Author: Liz Herrievan / Editor: Charlotte Davies / Codes: ELC3, MHP1, PC3, SLO1, SLO2, SLO3, SLO5, SLO7, XC3 / Published: 16/06/2025
This blog is something a bit different. Based on real Coroner’s cases, we’ve pulled out some critical decision moments so you can work your way through the patient journey and decide what you would do. We’ll also be letting you know what actually took place, and how we can all aim to prevent further similar tragedies. We can’t change what’s happened, but we can try to learn from it. All the case information is taken from judiciary reports, press articles, online blogs and, in the first case, from the patient’s family.
These cases all involve people with a learning disability. People with a learning disability die, on average, 20 years earlier than the rest of the population1, and are more than 3 times (much higher in some reports) more likely to die of something which should be treatable2. Laws such as the Equality Act (2010) and Mental Capacity Act (2005) exist, at least in part, to try to protect people with a learning disability, but are often not followed appropriately2. You can read more here, and don’t forget to download and use the RCEM Learning Disability Toolkit.