The critical finding at the inquest into Laura Booth’s death raises alarming concerns about the failing system of investigation into the deaths of people with learning disabilities (Report, 26 4月). Initially, Laura’s death was said to be expected and was attributed to natural causes on the basis of a death certificate signed by a hospital doctor. Without the determination of Laura’s family and the intervention of the media, this inquest would never have happened, and the truth about her death from malnutrition and neglect would not have been uncovered. The coroner found that there was inappropriate weight placed on Laura’s clinical history and diagnoses, which masked the failings in her care. Laura’s family were also forced to endure an adversarial approach adopted by an NHS Trust seemingly more concerned with reputational management than learning and accountability.
We are concerned about how many other avoidable deaths have not been scrutinised because there is no one to speak up on behalf of those who died or because families are obstructed in their search for answers by the prevailing assumption that people will die early. The premature deaths of people with learning disabilities (平均して 30 years before their non-disabled peers) demand robust scrutiny particularly as when inquests do take place, they so often reveal basic failings in healthcare. The way in which the Booth family were so nearly failed by the coronial system is a sharp reminder of how urgently reform of these processes is needed.
Deborah Coles Director, Inquest
Prof Sara Ryan Manchester Metropolitan University
Dr George Julian