): • The CQC stated its preference to continue receiving death notifications via the National Reporting and Learning System (NRLS) and Strategic Executive Information System (STEIS), noting that a separate reporting … (AI summary)
Response (Dept. of Health and Social Care): • The Manchester University NHS Foundation Trust apologised for failings in care and the investigation, and stated it had taken significant learning from its reflections. • The Trust confirmed it … (AI summary)
Responded
Alfred Jones
Concerns: The coroner noted prolonged hospital admission due to a shortage of MRI scanner availability and a national shortage of radiology staff, which resulted in the patient having a fall and contracting Covid-19.
Response (GMCA GMHSCP): • The Trust implemented a mobile MRI scanner to provide additional outpatient scanning capacity. • The Trust increased its substantive radiologist workforce and added locum consultants and advanced practice reporting … (AI summary)
Response (NHS England): • NHS England accepted recommendations from an independent review of diagnostic services, which included increasing imaging equipment and workforce. • Funding was targeted for community diagnostic hubs to augment access … (AI summary)
Responded
Juliet Saunders
Concerns: The coroner identified issues with insufficient supervision of junior doctors and poor medical record keeping within the emergency department. These factors contributed to diagnostic overshadowing, a failure to diagnose an acute condition, and inadequate escalation of complex cases, alongside concerns about patient transfer procedures and safety-netting advice.
Response (Queens Hospital): • The Trust implemented a Safeguarding Oncall Manual and a Learning Disability Checklist for use in Emergency Departments. • A new IT system, Care Flow, has been installed, which requires … (AI summary)
Responded
Ben King
Concerns: Concerns included staff non-compliance with observation and dietary policies, incomplete record-keeping, and infrequent multi-disciplinary team meetings that did not address weight management. The coroner also noted issues with a software system and the absence of CCTV.
Response (Jeesal Residential Care Services): • The organisation has made changes to its board structure, including balancing executive and non-executive directors, and will seek independent verification of operational management reports and commission independent staff and … (AI summary)
Response (Norfolk and Norwich University Hospitals): • The Respiratory team now holds daily morning report meetings to discuss cases and refer to other specialities. • The ED clinical governance process has discussed the case to raise … (AI summary)
Responded
Tripta Bhanote
Concerns: The coroner noted a lack of clarity among care staff regarding when to escalate acutely unwell residents to emergency services and the role of the enhanced care team. There were also poor procedures for identifying residents' DNAR status.
Overdue
Arthur Hall
Concerns: The coroner noted an inadequate investigation of possible bowel perforation, including the use of a limited diagnostic tool and missed signs of sepsis. A surgical opinion was not sought when a patient with post-surgical symptoms attended A&E.
Overdue
Freda Lennox
Concerns: A requested echocardiogram was not performed prior to surgery, and the patient was not recently reviewed by the orthopaedic surgeon. There was a lack of funding and resources for a dedicated high-risk consultant-led anaesthetic pre-operative assessment clinic.
Response (St Peters Hospital): • The Trust appointed an anaesthetic lead for high-risk anaesthetic patient pathways. • The Trust established four dedicated high-risk anaesthetic pre-assessment clinics per week, led by consultant anaesthetists. • The … (AI summary)
Responded
John Stiff
Concerns: The coroner raised concerns regarding the lack of increased orthogeriatric provision for elderly patients with hip and pelvic fractures and co-morbidities, noting that improved access to this specialist care could prevent future deaths.
Response (Department of Health and Social Care): • The Department of Health and Social Care stated the NHS Long Term Workforce Plan aims to double medical school places to 15,000 by 2031/32. • It confirmed 205 and … (AI summary)
Overdue
Joseph Maunick
Concerns: The report highlights a national shortage of appropriate care placements and insufficient hospital resources, which meant a patient requiring constant supervision for cognitive impairment could not receive adequate care in an Emergency Department, contributing to a fall.
Response (NHS England): • The Trust plans to share a report with the Integrated Care Board (ICB) to raise awareness of available community resources. • A review will be undertaken with Emergency Department … (AI summary)
Response (Department of Health and Social Care): • A duty for the Care Quality Commission (CQC) to assess local authorities' delivery of adult social care duties went live on 1 April 2023. • The roll out of … (AI summary)
Responded
Shane West
Concerns: Discrepancies existed in laxative administration records, and staff faced challenges assessing the patient's condition due to learning disabilities. Concerns were raised about medical staff's appreciation of the risk of respiratory compromise from abdominal distension related to laxative use.
Response (Swansea Bay University Health Board): • The health board stated it would amend its Serious Incident strategy meeting template to include an explicit question on medication involvement. • The health board committed to developing a … (AI summary)
Responded
Stephen Dulling
Concerns: The coroner identified inadequate assessment and practical advice during a crisis call by Tees Esk and Wear Valley NHS FT. There were also multiple lapses in basic nursing care at York & Scarborough Teaching Hospitals NHS FT, including nutritional management and a delayed response to choking.
Response (Tees Esk & Wear Valley NHS Foundation Trust): • The case will be presented at the Trust Urgent Care Board on 23 January 2025. • Learning from the incident will be shared at various Trust Specialty Clinical Networks … (AI summary)
Response (York and Scarborough Teaching Hospitals NHS Foundation Trust): • The Trust updated its Food, Nutrition and Hydration Policy in November 2024. • New fluid assessment and nutrition assessments are being integrated into the digital patient record, with the … (AI summary)
Responded
Chloe Every
Concerns: Lack of contemporary medical notes, infrequent clinical observations, and a procedure performed without informed consent on an unconscious patient. The report also notes delays in incident reporting and coroner notification, which impacted the investigation.
Response (Barking Havering and Redbridge NHS Foundation Trust): • The Trust provides mandatory training for all staff on learning disability care, including Oliver McGowan training, and is recruiting more nurses with Learning Disability qualifications. • The Trust is … (AI summary)
Response (Department of Health and Social Care): • The Department of Health and Social Care reported that Barking, Havering & Redbridge NHS Foundation Trust (BHRUT) has implemented daily checks by its Learning Disability Team, introduced specific care … (AI summary)
Responded
David Lodge
Concerns: The coroner identified inadequate pain assessment for non-verbal patients and insufficient basic chest examinations for learning disabled adults at risk of pneumonia in the emergency department, alongside inadequate escalation of high NEWS2 scores.
Response (NHS England): • NHS England stated it would disseminate the findings from David's case through its network of health services contacts. • NHS England stated it would inform Medical Royal Colleges and … (AI summary)
Response (CQC): • The CQC had previously issued urgent enforcement action (Section 31) in November 2022 to the Trust due to serious concerns in Urgent and Emergency Care, including the identification and … (AI summary)
Response (Humber Health): • The Trust implemented an action plan to improve pain assessment for non-verbal patients, including distributing guides and posters, and introducing a dedicated pain assessment section in Nervecentre. • The … (AI summary)
Responded
Rose Harfleet
Concerns: The coroner identified insufficient guidance for managing profoundly disabled children in hospital, inadequate parental consultation leading to poor clinical decisions, staff not acting on observations, and the absence of a Learning Disability Liaison Nurse.
Response (NHS England): • NHS England published Health and Care Passport guidance and a template in June 2024. • The Department of Health and Social Care launched the Oliver McGowan Code of Practice … (AI summary)
Response (Royal College of Emergency Medicine): • The Royal College of Emergency Medicine (RCEM) published a Learning Disabilities Toolkit in September 2024, which provides guidance for managing people with learning disabilities and emphasises the importance of … (AI summary)
Response (CQC): • CQC conducted a focused assessment of the Children and Young Persons Assessment Service Group in June 2024. • CQC initiated a review of Rose's case in line with its … (AI summary)
Response (Royal Surrey County Hospital NHS Foundation Trust): • The Trust has implemented mandatory Oliver McGowan Training on Learning Disabilities and Autism for all staff, with specific completion rates noted for paediatric and emergency department staff. • The … (AI summary)
Response (Royal College of Paediatrics): • The Royal College of Paediatrics and Child Health (RCPCH) is revising its Facing the Future: Emergency Care Standards, with publication anticipated in Autumn 2025. • The revised standards are … (AI summary)
Response (Department of Health and Social Care): • The Department stated that Care Quality Commission registered providers are required to ensure staff receive specific training on learning disability and autism, including the Oliver McGowan Mandatory Training. • … (AI summary)
Responded
Myles Scriven
Concerns: The coroner noted GPs had a superficial understanding of regulatory requirements and practicalities for patients with Learning Disabilities and Autism, leading to inadequate adjustments and poor management of the Learning Disabilities Register. Concerns were also raised about the failure to properly record numeric observations and undertake a rigorous internal review for learning.
