Learning Disability Today
Supporting professionals working in learning disability and autism services

Ombudsman finds severe failures in care in death of woman with learning disabilities

TinaA string of failings by various NHS bodies contributed to the death of a woman with learning and physical disabilities, the Parliamentary and Health Service Ombudsman has found in a report. 

The report found that Tina Papalabropoulos, who was 23 years old, died of aspirational pneumonia on January 30, 2009, at Basildon Hospital, after staff there did not give her the treatment she needed or even meet her basic care needs. She suffered several seizures in hospital and went four days without food.

In addition, the Ombudsman’s report criticised the failure of an out-of-hours GP service to make a requested home visit to Tina when her condition was initially worsening. 

The Ombudsman’s investigation found service failure on the part of South Essex Emergency Doctors Service and Basildon and Thurrock University Hospitals NHS Foundation Trust and that this service failure had resulted in missed opportunities to save Tina’s life and caused distress to her parents.

Tina had lived at home with her parents and her sister. She had learning disabilities, epilepsy, Russell-Silver Syndrome – a form of dwarfism – and severe scoliosis of the spine.  

The Ombudsman, Dame Julie Mellor, said: “The experience of this young woman and her family is another example of the NHS having further to go in serving patients with learning disabilities well. The challenge of ensuring that all health and social care services improve the day to day experience and outcomes of patients with learning disabilities remains central to delivering a patient-centred NHS.

“The NHS must treat the most vulnerable members of our society better and we will continue to publish cases where the NHS has failed to serve people with learning disabilities so that this issue remains the focus of attention and improvement across health and social care.” 

Avoidable tragedy

Beverley Dawkins, Mencap’s policy manager, who has worked with Tina’s family, said: “Tina’s death was an avoidable tragedy. Her family and Mencap believe that the failings that led to her losing her life at 23 were because doctors held the view that Tina’s life was not worth saving, due to her disability. 

“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.” 

Tina’s mother, Christine, added: “When your child becomes ill and you need professional help from doctors – you and your child are looked at, and you can see their mind working: is there any point in trying to save this child’s life? You can see that they think, ‘this child has an existence and not a life’. Wrong! This child is loved by all the people, family and friends that they come in contact with. This child is a human being. They just happen to be born with a disability.”

This report comes ahead of an expected Department of Health response to a 2009 Health Service Ombudsman and Local Government Ombudsman report Six lives: the provision of public services to people with learning disabilities next month.  

Six Lives included cases illustrating significant and distressing failures in service across health and social care, leading to situations in which people with learning disabilities experienced prolonged suffering and inappropriate care.


Tina’s mother, Christine, has written a blog about her experiences. Read it here on Mencap’s website.


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