Learning disability register access
Low uptake of the learning disability register due to unidentified barriers and the need to review and update GP guidance.
Source spread
Where this theme appears
This theme appears across 13 independent accountability sources, so the source mix matters as much as the headline total.
7 inquiry recs
2 PFD reports
20 committee recs
5 CQC actions
7 IMB recs
1 detention investigation rec
4 DHR recs
3 PHSO decisions
9 LGO/SPSO decisions
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(7)
R97 — Funded access to primary care
Recommendation: The SPPG must ensure that commissioning includes provision for people with learning disabilities and autistic people cared for in any facility to have fully funded access to primary care services. These may be provided by LD nurse practitioners/LD nurse consultants. …
No response yet
R96 — Access to mainstream mental health services
Recommendation: SPPG must ensure that people with learning disabilities and autistic people have access to mainstream (i.e. the same services that are available to those without a learning disability) mental health services, with appropriate adjustments for their disabilities.
No response yet
R94 — Continuing community support provision
Recommendation: There will be a continuing need, which must be met, for new and ongoing community-based support for young people and adults with learning disabilities and autistic people whose families become unable to cope full time. This means there is a …
No response yet
R90 — Regional standing committee of service users and families
Recommendation: A regional standing committee of people with learning disabilities and autistic people and their relatives should be established, to be consulted by the DoH and other bodies on services for learning disabilities and autistic people. This should be funded by …
No response yet
R87 — PCC awareness of statutory functions
Recommendation: The PCC should take further steps to ensure that health service users, including carers and families of people with learning disabilities and autistic people, are aware of its statutory functions and the assistance it is required to provide with respect …
No response yet
R86 — PCC information on quality of care standards
Recommendation: The PCC should support service users/families and provide information on what constitutes good quality care for people with learning disabilities and autistic people, and how to spot when care is falling short.
No response yet
R85 — RQIA communication with patients
Recommendation: RQIA needs to spend proportionately more time talking to patients/residents, and its staff need to be trained in specific communication techniques such as Makaton and Talking Mats.
No response yet
Prevention of Future Deaths reports(2)
Stefan Kluibenschadl
Concerns: The coroner raised concerns that Stefan, a young person with autism, did not have a case manager or key worker as recommended by NICE guidance. Current service provision for these roles is restricted to a small cohort, leaving many young people with autism without this support to navigate services.
Overdue
Beverley Stanisauskis
Concerns: The coroner noted a lack of recognition in primary care that the patient's learning disability affected their engagement, with no doctor attempts to speak to the patient and no involvement from the learning disability team.
Response (GM ICB): • The GP practice organised a learning event and updated its policies and protocols following the patient's death. • The Learning Disability Team employed a Health Inequalities lead practitioner and … (AI summary)
Responded
Select committee recommendations(20)
#4 — Significant proportion of eligible people remain unregistered on the learning disability register.
Recommendation: The learning disability register is vital for people with a learning disability to receive important, life-saving annual health checks and reasonable adjustments. Yet around 75% of people with a learning disability are not registered. We heard from people who struggled …
Response status not verified
#5 — Investigate reasons for low learning disability register uptake and launch awareness campaign.
Recommendation: As an immediate priority, the Department for Health and Social Care and NHS England should work with national and local learning disability organisations and charities and the Royal College of General Practitioners to investigate why eligible people are not on …
Response status not verified
#13 —
Recommendation: There is an overarching concern that the education system is not delivering for young people with special educational needs. As a matter of urgency, the Government should review and improve the support young disabled people receive in the education system.
Response attribution not verified
#9 —
Recommendation: A single information hub that delivers tailored information to young disabled people and their parents or carers would help them navigate the transition from education to work, identify appropriate support, and understand their specific rights and entitlements.
