Confidential Inquiry into deaths of people with Learning Disabilities
Published: June, 2013
The key recommendations from the CIPOLD review of deaths
Clear identification of people with
learning disabilities on the NHS
central registration system and in
all healthcare record systems.
required by, and provided
to, individuals, to be audited
annually and examples of best
practice to be shared across
agencies and organisations.
Guidelines to take into
A named healthcare coordinator to
be allocated to people with complex
or multiple health needs, or two
or more long-term conditions.
Patient-held health records to be
introduced and given to all patients
with learning disabilities who
have multiple health conditions.
Standardisation of Annual Health
Checks and a clear pathway
between Annual Health Checks
and Health Action Plans.
People with learning disabilities
to have access to the same
investigations and treatments as
anyone else, but acknowledging
and accommodating that they may
need to be delivered differently
to achieve the same outcome.
Barriers in individuals’ access to
healthcare to be addressed by
proactive referral to specialist
learning disability services.
Adults with learning disabilities to
be considered a high-risk group for
deaths from respiratory problems.
Mental Capacity Act advice to be
easily available 24 hours a day.
The definition of Serious Medical
Treatment and what this means
in practice to be clarified.
Mental Capacity Act training and
regular updates to be mandatory
for staff involved in the delivery
of health or social care.
Do Not Attempt Cardiopulmonary
Resuscitation (DNACPR) Guidelines
to be more clearly defined and
standardised across England.
Advanced health and care planning
to be prioritised. Commissioning
processes to take this into
account, and to be flexible and
responsive to change.
All decisions that a person
with learning disabilities is to
receive palliative care only to
be supported by the framework
of the Mental Capacity Act
and the person referred to a
specialist palliative care team.
Improved systems to be put in
place nationally for the collection of
standardised mortality data about
people with learning disabilities.
Systems to be put in place
to ensure that local learning
disability mortality data is
analysed and published on
population profiles and Joint
Strategic Needs Assessments.
A National Learning
Disability Mortality Review
Body to be established.
A death which was not anticipated as a significant possibility 24 hours
before the death or where there was a similarly unexpected collapse
leading to or predicating the events which led to death
The International Classification of Diseases and Related Health Problems
codes diseases, signs and symptoms, abnormal physical findings and
causes of injury. ICD-10 is the 10th revision of this classification system
Disability Distress Assessment Tool (DisDAT)
Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)
National Institute for Health and Clinical Excellence
Confidential Inquiry into premature deaths of people with learning disabilities