8 February 2018

Before HM Senior Coroner for Suffolk Dr Peter Dean
Sitting at The Coroner’s Court, Beacon House,
Whitehouse Road, Ipswich, Suffolk, IP1 5PB
22 January – 8 February 2018

Richard Handley had Down’s Syndrome and a history of mental ill health. In November 2012 he died aged 33 in Ipswich Hospital from complications arising from constipation. The inquest into his death has concluded with the coroner finding gross failures in treatment at Ipswich Hospital. He also found that changes in Richard’s care led to significant worsening of his condition, without which his death would not have occurred.

Richard died from aspiration of gastric contents, large bowel obstruction and faecal impact in Ipswich Hospital.  The Senior Coroner for Suffolk, Dr. Peter Dean found “gross failures” in spotting the critical state Richard was in after surgery. He said this was a missed opportunity to provide potentially life-saving early intervention and additional procedures”.

Richard had lifelong bowel issues which, as the coroner acknowledged, required careful attention to prevent episodes of recurrent constipation. He was in the care of multiple agencies including Bonds Meadow Residential Home which is run by the charity United Response. Suffolk County Council commissioned and paid for Richard’s care, and led the 2010 change from residential care to supported living.

The coroner said changes in his diet and the “monitoring of his bowel movements in the period of time leading up to and following the transition from residential care to supported living”… “on the balance of probability led to Richard developing significant worsening of his constipation and resultant faecal impaction”. He continued, “Without the recurrence of his constipation to the extreme extent it was found when he attended hospital, Richard's death would not have occurred.”

Richard’s family waited over 5 years for this inquest. The coroner praised their “persistence and perseverance”. Most so called ‘natural cause’ deaths of learning disabled people and those with mental ill health are not afforded proper scrutiny and never have an inquest. There is no national oversight on preventable deaths of learning disabled people, and no requirement that they are independently investigated.

Sheila Handley, Richard's mother, says: “Given the evidence we’ve heard in court, and the gross failures and missed opportunities noted, we are profoundly disappointed that the coroner felt unable to make a finding of neglect. 

“The Coroner did, however, recognise that without our diligence and persistence many of the reviews into Richard’s death would not have occurred and the inquest would not have been able to explore the extent of the failings in his care. Richard was wholly reliant on health and social care services to exist, and now he doesn’t. 

“We will now take time to digest what we’ve heard today and consider next steps with our lawyer, Nina Ali.”

Selen Cavcav, an INQUEST caseworker who supported the family said: “Richard’s death would not have occurred if there had been proper care and monitoring of his condition, as there was with his family and some previous care professionals. If it wasn’t for this family’s persistent fight for answers, assisted by INQUEST, an expert legal team, and experienced campaigners, this death would have been brushed under the carpet as ‘natural causes’. The decreased life expectancy and prevalence of premature deaths among learning disabled people is an unacceptable situation, which can only be addressed through independent investigation and scrutiny of deaths.”




For further information, please contact Lucy McKay on 020 7263 1111 or here

  • INQUEST has been working with the family of Richard Handley since his death. The family is represented by INQUEST Lawyers Group members Nina Ali from Hodge Jones and Allen Solicitors and Dominic Ruck-Keene from 1 Crown Office Row.

  • More background information is available in the press release issued at the opening of the inquest here. The press release on the conclision by the family’s legal team is available here.

  • A serious case review which looked at the circumstances of Richard’ death was published in October 2015. This review identified failings surrounding his care. It refers to Richard under the fictitious name of James.  Available here

  • Emily Handley, Richard’s sister and a senior clinical psychologist in the mental health and learning disabilities service at South London and Maudsley NHS Foundation Trust, wrote an account of Richard’s life and preventable death here. She noted, “Another lady with learning disabilities died in Suffolk with constipation six months after Richard. I will always wonder whether a timely investigation and service improvements after Richard’s death could have saved her.”

  • The inquest was live tweeted throughout @HandleyInquest by George Julian, an advocate and campaigner on the premature deaths of learning disabled people. George also wrote a blog summarising some of the initial evidence heard, available here. If you find these resources useful please consider donating to support this work.

  • Following the death of Connor Sparrowhawk, one NHS Trust undertook a review known as the Mazars review, the Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015 (available here). This identified issues around the lack of oversight and investigation of ‘unexpected’ deaths.

  • An inquiry into the premature deaths of people with learning disabilities found that 42% of deaths of learning disabled people were considered to be premature, and over a quarter were amenable to better-quality healthcare. The report of the Confidential Inquiry into premature deaths of people with learning disabilities is available here.

  • In 2015 INQUEST published a report called Deaths in mental health detention: An investigation framework fit for purpose? which details the issues with the lack of an independent system of investigation, and the lack of a robust mechanism for ensuring post-death accountability and learning in secure health settings, much of which applies to non-secure inpatient services as is relevant in this case.