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
#17 — Disabled claimants require significant external support to navigate inaccessible benefit applications
Recommendation: Written evidence from Sense highlighted findings from a survey of claimants with complex disabilities–49% of those surveyed reported that they could not apply for benefits without the support of friends, family or a support service. Sense recommended that DWP should …
Response attribution not verified
#12 — Disabled people experience significant difficulty and negative impacts from benefit application process
Recommendation: Written evidence from Sense highlighted that disabled people’s experiences of the benefit system were often negative due to issues with the design of the system and how DWP communicates. In May 2024, Sense commissioned a survey of 1,000 people with …
Response attribution not verified
#6 — Detail barriers for elderly and disabled bus users, promoting concessionary pass uptake
Recommendation: The Department does not understand why elderly and disabled people are using buses far less than they used to. The Department could not adequately explain to us why elderly and disabled people have not returned to buses to the same …
Response attribution not verified
#60 —
Recommendation: Alongside work to support and incentivise employer bodies to improve access to work experience, the Government should work with representative bodies and membership organisations, including Chambers of Commerce to improve awareness and support businesses to recruit and retain young disabled …
Response attribution not verified
#18 —
Recommendation: Because of the greater barriers they face to accessing employment, and their need for a deeper understanding of the kinds of support employees can access, young disabled people are particularly likely to benefit from targeted, specialist careers advice. It is …
Response attribution not verified
#8 —
Recommendation: The Government should take steps to increase the number of supported internships, and should introduce ambitious, time-bound rolling targets for this. Building on the success of supported internships in NHS Trusts, the campaign should include targeted work to increase public …
Response attribution not verified
#7 —
Recommendation: The Government should honour the commitment of the previous Government to double the number of supported internships and should take steps to ensure that as many young disabled people as possible are eligible for them.
Response attribution not verified
#6 —
Recommendation: Supported internships are an effective way to support people furthest from the job market to gain experience of the workplace and enter the workforce. They also provide effective support for employers to address cultural and practical barriers to employing disabled …
Response attribution not verified
#2 —
Recommendation: Vocational profiling provides an effective way to identify the aspirations and development needs of young disabled people at an early stage and may enable schools and colleges to put the right careers support in place.
Response attribution not verified
#3 — Set out steps and statistics to ease Child Trust Fund access for young people lacking mental capacity
Recommendation: The Child Trust Fund scheme is not easily accessible for the families and carers of children and young people lacking mental capacity. The Ministry of Justice estimates that between 63,000 and 126,000 young people may not have the mental capacity …
Response attribution not verified
#8 — Implicit inclusion of children with SEND in breakfast clubs risks unequal access.
Recommendation: Despite the implicit inclusion of children with SEND in the Bill’s provisions on breakfast clubs, we consider that express inclusion of the needs of those children on the face of the Bill would be a much stronger safeguard against schools …
Response attribution not verified
NCEPOD recommendations(3)
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
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
CQC inspection actions(5)
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
The York 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
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
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
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
IMB individual recommendations(7)
Foston Hall (2021)
The IMB is concerned about: the ongoing absence of initial screening of prisoners for learning difficulties and disability (LDD) due to a staffing shortage.
Governor / Director
Isle of Wight (2021)
All prisoners are offered rapid LDD screening, irrespective of whether they have a self-declared LDD, and all those requiring follow up have in-depth LDD screening.
Governor / Director
Hewell (2021)
Improve identification of those prisoners with learning difficulties/disabilities and their consequential support.
Governor / Director
Norwich (2023)
Will the minister please explain why prisoners with severe mental health issues or learning difficulties are still being held in custody?
Ministry of Justice
Norwich (2024)
Will the Minister please explain why prisoners with severe mental health issues or learning difficulties are still being held in custody?
Ministry of Justice
In Progress
Feltham (2025)
Investigate if local authority funding for SEN/EHCP children can follow them into custody.
HMPPS
Birmingham (2021)
How will the Prison Service plan a more coordinated, consistent and fair system of recording and tracking provision for prisoners with autism and learning difficulties, and how will they ensure that staff are fully trained and competent at recognising, working and interacting with prisoners with these conditions?
