1. ITV Report

NHS apologises for 'avoidable' death of woman with learning disabilities

Judith Benn Photo:

The family of a women with learning difficulties, who died following a treatable illness, has received an apology from the NHS in a review published today.

Jeanette McDiarmid, Independent Chair of the Cumbria Safeguarding Adults Board, said Judith's death was 'untimely and avoidable'.

Judith Benn died at the Cumberland Infirmary at the age of 54 from a twisted bowel on 29 April 2014. She received round-the-clock care in supported accommodation.

Judy had learning difficulties that meant she was unable to verbally communicate with others, but made her feelings clear to those who knew her.

Over the years, Judy lived with a range of bowel problems including chronic constipation. When Judy became unwell, staff who cared for her called the GP and out-of-hour services several times. They were visited by two General Practitioners and District Nurses over the course of three days.

However, her condition continued to worsen and she was eventually admitted to hospital. Too unwell for surgery, Judy died later the same day of a twisted bowel.

Judith Benn was only 54 when she died of a condition which could have been treated. Credit: ITV News

In 2015, a coroner concluded her death was treatable and could have been avoided.

Cumbria Safeguarding Adults Board commissioned People First Cumbria to undertake a Safeguarding Adults Review (SAR) into the circumstances leading up to Judy’s death.

An SAR is conducted when an adult dies due to abuse or neglect, whether known or suspected. An SAR review is also issued if there is concern that partner agencies could have worked more effectively to protect the adult.

Since the report was completed, safeguarding partners have had an opportunity to consider the recommendations and have made changes to practices as a result:

  • The use of ‘Special Patient Notes’ has now been implemented across England, allowing emergency services to have immediate access to medical information about patients with a learning disability.
  • North Cumbria University Hospital NHS Trust has also implemented a system to advise medical practitioners when a patient has a learning disability.
  • Specialist Nurses are now in place across Cumbria to strengthen links between community teams, GPs and hospital teams.
  • Clinicians from Cumbria Health On Call (CHOC) Service and acute and community clinicians now have access to the summary care record of patients, this includes recent test results and any special patient notes.
  • Learning from this case has been shared and educational events have been held. This training is ongoing.
  • Hospital passports have been implemented for individuals with a learning disability, to ensure that medical teams are clear of the patient’s needs and any adjustments required when they are admitted to hospital.
  • A Disability Distress Assessment Tool is now utilised to provide practitioners with vital information about how patients with a learning disability normally present and how they indicate when they are anxious or in pain.
  • Learning Events have been held to develop skills of medical professionals involved in the complex case management of patients with a learning disability. Training continues to be delivered on an on-going basis and will continue to be assessed
  • Quality Assurance audits and inspections will continue on an on-going basis
A review into emergency care given to Judith Benn has concluded she was seriously let down Credit: ITV News

This is a tragic set of circumstances and highlights that professionals must do more to understand the care and support needs of individuals with a learning disability and to ensure these are prioritised during any health assessment."


We are very sorry that Judy and her family were let down and that processes were not in place that meant she was given appropriate treatment sooner. We are very grateful to Judy’s family for taking the time to ensure all parts of our health and care system have been able to learn from her death"