Response (NHS England): • NHS England stated that over 3 million people have completed the e-learning package of the Oliver McGowan Mandatory Training on Learning Disability and Autism. • NHS England confirmed it … (AI summary)
Response (Dalton Surgery): • Dalton Surgery designated three Learning Disability and Autism champions and ensured all practice staff completed Oliver McGowan Level 1 training. • The practice implemented standard reasonable adjustments for patients … (AI summary)
Response (CQC): • CQC held a Decision Review Meeting (DRM) regarding Dalton Surgery, contacted the practice, and received an action plan. • CQC decided to carry out a full comprehensive inspection of … (AI summary)
Response (CQC): • A Decision Review Meeting (DRM) was held to assess the report and determine a regulatory response. • The CQC is reviewing and will update guidance for inspection teams to … (AI summary)
Responded
Myles Scriven
Concerns: The coroner noted a lack of adjustments for a patient with learning disabilities and autism, despite existing policies and training. Concerns remain regarding the auditing of the impact and compliance of these policies, as identified needs were not consistently acted upon by clinicians.
Response (Calderdale and Huddersfield NHS Foundation Trust): • The Trust revised its quality improvement approach and strengthened leadership for its Learning Disabilities group, including new medical and senior nursing leads. • It implemented the national Oliver McGowan … (AI summary)
Overdue
Pamela Singh
Concerns: The coroner noted the absence of a specific practice tool in Wales for family and care staff to recognise and escalate signs of acute deterioration in people with learning disabilities. This lack contributes to avoidable deaths from conditions such as pneumonia, despite recommendations to adopt such tools.
Response (the Department for Health and Social Care Wales): • The Welsh Government launched the Paul Ridd Learning Disability Awareness Training Programme for NHS staff in April 2022, which over 80,000 staff have completed. • The Welsh Government is … (AI summary)
Responded
Jacqueline Aarons
Concerns: The coroner raised concerns about the need for a lower threshold for hospital admission for patients with learning disabilities, requiring face-to-face doctor consultations. Post-consultation, written instructions including safety netting advice should be provided in an accessible format for non-medically trained staff.
Response (NHS England): • NHS England stated that a lower threshold for hospital admission for patients with a learning disability is warranted, consistent with existing guidance and tools. • NHS England acknowledged the … (AI summary)
Responded
Select committee recommendations(33)
#10 —
Recommendation: We recognise the risk that permitting detention on the basis of autism or learning disabilities under Part 3 of the MHA whilst prohibiting it under Part 2 amounts to a difference in treatment falling under the prohibition on discrimination in …
Response attribution not verified
#8 —
Recommendation: The detention of autistic people and people with learning disabilities under the MHA is a significant human rights concern. Detention in the absence of individualised, therapeutic treatment risks violating the Article 5 ECHR right to liberty and may even result …
Response attribution not verified
#6 —
Recommendation: While the evidence we have received supports the view that rushing implementation of the Bill could undermine efforts to improve the treatment of autistic people and people with learning disabilities, we also note that the implementation of other substantial changes …
Response attribution not verified
#5 —
Recommendation: We are pleased to see that the Government has committed to monitoring the number of autistic people and people with learning disabilities who are detained under the Mental Capacity Act. The Government should report these numbers to Parliament within a …
Response attribution not verified
#4 —
Recommendation: There is an inherent lack of justification for detaining a person for treatment based only on their learning disability or autism, giving rise to clear concerns over compatibility with Article 5 ECHR. We welcome the Bill’s attempts to remove autistic …
Response attribution not verified
#3 —
Recommendation: It is particularly troubling that the accounts we heard at the roundtable event in 2025 echoed those the JCHR heard in 2019. This emphasised to us that reform of the Mental Health Act is both pressing and overdue. (Conclusion, Paragraph …
Response attribution not verified
#55 —
Recommendation: People with learning disabilities have experienced significantly higher death rates from covid-19 than the country as a whole. Deaths have been especially high among younger adults with learning disabilities. Initial research suggests that people with learning disabilities entered the pandemic …
Response attribution not verified
#55 —
Recommendation: People with learning disabilities have experienced significantly higher death rates from covid-19 than the country as a whole. Deaths have been especially high among younger adults with learning disabilities. Initial research suggests that people with learning disabilities entered the pandemic …
Response attribution not verified
#22 —
Recommendation: In the light of starkly disproportionate and tragic data on death rates from coronavirus of disabled people, including shocking figures for deaths of people, including young people, with learning disabilities, there must be a discrete independent inquiry into the causes. …
Response attribution not verified
#9 —
Recommendation: Prior to the pandemic, people with learning disabilities experienced health inequalities and faced difficulties accessing healthcare and receiving accurate diagnoses and effective treatments. They had increased risks of dying from a range of illnesses, including respiratory infections. These problems have …
Response attribution not verified
#12 —
Recommendation: We recommend that, in addition to the implementation of the Mental Health Units (Use of Force Act) (i.e. ‘Seni’s Law’), all Assessment and Treatment Units (ATUs) are closed within two years and replaced with person-centred services that are: i) designed …
Response attribution not verified
#11 —
Recommendation: Inpatient facilities do not consistently meet the needs of autistic people and people with learning disabilities and too often this is because of factors such as the unnecessary use of restrictive practices; inpatient facilities being unable to accommodate individuals’ needs …
Response attribution not verified
#5 —
Recommendation: While we welcome the vision set out by Helen Whately MP (Minister of State, Department of Health & Social Care), we believe this is a matter of delivery and The treatment of autistic people and people with learning disabilities 39 …
Response attribution not verified
#1 —
Recommendation: Autistic people and people with learning disabilities have the right to live independent, free and fulfilled lives in the community and it is an unacceptable violation of their human rights to deny them the chance to do so. It is …
Response attribution not verified
#56 —
Recommendation: Although there was never national NHS guidance to apply “Do not attempt CPR” (DNACPR) notices to people with learning disabilities, there have been widespread concerns that there were cases in which they have been issued inappropriately during the pandemic.
Response attribution not verified
#56 —
Recommendation: Although there was never national NHS guidance to apply “Do not attempt CPR” (DNACPR) notices to people with learning disabilities, there have been widespread concerns that there were cases in which they have been issued inappropriately during the pandemic.
Response attribution not verified
#20 —
Recommendation: We therefore recommend that the Government and NHS England & Improvement bring forward the necessary financial and workforce resources required to mandate the independent review of the deaths of all autistic people and people with learning disabilities in inpatient and …
Response attribution not verified
#19 —
Recommendation: In recent years there have been too many incidences of autistic people and people with learning disabilities dying in inpatient settings. Families and friends have too often had to go to extreme and difficult lengths to have independent reviews into …
Response attribution not verified
#1 — Significant health inequalities persist for people with learning disabilities and autism.
Recommendation: Health inequalities continue to be significant among people with learning disabilities and autism, including an unacceptable level of premature and avoidable deaths compared to the general population. Although some measures are now in place to monitor mortality, such as the …
Response status not verified
#14 —
Recommendation: We recommend that staff involved in the treatment of autistic people and people with disabilities in inpatient settings receive training in care planning which has a clear and unhindered focus on: i) understanding that autistic people and people with learning …
Response attribution not verified
#13 —
Recommendation: We have significant concerns about the quality of training and support provided to staff working in inpatient facilities and the negative consequences this can have on the treatment of autistic people and people with learning disabilities in inpatient facilities. While …
Response attribution not verified
#10 —
Recommendation: We welcome the Government’s announcement that it will bring into force the Mental Health Units (Use of Force) Act 2018 in November 2021. This will go some way to reducing the use of restricted practices in inpatient facilities. However, we …
Gov response: We agree with this recommendation in principle. We agree that there are too many instances of restrictive practices being used for people with a learning disability and autistic people. We agree about the importance of …
Accepted
#9 —
Recommendation: Furthermore, we recommend that autistic people and people with learning disabilities should never be admitted to an inpatient facilities that has received an “inadequate” rating from the Care Quality Commission (CQC). The Department for Health & Social Care must bring …
Response attribution not verified
#8 —
Recommendation: In pursuing that policy, we recommend that by the end of 2021 the Department and NHS England & Improvement: i) introduce weekly formal reviews of the suitability of admission for all autistic people and people with learning disabilities who have …
Response attribution not verified
#7 —
Recommendation: We recommend that the Trieste model of care is implemented for autistic people and people with learning disabilities by the Department of Health & Social Care and NHS England & Improvement. All new long-term admissions of such people to institutions …
Response attribution not verified
#6 —
Recommendation: The Trieste model of care—characterised by simplified and quicker admissions to and discharges from inpatient facilities; limited number of individuals in inpatient facilities for lengthy durations; and emphasis on well-resourced community support—presents a clear and better alternative to supporting autistic …
Response attribution not verified
#4 —
Recommendation: Since the Winterbourne View scandal, over 10 years ago, successive governments have committed to reducing the number of autistic people and people with learning disabilities in inpatient settings and prioritising community support for these individuals. However, missed and delayed policy …
Response attribution not verified
#2 —
Recommendation: We recommend that the Department of Health & Social Care provides us with a complete assessment of the cost of providing community support for all autistic people and people with learning disabilities currently in inpatient units. Alongside this, an assessment …
Gov response: We accept this recommendation in principle. We agree that having clarity over the respective costs of providing community support for autistic people and people with a learning disability and costs associated with inpatient care is …
Accepted
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#15 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#72 —
Recommendation: The NHS should develop and publish new protocols for infection prevention and control in pandemics covering staffing, bed capacity and physical infrastructure. In developing these protocols the NHS should consider the importance of maintaining access for people accompanying some patients …
Response attribution not verified
#2 — EHRC formal investigation into DWP’s treatment of disabled claimants is currently ongoing.