HMPPS
In Progress
Health investigations(5)
Independent investigation: Lorna Thomas, Milton Keynes (1995) — Rec 4
The Milton Keynes Council and Buckinghamshire County Council Social Services Departments and the Milton Keynes Community NHS Trust should review their referral policies to allow Psychiatrists in Learning Disability to refer patients with a mild learning disability and mental health needs, who may benefit from the service, to Keystone or …
south_east
*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
An independent care pathway review of a young person: Published … — Rec 7
All services should introduce the Autistica guidance in supporting families with autism diagnoses. This should be embedded in protocols for organisations. The application of support to families with a newly diagnosed family member with autism should be the subject of a thematic review.
london
An independent care pathway review of a young person: Published … — Rec 3
NHS England and Specialised Commissioning should establish if a wider introduction of the Autistica guidance in supporting families with autism diagnoses is required across services.
london
Independent investigation: Lorna Thomas, Milton Keynes (1995) — Rec 7
The Milton Keynes Council and Buckinghamshire County Council Social Services Departments should review their "appropriate" adult procedures to support people with a learning disability who are to be interviewed by the Police and should provide the necessary continuing support afterwards.
south_east
Detention investigations(1)
Independent reviews(7)
Bubb Report — Rec 1
The Government should draw up a Charter of Rights for people with learning disabilities and/or autism and their families, and it should underpin all commissioning. The Charter should clarify existing rights, and set out new rights we propose below. The mandatory commissioning framework later in our recommendations should require all …
Health & Social Care
Litchfield WCA Review Year 5 — Rec 24
The Department ensures that it seeks the most appropriate evidence for people with learning disabilities, including Hospital Passports and care or support plans. The Department should consider options in each case rather than defaulting to a GP report.
Employment & Work
Litchfield WCA Review Year 5 — Rec 23
The Department reviews the training given to its own staff and those of the Provider in relation to learning disabilities to ensure that the risk of overstatement of capability is fully understood.
Employment & Work
Litchfield WCA Review Year 5 — Rec 21
The Department should work with the Department for Education and the devolved administrations to develop improved mechanisms for providing information about the world of work, including the WCA, to those with learning disabilities at the point of leaving education.
Employment & Work
Litchfield WCA Review Year 5 — Rec 7
Further work to develop and implement a semi-structured interview should continue. This should be developed in conjunction with a small number of representative groups. Particular attention should be paid to interview practices for those with mental health conditions, learning disabilities and autism, and this should be reflected in the guidance …
Employment & Work
Coates Prison Education Review — Rec 1
Every prison must use a consistent and rigorous assessment mechanism to set a baseline against which to measure individuals' academic performance and screen for learning difficulties and/or disabilities (LDD).
Justice & Legal
Angiolini Review — Rec 91
Mandatory police training on vulnerability must include understanding of, and appropriate policing responses to those with learning disabilities and difficulties, mental ill health, epilepsy or who are on the autistic spectrum as well as other conditions which may compromise the ability to communicate and understand police actions or processes.
Policing & Security
Accepted
PHSO casework decisions(3)
P-003183 — South West Yorkshire Partnership NHS Foundation Trust
Miss A complained the Trust wrongly discharged her son, P, from learning disability services, misjudged his abilities, and discriminated against him. She also complained the GP removed his diagnosis.
NHS in England
Dec 2024
P-004265 — Cornwall Partnership NHS Foundation Trust
Dr J complained Cornwall Partnership NHS Foundation Trust's CAMHS assessment failed to measure her son's needs, use full evidence, and inappropriately labelled him with a mild learning disability.
NHS in England
Nov 2025
P-002790 — Derbyshire Healthcare NHS Foundation Trust
Mrs A complained the Trust failed to recognise her son's autism and vulnerability, provide follow-up care after suicide attempts, and notify the family, contributing to his death.
