The aim was to review the patterns of care that people received in the period leading up to their deaths and to identify errors or omissions contributing to these deaths. It also aimed to illustrate evidence of good practice and to provide improved evidence for avoiding premature death.
The final report highlights deficiencies in the quality and effectiveness of health and social care given to people with learning disabilities. The inquiry’s findings include the continuing need to identify people with learning disabilities in healthcare settings and to record, implement and audit the provision of ‘reasonable adjustments’ to avoid their serious disadvantage.
Download the final report (English only)