Recommendation: We note that in April 2022, the Equality and Human Rights Commission (EHRC) and DWP were working to improve DWP’s treatment of disabled benefit claimants in accordance with a legally binding section 23 agreement. We further note that the EHRC …
Response attribution not verified
HSSIB safety recommendations(15)
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that NHSX develops a standardised care passport, which should include sections to support patients with autism, learning disabilities or learning difficulties.
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that as part of the work to support the NHS Long Term Plan, NHS England and NHS Improvement should develop a role and competency framework for learning disability liaison nurses, to ensure that people with learning disabilities …
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that NHSX develops a system for sharing care plans for patients with autism, learning disabilities or learning difficulties to enable reasonable adjustments to be made. It is recommended that NHSX develops a standardised care passport, which should …
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that NHS England and NHS Improvement strengthens its ‘Learning disability improvement standards for NHS trusts’ by including metrics which enable organisations to assess their progress against the outcomes for specialist learning disability teams. It is recommended that …
Safety Recommendation
Medicine omissions in learning disability secure units
It may be beneficial if organisations that use mental health nurses to cover shortages of registered learning disability nurses review their clinical model and conduct a training needs analysis. The aim of this would be to identify skills or training …
Safety Observation
Caring for adults with a learning disability in acute hospitals
HSSIB suggests that integrated care boards develop and use communities of practice (‘networks’) for acute learning disability staff across the integrated care system area, with the aim of providing peer support and sharing learning to support service improvement.
Safety Action
Caring for adults with a learning disability in acute hospitals
HSSIB suggests that integrated care boards work with acute hospitals to share good practice and assure they meet the national learning disability improvement standards.
Safety Action
Caring for adults with a learning disability in acute hospitals
Health and care providers can improve patient safety by advocating for all people with a learning disability to have an up-to-date care passport.
Safety Observation
Caring for adults with a learning disability in acute hospitals
Health and care curricula can improve patient safety by aligning with the national code of practice on statutory learning disability and autism training, when finalised.
Safety Observation
Caring for adults with a learning disability in acute hospitals
Health and care providers can improve patient safety by ensuring that local configuration of electronic patient record systems consider the accessibility and usability of the digital record reasonable adjustments flag in patient records.
Safety Observation
Caring for adults with a learning disability in acute hospitals
HSSIB recommends that NHS England, with support from key stakeholders including the Professional Record Standards Body, works collaboratively to develop and publish a set of guidelines on information to be included in a health and care passport (which could be …
Safety Recommendation
Caring for adults with a learning disability in acute hospitals
HSSIB recommends that the NHS England commissions the development and dissemination of guidance on the practical assessment of the mental capacity of people with a learning disability in acute hospitals. This is to ensure that appropriate decisions are made about …
Safety Recommendation
Caring for adults with a learning disability in acute hospitals
HSSIB recommends that NHS England ensures that the national learning disability improvement standards annual benchmarking survey for the care of people with a learning disability is continued for acute hospitals in order to help assure that local population needs are …
Safety Recommendation
Caring for adults with a learning disability in acute hospitals
HSSIB recommends that NHS England develops and issues learning disability liaison nursing service best practice and workforce guidance to all acute hospitals. This is to help local decision making about specialist learning disability provision and enable appropriate support for people …
Safety Recommendation
Medicine omissions in learning disability secure units
HSIB recommends that NHS England and NHS Improvement reviews and updates all health building guidance relating to learning disability secure units to reflect current clinical guidance on ensuring the design and layout provides a suitable environment for patients and staff.
Safety Recommendation
NCEPOD recommendations(12)
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
CQC inspection actions(57)— showing 50 strongest matches
Wavertree Bungalow
We recommend the provider assess the service using the principles of Right Support, Right Care, Right Culture, the CQC's guidance when providing support for autistic people and people with a learning disability.
Should Do
Sunderland Royal Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Must Do
Sunderland Royal Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Must Do
Sunderland Royal Hospital
The trust must ensure any patient presenting and assessed by staff as having a learning disability regardless of whether this is identified on GP systems have their individual needs assessed and reviewed by specialist learning disability staff.
Must Do
Sunderland Royal Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, care needs are assessed and planned to meet their individual needs.
Must Do
St Richard's Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Must Do
South Tyneside District Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Must Do
South Tyneside District Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, where care needs are assessed and planned to meet their individual needs.
Must Do
South Tyneside District Hospital
The trust must ensure any patient presenting and assessed by staff as having a learning disability regardless of whether this is identified on GP systems have their individual needs assessed and reviewed by specialist learning disability staff.
Must Do
South Tyneside District Hospital
The trust must ensure staff undertake assessments for patients who have a learning disability, care needs are assessed and planned to meet their individual needs.
Must Do
Scarborough Hospital
The trust must fully investigate and seek to learn from the death of a person with a learning disability or autistic people including seeking LeDeR reviews.
Must Do
Salford Royal Hospital
The service should consider developing a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism or a learning disability.
Should Do
Royal Sussex County Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Must Do
Royal Sussex County Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, and autism.
Must Do
Rochdale Infirmary
The service should consider developing a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism or a learning disability.
Should Do
Rochdale Infirmary
The service must ensure staff receive the required training to enable them to carry out the duties they are employed to perform. This includes but is not limited to safeguarding and training on learning disability and autism.
Must Do
Rochdale Infirmary
The service must ensure staff receive the required training to enable them to carry out the duties they are employed to perform. This includes but is not limited to life support, training on learning disabilities and autism and safeguarding training.
Must Do
Rochdale Infirmary
The trust must take action to develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability and monitor staff compliance.
Must Do
Kettering General Hospital
The servicemust ensure the needs of patients with a learning disability or autistic people are regularly assessed and they are provided with person centred care.
Must Do
Fleetwood Hospital
The trust should consider including mental health, learning disability and autism needs in their model for identifying patients for supportive and palliative care.
Should Do
Ellesmere Port Hospital
The trust should ensure that reasonable adjustments are in place to meet the needs of patients living with complex needs such as dementia and learning disabilities.
Should Do
Ellesmere Port Hospital
The trust must ensure staff undertake thorough assessments for patients who have a learning disability, care needs are assessed and planned to meet their individual needs.
Must Do
Poole Hospital
Consider how to link the more specific strategies, such as those relating to dementia and learning disabilities either to the main strategy, or into a framework which monitors their progress and documents assurance and success. This was of specific concern …
Should Do
Durham Diagnostics and Treatment Centre
The service must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Must Do
Durham Diagnostics and Treatment Centre
The trust must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Must Do
Worthing Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Must Do
Worthing Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Must Do
Scarborough Hospital
The service must ensure ED medical staff’s additional learning compliance in dementia and learning disabilities (LD) awareness meets trust target.
Must Do
Russells Hall Hospital
The trust should continue to review and identify if their training meets the statutory learning disability and autism training requirements.
Should Do
Royal Victoria Infirmary
The service must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.
Must Do
Royal Victoria Infirmary
The service must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.
Must Do
Royal Victoria Infirmary
The service must ensure that all staff receive training at a level appropriate to their role in how to respond appropriately to the needs of autistic people.
Must Do
Royal Victoria Infirmary
The service must ensure that all staff receive training in how to interact appropriately with people with a learning disability and autistic people, at a level appropriate to their role.
