Confidential inquiry into premature deaths of people with learning difficulties

  • Heslop, Pauline (Principal Investigator)
  • Marriott, Anna (Manager)
  • Blair, Pete (Researcher)
  • Fleming, Peter (Researcher)
  • Houghton, Matt (Researcher)
  • Russ, Lesley (Researcher)

Project Details


CIPOLD took place from 2010 to 2013 and reviewed the deaths of 247 people with learning disabilities within 5 Primary Care Trusts in the South-West of England. It also reviewed the deaths of 58 people without learning disabilities, to place the findings in context. The aim was to review the patterns of care that people received in the period leading up to their deaths, to identify errors or omissions contributing to these deaths, to illustrate evidence of good practice, and to provide improved evidence on avoiding premature death.

The study reveals that the quality and effectiveness of health and social care given to people with learning disabilities has been deficient in a number of ways. Of the 238 deaths of people with learning disabilities for which agreement was reached by a multidisciplinary Overview Panel, 42% were assessed as being premature. The most common reasons for deaths being assessed as premature were: delays or problems with diagnosis or treatment; and problems with identifying needs and providing appropriate care in response to changing needs.

Eighteen key recommendations are made which, were they to be individually and collectively implemented, would lessen the risk of premature death in people with learning disabilities.
Effective start/end date15/03/1015/07/15

Structured keywords

  • PolicyBristolHealthAndWellbeing
  • SPS Norah Fry Centre for Disability Studies


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