NHS and social services in England are failing to meet the health needs of people with learning disabilities, investigators say.
The Health Service and Local Government Ombudsmen said the standard of care was an "indictment of our society" after reviewing the deaths of six people.
They found one man died as a result of failings in his care, while a second death could have been avoided.
The government said it was taking steps to address the problems.
The ombudsmen investigated the cases after they were highlighted by the charity Mencap.
CARE LINKED TO DEATH
- The 30-year-old died eight weeks after being admitted to hospital with a broken leg. He waited three days to see a pain team and developed an infection. Complaints were upheld against the hospital and council - he was in a care home when he was first injured. The ombudsmen ruled care contributed to death.
- Died several weeks after having stroke. While in hospital, the 43-year-old went 26 days without being fed. The hospital was criticised: death could have been avoided if care had been better.
They looked into complaints made by the families of the six people who died between 2003 and 2005.
The report found failings by hospitals, local health bosses, the official NHS regulator and social care services provided by councils, although none of the complaints against GPs were upheld.
It linked the care of two of the six - Mark Cannon, 30, from Romford, east London, and Martin Ryan, 43, from Richmond, west London - to their eventual deaths.
It also said the failings in the care of two more - Tom Wakefield, 20, from Cheltenham, Gloucestershire, and Ted Hughes, 61, from High Wycombe, Buckinghamshire - was partly due to the fact that they had learning disabilities.
In the final two cases - those of Emma Kemp, 26, from Newbury, Berkshire, and Warren Cox, 30, from St Leonards, East Sussex - the complaints were not upheld, although some aspects of their care were criticised.
The ombudsmen also ruled that investigation of their complaints was flawed, although at different stages in the process.
The investigtors said there was enough evidence to suggest problems were endemic across the services.
Ann Abraham, the Health Service Ombudsman, said: "The recurrence of complaints across different agencies leads us to believe that the quality of care in the NHS and social services for people with learning disabilities is at best patchy and at worst an indictment of our society."
Allan Cannon, father of Mark, said the family had to push at every stage to try to get better treatment.
He said no proper checks were done following Mark's surgery, and it was later discovered he had lost 40% of his blood.
"After the surgery, he was in an awful lot of pain and it just continued. He was being neglected by staff, we were calling for help."
In total, the role played by 20 different bodies in the cases was investigated.
Hospitals were criticised for the inadequate care and treatment given to people with learning disabilities as well as the way they looked into complaints.
POOR CARE BECAUSE OF DISABILITY
- The 20-year-old had long history of stomach problems before dying of pneumonia and reflux problems. The council and the NHS were criticised for not planning and providing adequate care. The Healthcare Commission complaint handling was also found at fault.
- After spending most of his life in care homes, the 61-year-old died the day after being released from hospital after an operation. Discharge arrangements by the hospital were found to be inadequate.
Councils were attacked for failing to provide or secure adequate levels of health care, while local health managers working for primary care trusts were said to be struggling to plan services properly.
The Healthcare Commission, the NHS regulator, was even ruled to have not handled complaints properly in some of the cases.
The ombudsmen said there was sufficient policy and guidance available, but agencies were not following it and, as a result, were in breach of human rights and disability discrimination laws.
They recommended all agencies review the systems they have in place for making sure the needs of people with learning disabilities were met.
In particular, they said staff needed to improve communication with the patients and their families, and social care and NHS teams had to work together better to ensure discharge arrangements were good enough.
The ombudsmen's report comes after the government has already promised to improve training and carry out a full inquiry into premature deaths among people with learning disabilities.
POOR INVESTIGATION OF COMPLAINT
- The 26-year-old died shortly after being diagnosed with cancer. Her mother complained she should have been diagnosed earlier and given chemotherapy treatment. The complaint not upheld, but the way it was handled was criticised
- Died 90 minutes after being admitted to hospital with stomach pains. The hospital was found to have acted correctly, but the Healthcare Commission failed to offer them proper review of case
Ministers made the announcements earlier this year after an independent inquiry last year into the deaths found significant failings.
Care services minister Phil Hope said: "Preventable deaths of people with learning disabilities are absolutely unacceptable.
"We are taking action to ensure that people with learning disabilities get the equal access to the health care that they deserve."
But Mencap chief executive Mark Goldring said the findings were "damning".
He said: "We would have liked to see individuals held accountable where they have not met required standards.
"We will continue to fight for justice for the families and, with them, consider referring the individual doctors who failed in their duty of care to the General Medical Council."
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