There were 15 Prevention of Future Death Reports issued following inquests into deaths of autistic people in 2023.

First 5: Amarnih Lewis-Daniel 24, Benjamin Hart 25, Benjamin Hazelden 18(?), an anonymous child and Haik Nikolyan 21

[T/W Suicide]

1/16georgejulian.co.uk/2024/03/04/pre… Amarnih died aged 24, in April 2021. She fell to her death. The jury could not be certain whether she intended to die.

Amarnih had been on a waiting list to access a gender identity clinic for over 2.5yrs at the time of her death. The coroner identified five related concerns

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Here's all eleven 2023 Prevention of Future Death Reports I could find for learning disabled people.

Lugh Baker, 24, died April 2021 [Open conclusion]

David Hemmings, 71, died June 2021 [following complications of surgery as a result of an accidental fall in his home]

1/14 Owen Garnett, 19, died January 2023 [Misadventure, after swallowing paper towel while unsupervised at school. Concerns of his carers were not acted on]

Steven Duquemin, 'relatively young age', died August 2022 [accidental death, after choking on raw chicken overnight]

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#LDWeek is for raising awareness and busting myths.

I present to you a dose of revolting reality.

I spent the weekend revisiting Transforming Care, and the industry around it.

Over a decade of performative scrutiny and no meaningful action or progress.

Buckle up.

1/20+ Winterbourne View Panorama was broadcast on 31 May 2011.

There was much uproar and outcry at the abuse people with a learning disability were subjected to.

An Adult Safeguarding Review was written by the ever consistently brilliant Margaret Flynn. Published August 2012

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It's #LDWeek and your annual reminder to look behind the veneer of the largest national charity supposedly supporting learning disabled people.

@mencap_charity currently employee 207 ppl with a learning disability, a pitiful 2.5% of their workforce

1/4 https://t.co/7Bm18a4Pwzmencap.org.uk/about-us/annua…

https://twitter.com/mencap_charity/status/1671437748295684096

2021: 2.5% employees with a learning disability
2020: not reported
2019: 4% employees disabled, of which 2% had a learning disability
2018: 3.6% of which 1.9%
2017: 1.4% of which 1.2%
2016: 1.7% of which 1.1%
2015: 2.7% of which 0.9%
2014: 3% of which 1.1%

Woeful

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This has had the best legal minds on it, I'm not doubting their skill or ability, but I can't wrap my head around so much in this case and the Supreme Court's judgement. Jackie Maguire was deprived of her liberty, in a

@unitedresponse care home.

1/

https://twitter.com/TorButlerCole/status/1671457628797452293

If #socialcare truly had parity with healthcare I wonder if the same conclusions would be reached.

I note in the judgement learning difficulties and learning disabilities are used interchangeably, which is deeply problematic given they mean different things.

2/

This has had the best legal minds on it, I'm not doubting their skill or ability, but I can't wrap my head around so much in this case and the Supreme Court's judgement.

Jackie Maguire was deprived of her liberty, in a @unitedresponse care home.

1/ If #socialcare truly had parity with healthcare I wonder if the same conclusions would be reached.

I note in the judgement learning difficulties and learning disabilities are used interchangeably, which is deeply problematic given they mean different things.

2/

Last week I reported Sally Lewis's inquest. Sally died 5.5 years ago, from constipation, whilst in the care of @DimensionsUK

Final evidence will be heard tomorrow. In this thread I'll link to what we heard in court so far

Post mortem evidence

https://twitter.com/GeorgeJulian/status/1662081328479649793

1/20+ Evidence from Sally's key worker Susan Casey georgejulian.co.uk/2023/05/25/sal…

She told the court that @DimensionsUK provided staff no training in constipation, or sepsis, that she didn't understand constipation could be a serious health issue, or that you could die from it

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When sharing state of care for learning disabled and autistic people via latest @CareQualityComm stats, @AnnaOverThere asked about care homes for adults with severe mental illness.

CQC "service user band" mental health.

Data is as underwhelming, especially from charities

1/

https://twitter.com/AnnaOverThere/status/1590323682526007296

Data released 1 Nov, mental health care homes.

Interestingly, a number duplicate the care homes for learning disabled and autistic people, for example 2 of the 5 inadequate charitable homes are @mencap_charity homes.

3,971 care homes in total, providing 109,547 beds

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A learning disability nurse who spent his entire working life at @BelfastTrust has been found guilty of misconduct and suspended by @nmcnews

Richard Magee worked at Muckamore Abbey Hospital, as a Band 5 registered nurse on Six Mile Ward

Decision nmc.org.uk/globalassets/s…

1/ Mr Magee qualified as a registered general nurse in 1983 and went on to qualify as a registered learning disabilities nurse in 1987.

Mr Magee had worked for the Trust for the duration of his career until his retirement in 2018.

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I went digging to answer @sarasiobhan's question using @CareQualityComm data released last wk (1 Nov) on active locations I can tell you...

There are 14,843 care homes in England, providing 453,687 beds (which we'll shorthand to people even though they may not all be full)

1/24

https://twitter.com/sarasiobhan/status/1589865858440265728

14,843 homes, 12.5% have no registered manager

As for care:

4.5% people received outstanding care
70% good care
20% care requiring improvement
2% inadequate care
0.02% insufficient evidence to rate
3.5% not inspected yet

1 in 5 ppl receiving sub standard care, but, hang on

2/

The only @CareQualityComm reports finding inadequate care for learning disabled and autistic people in October I've not covered yet are @ASDspectrumASD homes in Cornwall.

