Ombudsman finds service failures once again in report on death of young woman with learning disabilities


As you know here at Elf towers, we are committed to bringing you the evidence, so that you can make informed decisions about practice. However I hope you’ll forgive a slight deviation from this aim this Friday, as we bring to your attention the publication of yet another report that highlights poor NHS care.

On Tuesday of this week, the Health Service Ombudsman published its findings into the death of Tina Papalabropoulos a 23 year old woman with learning disabilities, in a hospital in Essex.

The ombudsman found the care provided by the out of hours service doctor fell “so far below the applicable standard that this was service failure.” In relation to the care in hospital, that the care provided by the doctors also “fell so far below the applicable standard that this was service failure.”

We were particularly moved by the video of the young woman’s mother who, as well as celebrating Tina’s life, describes her own feelings of guilt brought on by the lack of information provided by the hospital staff.

This got me to thinking about what I could do in my local area to improve healthcare for people with learning disabilities, and I wondered if readers of the Elf would be happy to share what’s happening where they are?

Let us know what you are doing in your area – perhaps it is finding out about a local learning disability nurse who works as a facilitator at the local hospital and talking to them? Perhaps you have developed some really good communication tools that you use when you support somebody to visit the GP? Perhaps you have worked with people who are using their experience to help train doctors and nurses?

Whatever it is, it would be good hear from you – tell us and the other Elf readers what you are doing, how it’s going and what you have learnt.

Commenting on the publication of the report, Beverley Dawkins, Mencap’s Policy Manager, said:

We welcome the Ombudsman’s finding that service failure resulted in missed opportunities to save this young woman’s life. It is clear that hospital staff and the out of hours GP service missed any opportunity to save a deeply loved and much-missed young woman. But, this is yet another shocking example of the indifference and substandard care that people with a learning disability face in the NHS. It has taken her family four long years to get any kind of justice for her death. This must not happen again.”

The work you are doing can be a contribution to this aim, so we look forward to hearing from you.

You can read the findings and download the full report here: Report by the Health Service Ombudsman for England of an investigation into a complaint made by Mr and Mrs M


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John Northfield

After qualifying as a social worker, John worked in community learning disability teams before getting involved in a number of long-stay hospital closure programmes, working to develop individual plans for people moving into their own homes. He worked for BILD, helping to develop the Quality Network and was editorial lead for the NHS electronic library learning disabilities specialist collection. This led him to found the Learning Disabilities Elf site with Andre Tomlin as a way of making the evidence accessible to practitioners in health and social care. Most recently he has worked as part of Mencap's national quality team and also been involved in a number of national website developments, including the General Medical Council's learning disabilities site.

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