Must Do
Rochdale Infirmary
The service must take action to monitor staff compliance for sepsis training and develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability.
Must Do
Fleetwood Hospital
The services should use available forms at the front of patient records to record individual patient needs, such as disability and communication awareness, other additional needs and significant events.
Should Do
Fleetwood Hospital
The trust should work with partners to ensure that mental health needs of children and young people with a moderate-severe learning disability are met.
Should Do
Fairfield General Hospital
The service should consider developing a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism or a learning disability.
Should Do
Fairfield General Hospital
The trust must take action to develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability and monitor staff compliance.
Must Do
Fairfield General Hospital
The service must take action to monitor staff compliance for sepsis training and develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability.
Must Do
Poole Hospital
Working with the new equality and diversity lead, establish a wider equality and diversity strategy which looks at the support and needs of both staff and people who use the services. Build on the work already done and bring this …
Should Do
Salford Royal Hospital
The trust must take action to develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability and monitor staff compliance.
Must Do
Salford Royal Hospital
The service must take action to monitor staff compliance for sepsis training and develop a more comprehensive mandatory training package to enable staff to support complex patients such as those living with dementia, autism, or a learning disability.
Must Do
Rochdale Infirmary
The service should ensure it takes action to implement a more dementia-friendly environment across the surgical wards and theatre area.
Should Do
Rochdale Infirmary
The service must ensure staff receive the required training to enable them to carry out the duties they are employed to perform. This includes but is not limited to life support, learning disabilities and autism and safeguarding training.
Must Do
Princess Royal Hospital
The trust must ensure appropriate training, in line with guidance, is in place and completed by staff to support patients with learning disabilities, dementia and autism.
Must Do
Kidderminster Hospital and Treatment Centre
Make training available to all staff specific to understanding the additional needs of people with mental health conditions, a learning disability, autism or dementia.
Should Do
Kettering General Hospital
The service should ensure that staff have adequate dementia and learning disability and autism training to ensure appropriate care is provided at times when specialists are not available.
Should Do
Doncaster Royal Infirmary
The trust should ensure it continues to roll out the Oliver McGowan statutory learning disability and autism training or equivalent.
Should Do
St Benedict's Hospice
The service must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Must Do
St Benedict's Hospice
The trust must consider how to reduce the isolation of the learning disabilities team and explore ways to develop understanding of the learning disability service amongst other teams within the trust.
Must Do
PPO death in custody recommendations(4)
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners with learning disabilities are clearly recorded, staff receive relevant learning disability training and follow NHSE/I guidance for prisoners with learning disabilities.
The Governor
The Governor should ensure that staff are: aware of autism and the range of issues that prisoners with autism may face; and aware of prisoners with a communication support plan in place and refer to it before interacting with the …
The Head of Healthcare
The Head of Healthcare should ensure that in a medical emergency, the patient is moved to an appropriate area where they can be fully assessed and treated.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners who are unwell and require clinical monitoring are reviewed overnight.
IMB annual reports(9)
Nottingham (2023)
HMP/YOI Nottingham experienced a reduction in self-harm and use of force, but assaults on both prisoners and staff increased. Key challenges included inadequate provision for prisoners with severe mental health issues and disabilities, significant healthcare staff shortages, and concerns over the complaints system and property loss. The report also highlighted regime curtailments due to staff training and uncertainty for IPP prisoners.
PRISON
Key concerns
Northumberland (2023)
HMP Northumberland, a category C prison, is generally assessed as safe, despite a slight increase in violent incidents and self-harm. Significant progress has been made in primary healthcare provision, staff-prisoner relationships, and a revised regime aims to boost purposeful activity. However, the Board holds severe and repeated concerns regarding the profound lack of appropriate mental health provision, leading to the inappropriate use of segregation for acutely unwell prisoners, alongside challenges with education attendance and property management.
PRISON
Key concerns
Lancaster Farms (2025)
HMP Lancaster Farms, a Category C resettlement prison, continues to provide a largely safe environment for its 560 prisoners, with positive initiatives like the complex care unit and CrossFit program. However, significant concerns persist, particularly around healthcare provision, including long waiting times and issues with medication and data transparency. The Board also highlights problems with property management during transfers, a rise in prisoners on the restrictive basic regime, and continued challenges in placing prisoners with complex mental health needs in specialist facilities.
PRISON
Key concerns
Onley (2025)
HMP Onley, a Category C prison, experienced a challenging year with significant increases in violence and self-harm incidents. Key concerns include high levels of illicit substances, poor living conditions, and unacceptable waiting times for healthcare. Despite some positive developments in key worker delivery and resettlement initiatives, staffing shortages and backlogs in offender management continue to hinder progression.
PRISON
Key concerns
Erlestoke (2025)
HMP Erlestoke is a Category C training and resettlement prison with an operational capacity of 512. The Board observed improvements in healthcare attendance and use of force scrutiny, alongside a decrease in staff turnover. However, significant concerns remain regarding the deteriorating healthcare building, the pervasive availability of illicit substances, and the inadequate provision for vulnerable prisoners, including the elderly and those requiring essential medication on transfer.
PRISON
Key concerns
North Sea Camp (2023)
HMP North Sea Camp, an open Category D male resettlement prison, maintained a safe and humane environment with generally positive staff-prisoner relationships and good healthcare provision during the reporting year. Key challenges include persistent delays caused by Community Offender Managers impacting ROTL and Parole Board hearings, the insecurity faced by IPP prisoners, and ongoing issues with accommodation quality, property transfers, and routine maintenance due to contract failures. The Board noted diligent efforts in resettlement, purposeful activity, and equality, supported by robust internal programs.
PRISON
Key concerns
Springhill (2023)
HMP Springhill, an open Category D prison, faced significant challenges in 2023, primarily driven by a substantial increase in its population to 330. The Board highlighted deteriorating infrastructure, a persistent rat infestation, and widespread staff shortages impacting healthcare, education, and resettlement efforts. While some safety metrics like self-harm remained low, assaults rose, and concerns persist regarding accommodation quality, prisoner pay, and the effectiveness of the complaints system, hindering the prison's core resettlement purpose.
PRISON
Key concerns
Bure (2024)
HMP Bure is a Category C prison for men convicted of sexual offenses, housing 641 prisoners with an operational capacity of 643. The IMB found it to be a generally calm and safe environment with good staff-prisoner relationships and well-supported elderly prisoners. Key concerns include the lack of work and purposeful activity opportunities for the current population, the need for IPP re-sentencing, and insufficient funding for resettlement services. The Board also noted an increase in self-harm incidents and issues with archaic adjudication recording.
PRISON
Key concerns
Moorland (2025)
HMP/YOI Moorland faced significant pressures this year from a high turnover of prisoners and early release schemes, yet reception staff performed well. While positive developments include improved ACCT records, successful translation programs, and some regime liberalisations, the report highlights concerns over increased violence, self-harm, and use of force. Key areas for development include addressing overcrowding (single cells as doubles), improving healthcare quality and access, and enhancing rehabilitation and purposeful activity for prisoners, particularly for IPPs.
PRISON
Key concerns
IMB individual recommendations(30)
Eastwood Park (2021)
Our concerns continue about a prisoner with an acquired brain injury who has been continuously segregated at Downview and Eastwood Park prisons for 1,202 days by the end of this reporting period. In response to correspondence your predecessor stated that ‘the truth is that the right environment simply doesn’t exist within the prison system to cater for her unique needs’. …
Other
In Progress
Werrington (2025)
Why are children with complex needs sent to Werrington when there are no specialist facilities available? And why is it so time-consuming to get them transferred? How will this be improved?
HMPPS
Wandsworth (2022)
The previous report noted that the new healthcare facility, when it opens, will not include any cell accommodation to relieve pressure on the totally inadequate Jones and Addison units. HMIP recently described the units as ‘not a fit place to care for seriously unwell patients’. Funding was secured for the refurbishment of six cells in Addison, and work began in …
HMPPS
In Progress
Altcourse (2022)
Once again, the Board has highlighted the plight of severely mentally unwell men being contained in totally unsuitable conditions and without access to appropriate treatment for long periods of time before being transferred to appropriate secure units.
Ministry of Justice
Ashfield (2023)
With the large number of elderly prisoners in the custodial estate (particularly in prisons such as Ashfield), cases of dementia and terminal illness requiring 24-hour care are increasing. The specific needs of these prisoners cannot be adequately met in normal prison conditions. What plans does the Prison Service have for addressing this issue through the creation of specialist custodial centres?
