Pauline Heslop, et al.


University of Bristol, 2013


Mencap's report Death by Indifference described the circumstances surrounding the deaths of six people with learning disabilities who died while they were in the care of the NHS, exposing 'institutional  discrimination'. An Independent Inquiry chaired by Sir Jonathan Michael followed, which recommended the establishment of the learning disabilities Public Health Observatory, and a time-limited Confidential Inquiry into premature deaths of people with learning disabilities. The Confidential Inquiry into the deaths of people with learning disabilities (CIPOLD) was tasked with investigating the avoidable or premature deaths of people with learning disabilities through a series of retrospective reviews of deaths. 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.