The safety of people with learning disabilities in England is being compromised when they are admitted to hospital, a watchdog says.
The Health Services Safety Investigations Body (HSSIB) reviewed the care people receive and said there were "persistent and widespread" risks.
It warned staff are not equipped with the skills or support to meet the needs of patients with learning disabilities.
The watchdog launched its review after receiving a report about a 79-year-old who died following a cardiac arrest two weeks after being admitted to hospital.
As part of its investigation, HSSIB also looked at the care provided in other places to people with learning disabilities.
It warned systems in place to share information about them were unreliable, and that there was an inconsistency in the availability of specialist teams - known as learning disability liaison services - that were in place in hospitals to support general staff.
It also said general staff had insufficient training - although it did note a national mandatory training programme is currently being rolled out.
Senior investigator Clare Crowley said: "If needs are not met, it can cause distress and confusion for the patient and their families and carers, and raises the risk of poor health outcomes and, in the worst cases, harm."
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Source: BBC News, 2 November 2023