An inquest has found the death of Anthony Dawson, a man with severe learning disabilities, was avoidable and neglectful

An inquest at Woking Coroners Court concluded today (18th October 2017) that the death of Anthony Dawson, a 64 year old man with severe learning disabilities and autism, may have been avoided had he received medical attention earlier. The jury considered whether Anthony’s care violated his Right to Life and concluded that Anthony’s death was contributed to by neglect and there was a gross failure in the decisions of care home staff. Anthony died from a bleeding gastric ulcer on 16th May 2015 at Ashmount care home in Surrey, run by Surrey and Borders Partnership Trust.

Vivien Cooper, CEO of The Challenging Behaviour Foundation and Jan Tregelles, chief executive of Mencap said:

"Anthony Dawson lived and died in an institution located in the grounds of a former long-stay hospital setting. Despite all the efforts of his family to try and get his needs properly met, they were side-lined, their concerns not acted upon, his health needs were neglected and Anthony died an untimely death that could have been prevented. Despite living in an NHS service provided by Surrey and Borders Partnership Trust, Anthony Dawson's basic healthcare needs were not met by those paid to care for him.

“Anthony needed continual 1-1 support yet was often left to walk the grounds alone. He lacked basic health checks and was on four medications for mental health conditions for which he had no diagnosis. The commissioner of his service and the Care Quality Commission who inspected it failed to take action. He spent his life in the same place shut away froAnthony Dawsonm the world, despite the efforts of his family to change this.

“The Government is clear that "Hospitals are not homes” and Anthony should not have been shut away from the community. Its own research has highlighted the premature and preventable deaths of 1,200 people with a learning disability every year. Yet despite two NHS England programmes  – one to transform care and one to reduce premature mortality - Anthony’s care was not transformed and he continued to live in a hospital setting, dying there aged 64.

"It is taking too long for the Government, the NHS, the Care Quality Commission and local authorities to deliver on their promises to ensure people with a learning disability get the right support, within their communities and with access to proper healthcare. There is no accountability for this painfully slow progress. For people with a learning disability and their families, it is a matter of life and death that must not be ignored.”

Anthony’s sister Julia Dawson has waited over 2 years for the inquest and is satisfied with the outcome. She said “An entrenched culture of neglect had taken hold and nothing was done to prevent this avoidable catastrophe. My brother had his right to healthcare taken from him and was unable to protest.”

The coroner when summing up the inquest commented on Julia’s dedication and commitment to her brother. Julia’s work to bring to light all the facts about her brother’s care and his premature death do not end here, as NHS England have commissioned an independent investigation that will continue until next year. The CBF has provided ongoing support to Julia throughout this long process since Anthony died in May 2015. She has spoken out on Anthony’s behalf and also for the many other people with learning disabilities and autism who may be experiencing similar poor care.

We’d like to thank the family carers who have attended the inquest and offered support to Julia, when their only connection with the family is having a brother, sister, son or daughter with learning disabilities. Sadly, lack of access to healthcare is a wide ranging issue for people with learning disabilities, who rely on the support of others to seek medical attention and to get the reasonable adjustments they need to be assessed and treated.

Please forward any messages of support for Julia to



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