A report into the deaths of six people with learning disabilities has uncovered “significant and distressing” failures in services across health and social care.
The joint report by the health service ombudsman and the local government ombudsman found one person died as a consequence of public service failure.
It is likely the death of another person could have been avoided, had the care and treatment provided not fallen so far below standard, it said.
The report, Six Lives: the provision of public services to people with learning disabilities , responds to complaints brought by the charity Mencap on behalf of the families of six people with learning disabilities who died while in NHS or local authority care between 2003 and 2005.
Their cases were brought to public attention in Mencap’s 2007 report Death by Indifference.
Today’s report attacks some NHS bodies and councils for “failing to live up to human rights principles, especially those of dignity and equality”.
The report calls on all NHS and social care organisations to review systems for planning the care of people with learning disabilities.
It says they should also review the capacity and capability of the services they provide or commission.
The Care Quality Commission, Monitor and the Equality and Human Rights Commission must make sure their monitoring provides effective assurance that organisations are meeting requirements for people with learning disabilities.
The Department of Health is to produce a progress report in 18 months.
‘Indictment of our society’
Health service ombudsman for England Ann Abraham said: “The recurrence of complaints across different agencies leads us to believe that the quality of care in the NHS and social services for people with learning disabilities is at best patchy and at worst an indictment of our society.
”Six Lives has highlighted distressing failures in the quality of health and social care services for people with learning disabilities. No investigation can reverse the mistakes and failures but if NHS and social care leaders take positive steps to deliver improvements in services, this may bring some small consolation to the families and carers of those who died.”