HMPPS
In Progress
Ranby (2024)
Prisoners have been constantly located in the CSU due to their complex and challenging behaviour and mental health issues. Why is it taking so long to transfer these prisoners to an appropriate medical establishment?
Other
In Progress
Lewes (2020)
The Board, once again, is concerned at the number of prisoners seen over the reporting year who are seriously mentally unwell and kept in conditions, be it accommodation standards or the regime, which are entirely unsuitable for their care or rehabilitation. The same applies to many of the prisoners with learning or other disabilities. Will the minister undertake a comprehensive …
Ministry of Justice
In Progress
Eastwood Park (2020)
The IMB at Eastwood Park has raised concerns with the minister about a prisoner with an acquired brain injury who had been segregated in HMP Downview and HMP/YOI Eastwood Park for 827 days up to the end of this reporting period. While we understand that normal location is not a possible alternative in her case, because of her behaviour, is …
Ministry of Justice
Noted
Dovegate (2021)
Accelerate plans for the conversion of the in-patient unit in healthcare to provide consultation and treatment rooms adequate for the number of residents in the prison. Should it be decided not to proceed with the above, then urgently upgrade the inpatient bath/shower room.
Governor / Director
In Progress
Norwich (2022)
Will the Minister please explain why this continues to be the case and what plans there are to move them out of HMP/YOI Norwich?
Ministry of Justice
In Progress
Norwich (2022)
The Board asks the minister ‘Why are these men still being kept in custody?’ (referring to men with severe mental health issues and/or learning disabilities who should be in establishments that can properly address their issues).
Ministry of Justice
In Progress
Long Lartin (2022)
The healthcare centre (HCC), and in particular the inpatient unit and facilities for disabled prisoners, are in need of urgent modernisation. Will the Prison Service give priority to complete refurbishment and improvement of the in-patient unit and replacement of the stairlift?
HMPPS
Eastwood Park (2022)
After 1,484 days in continuous segregation a prisoner with an acquired brain injury was transferred from Eastwood Park to a medium secure NHS facility in September 2022 for assessment. What discussions has the Minister had with the Department of Health to ensure that adequate secure facilities for women with acquired brain injuries are available to avoid such inhumane treatment of …
Other
In Progress
Guys Marsh (2020)
There is a national concern about the increase in the number of prisoners with poor mental health, and those with educational or physical needs. How will the minister work with relevant departments in a coordinated way to facilitate a better strategy for the humane incarceration of all prisoners with complex needs?
Ministry of Justice
Bullingdon (2020)
Will the prison service review the provision for older prisoners in the prison estate as a whole, bearing in mind their increasing numbers and the examples in this report (see below, 5.4.7, 6.3.3) of unequal treatment for this group?
HMPPS
Whatton (2022)
Will the Prison Service, once again, consider substantial refurbishment or replacement of the healthcare facilities so that they match those expected in the community?
HMPPS
In Progress
Heathrow Immigration Removal Centre (2022)
In our 2021 annual report, we urged the Minister to fund a complete replacement of the core lift in Harmondsworth, a lift which is essential for enabling detainees with mobility issues to access healthcare. A replacement lift was not commissioned and during 2022 the central lift was out of order on numerous occasions over a five-month period. We continue to …
Ministry of Justice
Lincoln (2023)
Given the issues associated with the Victorian infrastructure of the prison, what alternative provisions are being considered for the increasing numbers of frail elderly, particularly those with dementia, end of life care and disabled prisoners?
HMPPS
In Progress
Heathrow Short Term Holding Facility (2020)
[Becket House] The Home Office should ensure that new holding rooms in a facility in Warehouse K, London E16 will include the provision of showers. (para. 21.6).
Home Office
Heathrow Short Term Holding Facility (2020)
[London Heathrow Airport T5] The Home Office should provide a shower in Terminal 5 to comply with the National Holding Room Standards (para. 3.9).
Home Office
Eastwood Park (2020)
Will the Governor review the suitability of mattresses, especially for older prisoners and those with health needs?
Governor / Director
Norwich (2021)
Are there plans for refurbishment of the healthcare unit and L Wing to provide a more suitable environment for the ill and elderly?
HMPPS
Rejected
Frankland (2021)
Given the ageing prison population and a growing number of prisoners being diagnosed with dementia, can consideration now be given to providing an appropriate physical environment for this group of prisoners along with suitably qualified care workers (para 6.4)?
Ministry of Justice
In Progress
Foston Hall (2021)
Are there plans to address: the inadequate accommodation for the provision of healthcare
HMPPS
In Progress
Erlestoke (2021)
Will the Minister consider providing more facilities to meet the needs of those within the autistic spectrum, unsuitable for location in a normal prison environment?
Ministry of Justice
In Progress
Frankland (2022)
HMP Frankland’s provision for pharmacy on the lower older wings is not fit for purpose. Does the Prison Service have a solution to this critical situation?
HMPPS
Winchester (2023)
Given the issues associated with the Victorian infrastructure of the prison, what alternative provisions are being considered for the increasing numbers of elderly and disabled prisoners?
Ministry of Justice
In Progress
Garth (2023)
For many years, complaints have been registered about the very inadequate waiting area in the healthcare unit. This needs to be addressed urgently.
HMPPS
Implemented
Lincoln (2024)
Given the issues associated with the Victorian infrastructure of the prison, what alternative provisions are being considered for the increasing numbers of frail elderly, particularly those with dementia, end-of-life-care and disabled prisoners?
HMPPS
In Progress
Hewell (2024)
Will the Minister invest more in the maintenance and updating of prisons, to end inhumane and unsanitary conditions, and to meet the needs of an ageing population with related health and mobility challenges?
Ministry of Justice
Implemented
Health investigations(20)
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec w.
That mental health and learning disability psychiatry services agree a joint clinical appointment at a senior level.
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec v.
That simple arrangements are agreed by the mental health trust and learning disability psychiatry services which ensure that patients are jointly assessed whenever one of them thinks that the patient would benefit from shared services.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 46
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff involved in the care of patients with a learning disability receive appropriate training in learning disability awareness and intervention.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 45
The Birmingham Primary Care Trusts should ensure that there is adequate provision of specialist mental health services for people with a learning disability.
midlands
Independent investigation: Shamim Akhtar, Birmingham (2000) — Rec 7
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people with a learning disability and mental illness.
midlands
Independent investigation: Lorna Thomas, Milton Keynes (1995) — Rec 5
The Buckinghamshire Health Authority should ensure that the Milton Keynes Community NHS Trust provides a more comprehensive inpatient service for people with mild learning disability. This should include access to beds within the Campbell Centre or other appropriate local resource, for those who are or may also be suffering from …
south_east
Independent investigation: Florise Corette, Lewisham (2015) — Rec 8
Trust-wide. Professional Leads for each CAG will enlist the help of experts in ASD to be considered when a patient with ASD is admitted to hospital. Pathways for obtaining this expertise to be clarified.
london
Assurance Review: Trust recommendations — Rec 17
Capacity and best interests: applying the Mental Capacity Act 2005 • Capacity assessment and best interest decision-making should be improved through audit, training, and best practice examples. • An enhanced focus should be given to people presenting with dementia or confusion and those with a learning disability. • A thematic …
north_west
Independent investigation into the care and treatment of M — Rec 6
We recommend that NHS England (Midlands region) obtain assurance to establish that improvements have been made in practice to the services provided to young people with a learning disability or autism at St Andrew’s Healthcar
london
Accepted
Independent investigation into the care and treatment of M — Rec 5
We recommend that St Andrew’s Healthcare (SAH) undertake a review of the approaches to working with children who have a combination of learning disability, autism and behaviour that challenges. This will require a shift towards a behavioural approach to intervention, which will require clinical leadership from a learning disability specialist, …
london
Accepted
Independent investigation into the care and treatment of M — Rec 4
All commissioners of mental health inpatient care for children and young people with a learning disability, autism or both are expected to commission care that is consistent with the NHS England (2017) Transforming Care service model specifications15/ Building the Right Support (2022)16: 1) Integrated Care Boards should take steps to …
london
Accepted
Independent investigation into the care and treatment of M — Rec 1
We recommend that the South East London Learning Disability and Autism programme continues to develop community support for this group of patients, in line with NHS England (2017) Transforming Care Model Service Specifications.
london
Accepted
An independent care pathway review of a young person: Published … — Rec 5
Trusts and their commissioners should ensure that inpatient teams have a directory of staff, services, or organisations where staff are trained in sensory integration assessments. The commissioning of such sensory integration assessments should be at the discretion of the treatment team where sensory function is being considered.
london
Independent investigation: Pamela Hardy, Wombwell (2010) — Rec 2
Training and ‘skills, rule and knowledge’-based performance regarding Autistic Spectrum Syndrome Disorders The Independent Team fully acknowledges the strides made with regards to developing a clear care pathway for individuals with Asperger‟s Syndrome who are provided with care, support and treatment via the specialist mental health service. However, in addition …
north_east_yorkshire
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 35
The establishment of the newly formed Integrated Care Service provides an opportunity to strength the service delivered by the shared specialist Mental Health and Learning Disability Team. Therefore, the team should be acknowledged and implanted in the ICS in the next 12 months.
