Six lives : the provision of public services to people with learning difficulties, second report, session 2008-2009

The Health Service Ombudsman and the Local Government Ombudsman investigated complaints made by Mencap on behalf of the families of Mark Cannon, Warren Cox, Edward Hughes, Emma Kemp, Martin Ryan, and Tom Wakefield, who died whilst in NHS or local authority care between 2003 and 2005.

This eight volume report, "Six Lives: The Provision of Public Services to People with Learning Disabilities (HC 203 I-VIII)", reveals significant and distressing failures in service across health and social care.

One person died as a consequence of public service failure.

It is likely the death of another individual could have been avoided, had the care and treatment provided not fallen so far below the relevant standards.

People with learning disabilities experienced prolonged suffering and poor care, and some of these failures were for disability related reasons.

Some public bodies failed to live up to human rights principles, especially those of dignity and equality.

Many organizations responded inadequately to the complaints made against them, which left family members feeling drained and demoralized. The Ombudsmen recommend that: NHS bodies and councils urgently confront whether they have the correct systems and culture in place to protect individuals with learning disabilities from discrimination, in line with existing laws and guidance; the Care Quality Commission, Monitor and the Equality and Human Rights Commission should satisfy themselves that the approach taken in their regulatory frameworks and performance monitoring regimes provide effective assurance that health and social care organizations are meeting their statutory and regulatory requirements in this area; and, the Department of Health should promote and support implementation of the recommendations and publish a progress report within 18 months.