Six Lives: the provision of public services to people with learning disabilities
Adult care services
In a report laid before Parliament on 23 March 2009 Ann Abraham, Health Service Ombudsman and Jerry White, Local Government Ombudsman, called for an urgent review of health and social care for people with learning disabilities. Three of the cases covered by the report concerned the actions of councils, together with other authorities:
London Borough of Havering (07B06309) Maladministration causing injustice
Gloucestershire County Council (07B06077) Maladministration causing injustice
Buckinghamshire County Council (07B09453) No maladministration
The report responds to complaints brought by the charity Mencap on behalf of the families of six people with learning disabilities who died whilst in NHS or local authority care between 2003 and 2005. The cases of Mark Cannon, 30; Warren Cox, 30; Edward Hughes, 61; Emma Kemp, 26; Martin Ryan, 43 and Tom Wakefield 20 and were brought to public attention in Mencap’s 2007 report Death by Indifference.
Six Lives shows that on many occasions basic policy and guidance were not observed, the needs of people with learning disabilities were not accommodated and services were unco-ordinated. The complex factors which led to these failures to protect vulnerable individuals demonstrate the need for stronger leadership throughout the health and care professions – this report is not solely a concern for specialists in learning disabilities.
Based on the findings of these investigations the Ombudsmen made three key recommendations in the report:
First, that all NHS and social care organisations in England should review urgently:
- the effectiveness of the systems they have in place to enable them to understand and plan to meet the full range of needs of people with learning disabilities in their areas;
and
- the capacity and capability of the services they provide and/or commission for their local populations to meet the additional and often complex needs of people with learning disabilities;
and should report accordingly to those responsible for the governance of those organisations within 12 months of the publication of the Ombudsmen’s report.
Secondly, that those responsible for the regulation of health and social care services (specifically the Care Quality Commission, Monitor and the Equality and Human Rights Commission) should satisfy themselves, individually and jointly, that the approach taken in their regulatory frameworks and performance monitoring regimes provides effective assurance that health and social care organisations are meeting their statutory and regulatory requirements in relation to the provision of services to people with learning disabilities; and that they should report accordingly to their respective Boards within 12 months of the publication of the Ombudsmen’s report.
Thirdly, that the Department of Health should promote and support the implementation of these recommendations, monitor progress against them and publish a progress report within 18 months of the publication of Ombudsmen’s report.
See downloads for overview report and the three cases above.
Remedy (1) London Borough of Havering (07B06309) Mark Cannon
The Health Service and Local Government Ombudsmen recommended that Mr Cannon’s parents should receive apologies and compensation totalling £40,000 from the bodies against which complaints were upheld. The compensation was in recognition of the injustice suffered in consequence of service failure and maladministration identified.
In accordance with the Ombudsman's recommendations, the Council:
- apologised to each of Mr Cannon’s parents;
- paid each of them £10,000; and
- took steps to ensure that provider care plans and risk assessments are properly in place for all persons in receipt of respite care commissioned by the Council.
LGO satisfied with Council's response: 7 August 2009
Remedy (2) Gloucestershire County Council (07B06077) Tom Wakefield
The Health Service and Local Government Ombudsmen concluded that there was service failure by most, although not all, of the bodies complained about, causing injustice for Tom's parents. They would never know if, had appropriate arrangements been in place for their son’s transition to adult care, his life would have been longer or more enjoyable in his last year. Poor complaint handling had compounded their distress. They also concluded that maladministration by the Council and service failure by the PCT, the Partnership Trust and the Acute Trust caused unnecessary suffering for Tom in the final months of his life.
The Ombudsmen recommended that Tom’s parents should receive apologies and compensation totalling £30,000 from the various bodies against which complaints were upheld.
LGO satisfied with Council's response: 17 March 2009
Date Updated: 10/12/09