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust: … — Rec 18
It is recommended that future NHS patient safety frameworks for Serious Incidents should acknowledge and incorporate the different needs of patient groups, such as physical health, mental health and learning disability and the unique context in which the incident took place.
Stage 2 Independent Investigation into Southern Health NHS Foundation Trust
south_east
An independent investigation into the care and treatment of Nadia … — Rec 9
TEWV/NHS England and Middlesbrough Council must provide assurance that all looked after children with a diagnosis of autism have care provided that is in line with the NICE guidance on Autism spectrum disorder in under 19s: support and management, recognising the challenges in the system.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
*Independent investigation into the care and treatment of Patient I: … — Rec 4
Patient I was never the subject of a psychological assessment of his cognitive ability even though the issue of a potential learning disability was raised on a number of occasions. It is recommended that it would be appropriate for there to be a formal assessment of any learning issues of …
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Partially Accepted
Independent investigation into the care and treatment of M — Rec 3
Integrated Care Boards, working with regional NHS England (NHSE), teams should work with providers to understand the workforce needed to provide support to people with a learning disability and autistic people and families in the community and to take active steps to address the gap between what is needed and …
london
Accepted
An independent investigation into the care and treatment of Nadia … — Rec 10
NHS England and provider collaboratives must provide effective quality oversight of inpatient environments for young people with autism, with auditable standards.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent reviews(3)
Wessely Review — Rec 121
Amend the MHA Code of Practice to clarify best practice when the MHA is used for people with autism, learning disability or both.
Health & Social Care
Accepted
Wessely Review — Rec 120
Health and social care commissioners should have a duty to collaborate to ensure provision of community based support and treatment for people with a learning disability, autism, or both to avoid admission into hospital and support a timely discharge back into the community.
Health & Social Care
Accepted
Wessely Review — Rec 123
The Mental Health Services Dataset should include specific data to monitor the number of detentions and circumstances surrounding that detention of people with autism, learning disabilities or both.
Health & Social Care
Accepted
PHSO casework decisions(43)
P-001113 — Northern Lincolnshire and Goole NHS Foundation Trust
Mrs L complained the Trust refused further treatment, including ventilation, for her COVID-19 positive daughter with learning difficulties, and a nurse sent her away from A&E.
NHS in England
Not Upheld
Sep 2021
P-001256 — A medical practice in the Gloucestershire area
Mrs V complained a medical practice and Trust failed to act on her brother's abdominal/urinary symptoms and provided inappropriate treatment for seizures, possibly contributing to his death.
NHS in England
Partly Upheld
Aug 2021
P-001454 — Barnsley Hospital NHS Foundation Trust
Mrs E complained hospital staff did not properly account for her husband's dementia, discharged him without adequate care, and he sadly passed away shortly after discharge.
NHS in England
Not Upheld
Jul 2022
P-002763 — Lancashire Teaching Hospitals NHS Foundation Trust
Miss T complained staff failed to hydrate her mother, properly monitor pressure areas, or regulate oxygen levels, which she believes contributed to her mother's deterioration and death.
NHS in England
Partly Upheld
Jul 2024
P-003084 — Sheffield Teaching Hospitals NHS Foundation Trust
Ms N complained the Trust prematurely discharged her autistic, non-verbal brother before his infection cleared, without suitable provisions. She believes his disability and skin colour influenced his care, leading to his death.
NHS in England
Oct 2024
P-001343 — North Bristol NHS Trust
Mrs A complained about poor nursing care, including removal of her mother's call bell, bedsores, delayed catheter repair, and inadequate family communication, which she believed caused unnecessary suffering.
NHS in England
Partly Upheld
Mar 2022
P-004558 — Manchester University NHS Foundation Trust
Mr U complained about his wife's care at two Trusts, citing inadequate mobilisation, inappropriate pain medication, suspended anticoagulants, poor food/drink supervision, and no psychiatric treatment, allegedly contributing to her death.
NHS in England
Dec 2025
P-002588 — County Durham and Darlington NHS Foundation Trust
Mrs T complained her father received inadequate food and drink, lacked mobility efforts, and had poor record keeping, contributing to his declining condition and death.
NHS in England
Partly Upheld
May 2024
P-002635 — Epsom and St Helier University Hospitals NHS Trust
Miss T complained the Trust failed to provide her father adequate nutrition, delayed dietitian referral, and did not consider alternative feeding methods, contributing to his death.
NHS in England
Upheld
May 2024
P-002909 — Mid Cheshire Hospitals NHS Foundation Trust
Mrs O complained the Trust delayed referring her father to speech and language therapy, inappropriately changed his fluid provision, failed to keep him nil by mouth, and inserted an NG tube without consent.
NHS in England
Upheld
Sep 2024
P-003086 — Chesterfield Royal Hospital NHS Foundation Trust
Staff left her father alone when at risk of falling, leading to falls and a brain bleed. His CT scan was overlooked, delaying diagnosis before his death.
NHS in England
Oct 2024
P-003645 — Barnsley Hospital NHS Foundation Trust
Ms G alleged her mother received inadequate basic nursing care, including cancelled procedures, delayed medication, and poor communication, leading to an undignified end of life.
NHS in England
Jul 2025
P-003676 — Barts Health NHS Trust
Mr H complained clinicians failed to properly monitor and medicate his mother, and had poor communication/cleanliness, believing these failures contributed to her death.
NHS in England
Jul 2025
P-003666 — Great Western Hospitals NHS Foundation Trust
Mr F complained staff gave his father poor nutrition/fluids, inadequate mouthcare, left him without oxygen, and administered allergic antibiotics, which he believes led to his father's avoidable death.
NHS in England
Jul 2025
P-003755 — North East and North Cumbria Integrated Care Board
Mr C complained the ICB stopped funding his son's carers during a hospital stay, denying continuity of care and causing anguish due to insufficient Trust staff support.
NHS in England
Aug 2025
P-004140 — Oxford University Hospitals NHS Foundation Trust
Miss A complained about her daughter's inadequate aftercare post-transplant, including insufficient monitoring and placement outside intensive care, leading to cardiac arrest and death.
NHS in England
Oct 2025
P-004247 — London North West University Healthcare NHS Trust
Mr N complained the Trust failed to make reasonable adjustments for his sister, diagnose and treat a lung infection, manage her conditions, and initiated end-of-life care without agreed antibiotics.
NHS in England
Nov 2025
P-004472 — An independent provider in the Cornwall area
Miss T complains Psychiatry UK rushed her online autism assessment, didn't obtain parents' input, and failed to consider her poor working memory or masking, leading to an unrobust diagnosis.
NHS in England
Upheld
Dec 2025
P-004715 — County Durham and Darlington NHS Foundation Trust
Ms U complained her father received inadequate assessment, leading to a preventable fall and injury, and cited delayed medication and poor communication regarding his deterioration and impending death.
NHS in England
Upheld
Jan 2026
P-004640 — The Hillingdon Hospitals NHS Foundation Trust
Miss B complained about inadequate care for her mother, an unwitnessed fall, poor nursing, delayed escalation, and poor communication during admission. She also cited poor complaint handling.
NHS in England
Upheld
Jan 2026
P-001111 — Gateshead Health NHS Foundation Trust
Mr T complained ED staff inadequately investigated his dislocated toe and orthopaedic care was severely delayed for a year, causing deterioration, infection, and toe amputation.
NHS in England
Partly Upheld
Sep 2021
P-004561 — Milton Keynes University Hospital NHS Foundation Trust
Mrs Y alleged staff at Milton Keynes University Hospital failed to provide timely pain relief and fluids, neglected hygiene, poorly managed post-surgical pain, and did not prevent falls for her mother.
NHS in England
Partly Upheld
Jan 2026
P-003834 — Northern Care Alliance NHS Foundation Trust
Mr A complained about the Trust's care for his swollen elbow, alleging incorrect medical care, unprofessional consultant behaviour, missed blood tests, and improper discharge.
