Get In Touch

Inquest highlights neglect into death of woman with a learning disability

An inquest into the care received by a woman with a learning disability, severe autism, and limited verbal communication, who was also partially sighted, has concluded with a finding of neglect and highlighted a number of failings.

Ms Robin Kitt Callender died, aged 53, on 23rd May 2012, following a period of over four months of intermittent vomiting, diarrhea, and significant loss of weight. She was a resident at Perrymans Care Home in Barkingside prior to her death. Throughout Robin’s period of vomiting, diarrhea and weight loss, her family, who usually attended medical appointments with her as she was reluctant to allow medical examinations without her family present, were not informed of her illness. Despite six GP visits between February and May 2012, and two visits to A&E, doctors failed to diagnose her condition and, according to the expert witnesses at the inquest, missed opportunities to save her life.

Following an inquest which lasted three-days, the coroner, Miss Nadia Persaud at Walthamstow Coroner’s Court concluded that Ms Kitt Callender’s death was the result of natural causes but was contributed to by neglect on the part of her GP and King George Hospital, Ilford.

Robin’s sister, Karen Callender Caplan, who attended and also gave evidence at the three day inquest, says: “From the day she was born, our family was devoted to and extremely protective of Robin because of her health problems. Medical examinations were always difficult for Robin as she did not like to be in an unfamiliar place with a stranger, or to be touched by people she didn’t know and trust.

“I now know that in the lead up to her death Robin was going back and forth to see her GP who, according to the coroner, missed an opportunity to save my sister’s life. Yet I am sure that if I, or my sister Sherry, had been with her she would have been properly examined and her death could have been prevented, as we understood how she communicated and expressed pain better than anyone else. At the very least, we would have advocated for sedation to facilitate a proper examination.

“Since Robin’s death I have been desperately trying to get to the bottom of how she became so ill, why she never received the care she needed and how it got to the point that she was at death’s door before anyone bothered to contact me. Even at A&E they just sent her home because she was being difficult.”

Ms Caplan is also making plans to launch a campaign, Casualties of Care, to highlight the plight of vulnerable people – from hospitals, to care homes, to children failed by the social services – which she hopes will lead to a change in the law. She explains: “It is too late for my younger sister but it is not too late for the thousands of vulnerable and unprotected Robins still out there. There is a growing crisis in the care of vulnerable people and I want to create a “Robin’s Law” which would make it a criminal offence for a care home not to inform a family if someone in their care, who lacks capacity, falls ill and subsequently dies.”

Nina Ali, partner at law firm Hodge Jones & Allen, who represented Ms Kitt Callender’s family at the inquest, says: “Today’s conclusion, which included a finding of neglect, highlighted a number of failings. It is extremely worrying that the doctors at both the GP practice and hospital clearly failed to provide Robin with the medical attention that she needed. It is good to note that some steps have already been taken to improve by both the GP practice and hospital. However, much more needs to be done.

“Karen’s quest for “Robin’s law” is totally understandable but whilst I agree that there need to be consequences when there are failings in care provided, that is not enough. It is just as important, if not more so, to prevent the failings in the first place and to raise standards of care. The best if not the only way to do that is through better training and appropriate recruitment. One of the things that shocked me on hearing the witness evidence, particularly in relation to both medically-qualified and non-qualified staff was how little they understood their roles and responsibilities. With regards to the care home, there was clearly a lack of communication between staff and very little, if any, attention paid of the need to notify Robin’s family.”

Mencap, the leading learning disability charity, has campaigned for many years against discrimination in the NHS. Mencap is calling on the next government to act with urgency to stop other people with a learning disability dying needlessly while in the care of health professionals.

Jan Tregelles, chief executive of Mencap, says: “Robin Callander’s sad death in May 2012 could have been avoided. The coroner today concluded that her death was contributed to by neglect. Despite seeing a GP on six occasions and attending the A&E department at King George Hospital twice between the beginning of February and 22 May 2012, at least two chances to save her life were missed.

“Tragically, the A&E doctor discharged her in March instead of admitting her and running more tests. The expert witness at the corner’s court, a Professor of Surgery, said that all the warning signs were there and that she should have been admitted. He said that if she had been admitted, Robin could have been successfully treated and would have lived a full life.

“On her sixth visit to her GP, in late May, Robin was once again sent home. Robin’s doctor should have urgently referred Robin to A&E for critical tests, according to the Professor of Surgery and the GP expert witness. If this had happened, ‘on the balance of probabilities’, her life would have been saved, the Professor of Surgery stated. The health professionals caring for Robin simply did not do enough to save her life.

“The care home did not notify Robin’s sister, Karen that any of this had happened until the day before she died. Karen was close to Robin, and believes that if she had been able to accompany Robin to her GP and A&E visits, Robin may have got the treatment that she needed and their family would still be complete.

“The circumstances surrounding Robin’s death mirror those reported to Mencap by over 100 other families who have lost loved ones with a learning disability in the health service. These families say they were ignored by health professionals, despite being the people who knew their loved ones best.

“There are 1,200 avoidable deaths of people with a learning disability in the NHS every single year. This tragic loss of life should not be happening in the 21st century. All professionals involved in caring for people with a learning disability need to ensure that they involve and listen to family members who often know their loved ones better than anyone else.”

For further information, please contact:

Kerry Jack at Black Letter Communications on 020 3567 1208 or

Notes to editors:

Hodge Jones & Allen was founded in 1977 in Camden and has 200 staff based in Euston NW1. The firm practices personal injury, clinical negligence, civil liberties, family law, wills and probate, housing, dispute resolution, criminal defence and serious fraud.

About Mencap

There are 1.4 million people with a learning disability in the UK. Mencap works to support people with a learning disability, their families and carers by fighting to change laws, improve services and access to education, employment and leisure facilities. Mencap supports thousands of people with a learning disability to live their lives the way they want.

For advice and information about learning disability and Mencap services in your area, contact Mencap Direct on 0808 808 1111 (9am-5pm, Monday-Friday) or email

What is a learning disability?

A learning disability is a reduced intellectual ability which can cause problems with everyday tasks – for example shopping and cooking, or travelling to new places – which affects someone for their whole life.

People with a learning disability can take longer to learn new things and may need support to develop new skills, understand difficult information and engage with other people. The level of support someone needs is different with every individual. For example, someone with a severe learning disability might need much more support with daily tasks than someone with a mild learning disability.

Learning disability is NOT a mental illness or a learning difficulty. Very often the term ‘learning difficulty’ is wrongly used interchangeably with ‘learning disability’.