NHS in England
Jul 2024
LGO / SPSO decisions(9)
PSOW-202503627 — Newport City Council
Mr A complained that Newport City Council did not appropriately address his complaint in relation to a communication failure, where staff of the vulnerable adult services were directing the public to use a callback system which cannot connect the caller back to them. The Ombudsman found that the Council mischaracterised …
PSOW (Public Services Om…
Health
Sep 2025
PSOW-202401795 — Newport City Council
Mr S complained that Newport City Council had failed to respond to a complaint he raised in March 2024. The Ombudsman found that the Council had received a complaint but it had failed it as it was received with incorrect contact details. She also found that the Council had been …
PSOW (Public Services Om…
Health
Jul 2024
PSOW-202200853 — Ceredigion County Council
Ms A complained about the Council’s failure to properly implement the terms of an early resolution undertaken in September 2020. Ms A was aggrieved that a Carer’s Assessment was not properly completed and that there remained significant uncertainty about respite care. Ms A was also aggrieved that the Council appeared …
PSOW (Public Services Om…
Health
Dec 2022
21-015-609 — London Borough of Hounslow
Summary: Miss X complained about the way the Council dealt with her application and appeal for a Blue Badge for her son who is autistic. Since she made her complaint, the Council has carried out a further face-to-face mobility assessment and come to the same decision as before. Any investigation …
LGO (Local Government & …
Children S Care Services
Not Upheld
Oct 2022
22-003-393 — London Borough of Redbridge
Summary: The Council was at fault in how it dealt with penalty charge notices issued to Mr X as a result of fraud. The Council requested duplicate information from Mr X causing frustration and anxiety. The Council also failed to meet its duty under the Equality Act to make a …
LGO (Local Government & …
Transport And Highways
Upheld
Nov 2022
PSOW-202106906 — Ceredigion County Council
Miss X complained that the Council failed to respond to her complaint about social services , and further failed to respond to her letters. The Ombudsman decided that the Council should contact Miss X (within 5 days) to establish if she would like her complaint dealt with at stage 1 …
PSOW (Public Services Om…
Health
Feb 2022
21-013-505 — Cumbria County Council
Summary: We cannot investigate this complaint about how the Council carried out an Education Health and Care needs assessment. This is because the complainant has used their right to appeal about the outcome to a tribunal, which places the matter outside our jurisdiction.
LGO (Local Government & …
Education
Feb 2022
21-013-801 — Kingston Upon Hull City Council
Summary: We will not investigate this complaint about how the Council have assessed a child’s special educational needs, which the complainant says will result in an inadequate Education Health and Care plan. This is because the contend of the plan carry the right of appeal to a tribunal.
LGO (Local Government & …
Education
Feb 2022
PSOW-202408040 — Cardiff Council
Mrs C complained that Cardiff Council had failed to take action to safeguard Mr A, who is a disabled adult, when he was left unaccompanied by an independent service provider. The Ombudsman decided that the Council had not adequately acknowledged or apologised for the lack of clarity in its communication …
PSOW (Public Services Om…
Health
Mar 2025
Domestic Homicide Reviews(4)
South Worcestershire — recommendation 6
That WSAB seeks assurance from local CCGs and GP Confederations and partner agencies that all patients with a learning disability are identified by their GP in order that they can receive the learning disability annual review to which they are entitled.
WSAB | local ICBs | GP …
Newport — recommendation 10
Examining the role and communication with third sector specialists in domestic violence, especially in relation to adults with any learning disability and developing service provision in support of persons with learning disabilities.
Newport City Council Adult Services
Newport City Council
Lincoln — recommendation 8
The LSAB will need to seek assurance about: • The progress of the CCG’s work around the use of Learning Disability Health Reviews, the extent to which these reviews address mental capacity and they are making a difference to adults with care and support needs.
LSAB | ICB
South Cambridgeshire — recommendation 12
A vulnerability scoring system is to be looked at to provide consistency among GP practices in relation to the assessment of their most vulnerable patients for inclusion onto MDT discussions. At the moment ‘vulnerability’ is multifactorial and will vary hugely in nuance and severity between individual patients (incorporating physical illness …
National Recommendation