NHS in England
Jul 2023
P-002837 — Liverpool University Hospitals NHS Foundation Trust
Mrs I complained about her mother's hospital care, including neglect in ED, lack of compassion for her AMD, and poor hygiene. She also alleged rough handling by ambulance staff during transfer.
NHS in England
Aug 2024
P-003370 — University Hospital Southampton NHS Foundation Trust
Mr R complained his father suffered a fall and head injury due to lack of supervision while using a commode, causing Mr R significant distress and worry about his father's safety.
NHS in England
Partly Upheld
Feb 2025
P-003419 — Hull University Teaching Hospitals NHS Trust
Mr A complained the Trust failed to allow his son to monitor his blood glucose with a wearable sensor and did not properly manage his diabetes. He also questioned his son's DNAR decision competence.
NHS in England
Partly Upheld
Mar 2025
P-003453 — Gateshead Health NHS Foundation Trust
Mrs H complained about Miss E's delayed toilet access after an enema and inadequate care, risk assessments, and one-to-one nursing, leading to injury and distress.
NHS in England
Partly Upheld
Mar 2025
P-004282 — North Cumbria Integrated Care NHS Foundation Trust
Mrs A complained clinicians delayed a stent procedure, mismanaged hydration and nutrition, failed to drain bile, and delayed response to peritonitis, contributing to her mother's death.
NHS in England
Not Upheld
Nov 2025
P-004731 — George Eliot Hospital NHS Trust
Mrs A complained the Trust failed to manage her mother's pressure sores, made her nil by mouth, failed to perform a hip replacement, and discharged her inappropriately, contributing to her death.
NHS in England
Jan 2026
P-004666 — Hampshire Hospitals NHS Foundation Trust
Mr R complained his mother developed unmonitored pressure sores due to poor care, and the family/district nurses were not informed about them upon discharge.
NHS in England
Jan 2026
P-004690 — University Hospitals Birmingham NHS Foundation Trust
Mrs A complained her mother was injured by a faulty dialysis chair, the incident was undocumented, and the Trust failed to provide an adequate discharge plan, leading to her mother's fall at home.
NHS in England
Jan 2026
P-001890 — Sandwell and West Birmingham Hospitals NHS Trust
Mr R complained his father received incorrect pureed food from the Trust, which he believes led to pneumonia and ultimately caused his father’s death.
NHS in England
Mar 2023
P-002550 — West Hertfordshire Teaching Hospitals NHS Trust
Mrs A complained about her husband's care, alleging staff did not move him enough, lacked empathy during washing, and left him in head blocks too long, causing pain, distress, and condition deterioration.
NHS in England
Apr 2024
P-002900 — King's College Hospital NHS Foundation Trust
Mrs A complained her elderly mother suffered from delayed hospital admission, inadequate hydration/nutrition, and untreated lung aspiration, leading to her death.
NHS in England
Aug 2024
P-003065 — Royal Cornwall Hospitals NHS Trust
Miss E complained the Trust failed to provide her mother with correct nutrition, dental care, or treat her delirium during hospital admission. She believed this led to rapid deterioration and earlier death.
NHS in England
Oct 2024
P-003331 — Blackpool Teaching Hospitals NHS Foundation Trust
Mrs D complained the Trust left her husband insufficiently clothed, causing him to be cold throughout his admission, which she believes contributed to his death from double pneumonia.
NHS in England
Feb 2025
P-003636 — Manchester University NHS Foundation Trust
Mrs L complained her father was placed in an unobservable ward area, received inappropriate fluids, and was given medication that worsened delirium, contributing to his death.
NHS in England
Partly Upheld
Jun 2025
P-003647 — University Hospitals Dorset NHS Foundation Trust
Miss T complained the Trust failed to conduct a falls risk assessment or lower bed rails for her godfather, resulting in a fall that she believes contributed to his death.
NHS in England
Partly Upheld
Jun 2025
P-003725 — East Sussex Healthcare NHS Trust
Mr O complained he was unnecessarily kept in hospital, received an incorrectly positioned iron transfusion, experienced delays in finding a vein for blood, and was misinformed, causing pain and disability.
NHS in England
Jul 2025
P-004322 — University Hospitals Birmingham NHS Foundation Trust
Mr B complained the Trust failed in falls management, leading to his father's fall and potential stroke, left a sedative in his mouth, and imposed restrictions without proper assessments.
NHS in England
Nov 2025
P-001306 — Mid Yorkshire Hospitals NHS Trust
Miss U complained the Trust failed to provide her father with adequate nutritional intake and IV fluids, which she believed worsened his condition and contributed to his death.
NHS in England
Not Upheld
Feb 2022
P-001499 — United Lincolnshire Hospitals NHS Trust
Mr E complained the Trust did not properly manage his late wife's nutritional requirements or administer her regular medicines, questioning if better care could have prolonged her life.
NHS in England
Aug 2022
P-002392 — Leeds Teaching Hospitals NHS Trust
Mr E complained the Trust failed to remove his wife's cancer, caused surgical damage, poorly managed hygiene and medication, and lost her rings, contributing to her premature death.
NHS in England
Jan 2024
LGO / SPSO decisions(32)
23-013-609b — Royal Free London NHS Foundation Trust - North …
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …
LGO (Local Government & …
Health
Upheld
Jun 2025
23-013-609a — Royal Free London NHS Foundation Trust - North …
Summary: We found that North Middlesex Hospital NHS Trust failed to consistently provide adequate overnight support to a patient with a learning disability. We also found that the London Borough of Barnet failed to review the patient’s needs in hospital when other professionals noted they had changed. And we found …
LGO (Local Government & …
Health
Upheld
Jun 2025
NIPSO-201912943 — Belfast Health and Social Care Trust
The sister of a man with Downs Syndrome has received an apology from the Belfast Trust following our investigation into his treatment in Belfast City Hospital.
NIPSO (NI Public Service…
Health & Social Care
May 2022
PSOW-202100024 — Wrexham County Borough Council
Mrs X complained that the Council failed to provide appropriate and adequate support to her sister, Ms Y, in the months leading to her death, including whether information was shared appropriately between the Council and a third-party organisation providing services on behalf of the Council (“the Provider”), and whether the …
PSOW (Public Services Om…
Health
Jul 2022
NIPSO-201916181 — Belfast Health and Social Care Trust
We investigated an incident in which a woman suffered a fractured vertebrae after a fall in hospital. We found that the Belfast Trust failed to prepare a proper falls assessment for the patient, and failed to fully investigate how the fall happened.
NIPSO (NI Public Service…
Health & Social Care
Jul 2022
23-017-219 — Birmingham City Council
Summary: Mrs X complained the Council refused to provide her son, Y, with school transport. Mrs X explained Y has additional needs, attends a special school and it was unsafe for him to walk to school. She said this caused Y and her distress because Y’s behaviours mean he is …
LGO (Local Government & …
Education
Upheld
Jul 2024
NIPSO-17493 — Belfast Health and Social Care Trust
A Health Trust has apologised for the care and treatment given to a patient in the Emergency Department of the Royal Victoria Hospital, Belfast.
NIPSO (NI Public Service…
Health & Social Care
Oct 2019
PSOW-202302461 — Cardiff and Vale University Health Board
Ms A complained on behalf of her husband, Mr A, about the assessment and treatment provided by Cardiff and Vale Health Board (“the Health Board”) for a laceration to his left wrist when he attended the University Hospital of Wales (“the Hospital”) Emergency Department on 24 August 2022. The investigation …
PSOW (Public Services Om…
Health
Upheld
Apr 2024
24-012-786 — London Borough of Lambeth
Summary: LGSCO finds the Council was at fault for failing to consider Ms X’s needs arising from her disability when replacing her shower. The Housing Ombudsman finds maladministration in the Council’s handling of Ms X’s reports of repairs. Both Ombudsmen find fault in the Council’s complaint handling. To remedy the …
LGO (Local Government & …
Adult Care Services
Upheld
Jun 2025
24-016-501 — London Borough of Enfield
Summary: The Council failed to provide Miss X homelessness accommodation when it should have done and when it did house Miss X, the accommodation was unsuitable. This meant Miss X accrued debt she should not have and has remained in accommodation which does not meet her needs as a Disabled …
LGO (Local Government & …
Housing
Upheld
Nov 2025
202503645 — Clackmannanshire and Stirling Health and Social Care Partnership
C, who has a progressive neurological disorder, complained that there was an unreasonable delay in the partnership providing adaptions to their home. We took independent advice from an occupational therapist (a healthcare professional who supports people to improve their ability to carry out everyday tasks). We found that this was …
SPSO (Scottish Public Se…
Health and Social Care
Not Upheld
Feb 2026
NIPSO-18500 — Belfast Health and Social Care Trust
The Ombudsman has upheld elements of a complaint that appropriate steps were not taken to prevent an elderly patient from falling out of a hospital bed, but did not establish a link between her fall and her death the following day.
