This is how experts want Doncaster services to improve after failings led to death of woman with learning disability

The woman, referred to in an independent investigation as Annette, died aged 56 in 2014, after a string of failings including a doctor with a fake registration among her health team and a ‘failure to listen to her relatives’.

Recommendations include:

• Awareness of the risk of ‘diagnostic overshadowing’ in people with a learning disability

• Listening to families, and taking seriously their concerns

• The application of mental health laws.

• Ensuring regular reviews of psychiatric medication.

The report was revealed to Doncaster NHS Clinical Commissioning Group’s board of governors this week.

David Crichton, chairman of Doncaster CCG, told the meeting: “I welcome the independent report into the care and treatment of Annette between 2009 and 2014, when she sadly died.

“I’d like to acknowledge how difficult this has been, especially for Annette’s family, but on the other side, I would like to thank those who contributed towards the investigation.

"The findings and recommendations from this report are important to ensure that health care services in Doncaster are aware of the issues highlighted by this case and going forward will enable CCG and other services to collectively review lessons learned to help avoid this happening again.

“While this is a historical case and many aspects of treatment and care for people with a learning disability have improved in Doncaster, it is important that all areas are addressed.”

Chief nurse Andrew Russell said the investigation touched on a number of services, and the task was now to check that with the passage of time, things had changed, and identify what gaps remained.

He said an action plan was being put together and shown to governors so they could see progress and challenge anything they felt needed action.

Lay governor Paul Wilkin was concerned that a doctor had been employed with a false registration. Mr Russell said a number of actions had been taken over several years, some of which were still ongoing.

Dr Emyr Jones, a governor and former Doncaster Royal Infirmary medical director, raised the importance of raising awareness, education and knowledge and changing processes.