Foreword
Jump to
I am laying this report before Parliament under section 14(4) of the Health Service Commissioners Act 1993 (as amended).
The report relates to six investigations which I have conducted as Health Service Ombudsman for England, three of them jointly with the Local Government Ombudsman, Jerry White, in accordance with the powers conferred on us by amendments to our legislation due to The Regulatory Reform (Collaboration etc. between Ombudsmen) Order 2007.
The complaints were made by Mencap on behalf of the families of six people with learning disabilities, all of whom died between 2003 and 2005 while in NHS or local authority care.
The complaints were made following Mencap’s report, Death by indifference, published in March 2007, which led to the setting up of the Independent Inquiry into Access to Healthcare for People with Learning Disabilities by Sir Jonathan Michael MB BS FRCP (Lond) FKC, commissioned by the then Secretary of State for Health. The Inquiry’s report, Healthcare for All, was published in July 2008.
The complaints were made against a total of 20 public bodies. They all concerned the quality of care which was provided and the majority of them also included concerns about the way in which subsequent complaints about the quality of that care had been handled at local level, and by the Healthcare Commission.
The report is in eight Parts (or volumes).
Part 1 provides an overview of the work we have undertaken, identifies the themes and issues arising from our work, and makes some general recommendations to address those issues. Part 1 also contains a summary of each of the individual investigation reports.
Parts 2 to 7 are the full reports of the six investigations.
Part 8 is an easy read version of Part 1.
Note: Unusually, the summary reports and the full investigation reports are not fully anonymised. This is because some of the names of the complainants are already in the public domain as a result of Mencap’s earlier report; and because Mencap have confirmed that the families are content to be named in the published reports. We have taken into account the public interest and the interest of the complainants and the other people affected by our reports and consider that it is necessary in that context to include the names of the complainants.
Our findings
Our investigation reports illustrate some significant and distressing failures in service across both health and social care, leading to situations in which people with learning disabilities experienced prolonged suffering and inappropriate care.
Our investigations found maladministration, service failure and unremedied injustice in relation to a number, but not all, of the NHS bodies and local councils involved. In some cases we concluded that there had been maladministration and service failure for disability related reasons. We also found in some cases that the public bodies concerned had failed to live up to human rights principles, especially those of dignity and equality.
Our findings contrast markedly with the first Principle of the recently published NHS Constitution for England and Wales, which says that ‘The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief. It has a duty to each and every individual it serves and must respect their human rights’.
A similar contrast is evident for social care. Independence, Well-being and Choice, published by the Department of Health in March 2005, set out a vision for adult social care and established a standard for social care which was endorsed by the white paper Our Health, Our Care, Our Say in January 2006. It says that ‘[Social care services] should treat people with respect and dignity and support them in overcoming barriers to inclusion… They should focus on positive outcomes and well-being and work proactively to include the most disadvantaged groups’.
The wider context
This report is timely in a number of respects.
On 19 January 2009 the Department of Health published Valuing People Now: a new three-year strategy for people with learning disabilities, which reaffirms the commitment to the principles of equality, dignity, rights and inclusion set out in Valuing People: A New Strategy for Learning Disability for the 21st Century, published by the Department of Health in 2001. The strategy places strong emphasis on leadership at all levels through the public sector from central government, through regions, to health and local authorities.
On 1 April 2009 a new regulator, the Care Quality Commission, comes into being and from April 2010 a new registration system will come into effect for all health and social care providers.
Finally, this report is laid before Parliament at a time of imminent change in the complaint handling landscape for both health and social care which will take effect from 1 April 2009. I welcome those changes and the opportunity to remind public bodies of the value of dealing with complaints promptly and effectively and, where complaints are justified, offering appropriate remedies.
Together with my Local Government Ombudsman colleague, I am also committed to ensuring that the learning from complaints is fed back to those responsible for the design and delivery of public services so that they can use that feedback to improve those services for the future. There is much to learn from the findings of these investigations, and much to improve. I hope that all NHS bodies and local authorities, together with the relevant regulators and the Department of Health, will respond positively to the recommendations in this report and demonstrate a willingness to learn from it, and that this might provide some small consolation to the families and carers of those who died.
Ann Abraham
Parliamentary and Health Service Ombudsman
March 2009