NIPSO (NI Public Service…
Health & Social Care
Jul 2020
PSOW-202100359 — Aneurin Bevan University Health Board
Mrs A complained about the care and treatment provided to her husband, Mr A, following a suspected stroke on 17 March 2019. In particular, she complained there was a delay in diagnosing diabetes, that record keeping had been poor, and that she felt the quality and timeliness of the Health …
PSOW (Public Services Om…
Health
Aug 2021
PSOW-202002273 — Betsi Cadwaladr University Health Board
During another investigation into concerns raised by Mr Y, the Ombudsman received evidence from the Health Board which indicated that, at the time Mr Y was placed on the urgent list for prostate cancer treatment in August 2019, there were a total of 16 other patients with the same urgent …
PSOW (Public Services Om…
Health
Aug 2021
PSOW-202005554 — Cwm Taf Morgannwg University Health Board
Mrs A complained to the Ombudsman about the treatment her mother, Mrs B, received from Velindre University NHS Trust(“the Trust”), Cwm Taf Morgannwg University Health Board (“the First Health Board”) and Swansea Bay University Health Board (“the Second Health Board”). Mrs B was diagnosed with asarcoma (a rare type of …
PSOW (Public Services Om…
Health
Upheld
Jun 2022
PSOW-202107463 — Ceredigion County Council
Mr A complained on behalf of his son, Mr B, who lives in a residential home for adults with additional needs. The other residents of the house receive support from a Support Service (“the Support Service”) which is funded by the Council. Mr A complained that a staff member from …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202304865 — Hywel Dda University Health Board
Dr C complained about the care and treatment her late mother, Mrs A, received from Hywel Dda University Health Board on 28 and 29 December 2022 when she was an inpatient at Withybush Hospital (“the Hospital”). The following matters were investigated: a) Whether Mrs A’s pain relief was appropriate and …
PSOW (Public Services Om…
Health
Upheld
Jun 2024
21-005-129 — Royal Borough of Greenwich
The Council refused to fund adaptations to a specialist bed. Consequently, Ms X does not have a bed that meets her needs.
LGO (Local Government & …
Adult Care Services
Upheld
Mar 2022
21-017-229 — Birmingham City Council
Summary: We will not investigate Mr X’s complaint about the outcome of his occupational therapy assessment in relation to his request for major adaptations to his home. This is because there is no sign of fault by the Council in how it carried out and decided the assessment.
LGO (Local Government & …
Adult Care Services
Mar 2022
22-002-090b — Northumbria Healthcare NHS Foundation Trust (22 002 090b)
Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not …
LGO (Local Government & …
Health
Upheld
Dec 2022
201104061 — Scottish Prison Service
Mr C, who is a prisoner, injured his hand and was advised by a prison doctor that he would need to attend hospital. He was unhappy that he was not taken to hospital until the next day and he complained about this to the prison. The prison told him that …
SPSO (Scottish Public Se…
Prisons
Upheld
Jul 2012
PSOW-202106137 — Isle of Anglesey County Council
Ms A complained that Direct Payments offered by the council were insufficient, that carer assessments were not in place and that adaptation work to her property had not been progressed because she was unable to appoint an agent. The council agreed to help Ms A identify and appoint an agent, …
PSOW (Public Services Om…
Local Government
Feb 2022
PSOW-202107102 — Betsi Cadwaladr University Health Board
Following receipt of the Health Board’s formal complaints response, Mr A had further questions about the standard of care and treatment provided to his late mother. He complained that the final complaints response erroneously referred to him by a different name. The Ombudsman was concerned that Mr A had outstanding …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202204393 — Flintshire County Council
Ms X complained about the Council’s handling of social services matters concerning her son, including direct payments, assessments, and plans. The assessment found that the independent investigation commissioned at stage 2 was thorough and competent. However, there were two issues identified which did not amount to best practice. The Council …
PSOW (Public Services Om…
Local Government
Feb 2023
PSOW-202405901 — Swansea Bay University Health Board
Mrs A complained that Swansea Bay University Health Board had failed to formally respond to her letters of complaint, in relation to her late grandmother’s care. The Ombudsman found that the Health Board had discussed Mrs A’s concerns with her in a meeting but it had failed to formally respond …
PSOW (Public Services Om…
Health
Nov 2024
20-007-956a — Black Country and West Birmingham Clinical Commissioning Group …
Summary: Miss X complained about problems with specialist equipment provided by the Council and NHS Clinical Commissioning Group. We have not upheld the complaint. We have now completed our investigation.
LGO (Local Government & …
Health
Not Upheld
Feb 2022
20-007-956 — City of Wolverhampton Council
Summary: Miss X complained about problems with specialist equipment provided by the Council and NHS Clinical Commissioning Group. We have not upheld the complaint. We have now completed our investigation.
LGO (Local Government & …
Adult Care Services
Not Upheld
Feb 2022
21-011-454 — Basingstoke & Deane Borough Council
Summary: Mrs X complains about the Council’s handling of her application for a disabled facilities grant. She says the Council produced an inadequate kitchen design which does not meet her needs. The Council was not at fault. It has designed a kitchen to meet Mrs X’s needs in line with …
LGO (Local Government & …
Adult Care Services
Not Upheld
May 2022
24-001-044 — Devon County Council
Summary: We will not investigate this complaint about an unsuccessful application for a Blue Badge. This is because there is insufficient evidence of fault by the Council.
LGO (Local Government & …
Adult Care Services
May 2024
24-022-186 — Norwich City Council
We will not investigate Mr X’s complaint about how the Council have managed his Disabled Facilities Grant application. This is because there is not enough evidence of fault to justify an investigation.
LGO (Local Government & …
Adult Care Services
Jun 2025
24-010-015 — Northumberland County Council
Summary: Mr X complained the Council failed to properly assess his needs in relation to adapting his home under a Disabled Facilities Grant (DFG). The Council was not at fault.
LGO (Local Government & …
Adult Care Services
Not Upheld
Jun 2025
PSOW-202202016 — Betsi Cadwaladr University Health Board
Ms P complained about care provided to her mother, Mrs Q, by the Health Board during her admission to the Emergency Department (“the ED”) at Ysbyty Glan Clwyd from November 30 2021. In particular, she complained that the Health Board failed to assess and transfer her mother to a ward …
PSOW (Public Services Om…
Health
Aug 2022
Domestic Homicide Reviews(1)
CQC enforcement actions(3)
Warning Notice: Tees, Esk and Wear Valleys NHS Foundation Trust
The Care Quality Commission (CQC) conducted an inspection of inpatient wards for people with a learning disability or autistic people at Lanchester Road Hospital and Bankfields Court, operated by Tees, Esk and Wear Valleys NHS Foundation Trust. Following the inspection, …
Lanchester Road Hospital in Durham and Bankfields…
Oct 2022
Warning Notice: Lincolnshire Partnership NHS Foundation Trust
The Care Quality Commission told Lincolnshire Partnership NHS Foundation Trust that it must take action to improve the care of those accessing its specialist mental health and learning disability services. Reports identified areas for improvement including the safety and suitability …
Mar 2011
Warning Notice: Southern Health NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Southern Health NHS Foundation Trust, requiring significant improvements to protect patients in its mental health and learning disability services. CQC found that the Trust did not operate effective governance arrangements …
Apr 2016
LeDeR reports(4)
LeDeR deep dive: Avoidable cancers
Thematic deep dive examining deaths from potentially avoidable cancers among people with a learning disability.
Deep dive
LeDeR Report 2021
Annual report on deaths notified in 2021. Half of reviewed deaths were assessed as avoidable, against 22 per cent for the general population.
2021
LeDeR Report 2022
Annual report on deaths notified in 2022, the first authored by the King's College London partnership. 42 per cent of reviewed deaths were assessed as avoidable. Median age at death was 62.9 for adults.
2022
LeDeR Report 2023 (updated January 2026)
Annual report analysing the deaths of 3,556 people with a learning disability notified to LeDeR in 2023. The report was first published in September 2025 and updated in January 2026 after correction of data collection errors, which revised the proportion …
2023
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