Review into learning disability deaths calls for care improvements

Collaboration and information sharing among care providers and agencies need to be strengthened after a review into the deaths of people with learning disabilities highlighted concerns about a lack of coordination among organisations.

An annual report of the Learning Disabilities Mortality Review programme, which was commissioned by the Healthcare Quality Improvement Partnership on behalf of NHS England, also found a lack of awareness when it came to the needs of people with learning disabilities.

The programme was notified about 1,311 deaths between 1 July 2016 and 30 November 2017. Of these, 103 reviews were completed.

Reviewers found that in 13 cases ‘the person’s health had been adversely affected’ by delays in care or treatment, gaps in service provision, organisational dysfunction, and neglect or abuse.

Of the completed reviews, there were 189 learning points or recommendations identified. The most common related to inter-agency collaboration and communication, awareness of the needs of people with learning disabilities, and understanding of the Mental Capacity Act.

The report said: ‘Most of the learning to-date echoes that of previous reports of deaths of people with learning disabilities, and the importance of addressing this cannot be overestimated.

‘We have a responsibility to families and others to ensure that any learning points at individual level are taken forward into relevant service improvements as appropriate.’

Of the 103 reviews, 36 did not identify any learnings.

The report made nine national recommendations including strengthening collaboration and information sharing, electronic integration of health and social care records, and mandatory learning disability awareness training.

Also, care providers ‘should clearly identify people requiring the provision of reasonable adjustments, record the adjustments that are required, and regularly audit their provision.’