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In 2009 the English Health Ombudsman wrote a report - ‘Six Lives”- about six people who died because of mismanagement and maltreatment in the English health care system.
The Six Lives report established policy and practice improvements to ensure that people with learning disabilities received good quality health care services all over England.
It was legislated and implemented in 2010.
The 2013 report is telling us what progress has been made in this policy area