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NHS report reveals decade of failings in vulnerable mans care

Posted on 10th December 2021 in Medical Negligence

Posted by

Simon Mansfield

Partner and Solicitor
NHS report reveals decade of failings in vulnerable mans care

Mr Treacey lived his life in the care of the NHS and social care authorities but experienced an “unacceptably poor quality of life” and was not kept safe from harm, an NHS report has found. 

The review revealed that his death, at just 47, was “potentially avoidable” only came about under the Learning Disability Mortality Review Program after his family fought for years for answers. The review also revealed that a flawed pathology and post-mortem report was used during the inquest into Mr Treacey’s death which did not follow national guidelines.

Mr Treacey suffered from learning disabilities along with a complex form of epilepsy called Leonard Gastaut Syndrome. The investigation into his care and death follows a series of other shocking reports into the poor care of people with learning disabilities.

The review found that throughout his life, Mr Treacey suffered as a consequence of healthcare professionals attributing his health needs solely to his epilepsy. The investigation into his care at Ceder Vale also found that staff were not trained in epilepsy care, and that access to vital breathing equipment was not provided for him at night.

Mr Treacey’s family have said they knew he was dying but nobody listened, even though it was obvious he was deteriorating and was telling people he did not feel well. Following his death, a coroner concluded he died of natural causes, however, the NHS report found evidence that it did not consider the risk of Sudden Unexpected Death in Epilepsy and that as a result, there may need to be a second inquest.

A spokesperson for Cygnet Health Care has said they have been working with those involved to support the review, to address any outstanding issues, and will continue to share lessons learned.


Partner and Solicitor Simon Mansfield of Tozers’ Medical Negligence team comments:

There is a lot in the news this week about Christmas parties and Covid plan B’s but this is also such an important story as too often the needs of people with learning disabilities get ignored and (as the author of this article put it elsewhere) lost in the noise.

I have acted for a number of families of patients with either learning disabilities or mental health problems who have died as a result of poor care. These patients are particularly vulnerable as often they are not able to advocate for themselves and ask questions. This can lead to small issues having big consequences such as a not understanding the need to chase up a missed referral for appointment leading to a diagnosis being missed.

A theme I have also seen is a tendency by clinicians (either by conscious or unconscious bias) to dismiss symptoms and perhaps put issues down to say mental health problems and a “patient making a fuss” without first seeking to exclude other potential physical causes, sometimes with tragic consequences.

It is crucial therefore that stories such as Clive’s are reported and that more attention is paid to the care of those in our society who need it the most.


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