I wanted to write a separate thread about them.

This was September's reports

https://twitter.com/GeorgeJulian/status/1568269181207846912

1/ There were 6 reports into their care in October.

4 inadequate, 1 requires improvement and 1 inspected not rated.

You can find them all here cqc.org.uk/provider/1-101…

Look at all those red blobs. I'll whizz through each of them in this thread

2/

Eurgh, I've been putting this off, because I know it's going to be grim.

Yesterday @CareQualityComm published four reports into care provided by @ASDspectrumASD in Cornwall.

All four found to be inadequate.

In this thread I'll cover some of what was found.

1/ Silverdale in Redruth inspected 5 May 2022 api.cqc.org.uk/public/v1/repo…

Silverdale is a residential care home providing personal care for up to four people with learning disabilities.

At the time of our inspection the service was supporting one person.

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It's been a wee while since I've introduced someone to you twitter, but ahead of @ChrisNInquest starting on Monday, please can I introduce you to Chris Nota

(Information from talking to his mum @JuliaCa20602661 and the @INQUEST_ORG press release)

1/ Chris was born at the tail end of 2000 on 30 December. He was a restless baby, he didn't sleep for long and he didn't like loud noises, instead preferring peace and quiet.

He was very much loved, and the eldest of three boys. His parents separated when he was 7.

2/

Paramount Care (Gateshead Ltd) has been closed down by @CareQualityComm

CQC inspected July 2021
Imposed urgent conditions August
Found they weren't adhered to in September

Took enforcement action to cancel the home from the provider's registration.

Home closed June 2022

1/ [Let's have a look at what CQC found when they visited in July 2021. From here on my comments will be in square brackets, all else are quotes from CQC, I may remove the odd word for brevity, but not if it changes interpretation or meaning]

Full report api.cqc.org.uk/public/v1/repo…

2/

I cant stop thinking about the people stuck in the homes in the @CareQualityComm reports I read.

Can't turn my brain off to it.

How is it that learning disabled and autistic people have fewer human rights than others?

Rights to freedom, family life, liberty? Cast aside There are so many situations right now that are wholly unacceptable. So many families desperately holding on by their finger tips, see @Dawn26467771 eg

https://twitter.com/Dawn26467771/status/1558492157241163777

Jack sectioned and forbidden from the comfort of his bear, of dancing, or watching DVDs. Human rights?

Six months after that last visit @CareQualityComm went back to @Hftonline Rowde in January and February 2022.

By now there are 28 people living there.

The service still couldn't demonstrate how it was meeting the principles of statutory guidance

83/ "The service was five bungalows in a campus style setting on the outskirts of a village.

Most people attended workshops on site in the providers day service".

I'm so ignorant. I'm appalled at how many of these total institutions still exist, non-care and non-lives

84/

These windows aren't shutting themselves, onto archived services.

2 services I reported on in July have already closed

https://twitter.com/GeorgeJulian/status/1545281795096301568

and

https://twitter.com/GeorgeJulian/status/1555139764961120256

Now @AffinityTrust Specialist Support Division North https://t.co/uHgyRPwXzD has shut down

1/ The original report into the Specialist Support Division North had no enforcement action recorded on its publication date, 22 June

Now the report is re-issued with enforcement action taken and the service is archived.

2/

Morning tweeps, I waited until after 6am before posting what will inevitably be more grim on the interwebs, nothing like a gloomy start to a Saturday. I think it needs witnessing tho.

Another @Achieve_Support home rated inadequate.

api.cqc.org.uk/public/v1/repo…

1/25+ [During July when I reviewed all inadequate/requires improvement care for learning disabled and/or autistic people, @Achieve_Support featured 7 times, 1 was inadequate, 6 required improvement. A week or two later and another inadequate.

Let's see what @CareQualityComm found]

2/

I need to close some browser windows, so I'm afraid that means I'm going to update on recent @CareQualityComm reports into inadequate care homes for learning disabled and/or autistic people. Not in detail, just some low lights.

First up Sandgate Manor api.cqc.org.uk/public/v1/repo…

1/ Sandgate Manor is a residential care home providing accommodation and personal care to 21 people at the time of the inspection.

The service can support up to 25 people.

Most people lived in one two story building.

2/

Right, this is it. Final July @CareQualityComm report into inadequate or requiring improvement care for learning disabled and/or autistic people.

It's long, I'll probably be selective. Read full report for detail

@elysiumcare Healthcare Arbury Court
api.cqc.org.uk/public/v1/repo…

1/ [Before get into it, let's be clear before anyone starts excusing whatever we find as down to covid, Brexit, or some social care staffing crisis, Elysium is making huge profits]

theguardian.com/society/2022/a…
2/

This is the last thread of my July coverage of @CareQualityComm reports finding care for learning disabled and/or autistic ppl to be inadequate or requiring improvement. Some are dated 1 Aug but they were all uploaded yesterday, so I've included them

First Queens Lodge

1/ You can find the Queens Lodge report api.cqc.org.uk/public/v1/repo…

I thought I was having a deja vu moment, but turns out I've already covered a report for the same address this month, for Queens Park Care Home which is inadequate

https://twitter.com/GeorgeJulian/status/1549387065158242305

2/