1. Confidential Inquiry into the deaths of people with learning disabilities Pauline Heslop and the CI team Norah Fry Research Centre University of Bristol

2. Aims of the CI To detect potentially avoidable and modifiable contributory factors in the care of a person with learning disabilities who has subsequently died To identify inadequate pathways of care or gaps in the treatment To contribute to the evidence base for best clinical and professional practice To provide information to guide the commissioning of services To establish a usable system for reporting the deaths of people with learning disabilities that can be replicated To improve the standard and quality of care for people with learning disabilities and ultimately their health outcomes.

3. How will we do this? Notification

4. How will we do this? Notification Data collection

5. How will we do this? Notification Data collection Talking to people

6. How will we do this? Notification Data collection Talking to people Looking at records

7. Local Review Panels Notification Data collection Talking to people Looking at records Potentially modifiable factors in relation to the death Was the death expected? Was the death premature? Good practice Learning points Recommendations

8. Overview Panels Key risk factors Management of these Inadequate pathways of care Data improvements Good practice Learning points

9. How are we doing so far? Investigating the deaths of all people with learning disabilities in Avon and Gloucestershire Started investigating deaths 1 st June 2010 50+ deaths reported and being investigated to-date Some amendments to the process have been made Experienced pool of investigators and nurses in place Many cases do involve potentially modifiable factors Some changes being made to local practice as a result of practitioners being involved in the CI process

10. What will happen in the future? Submit a report to the Department of Health Work collaboratively with the Learning Disabilities Observatory Write an easy read report to share with people with learning disabilities

11. Confidential Inquiry into the deaths of people with learning disabilities For further information: Email: ci-team@bristol.ac.ukci-team@bristol.ac.uk Website: www.bris.ac.uk/cipold/www.bris.ac.uk/cipold/