Richard Handley was a young man we supported in Suffolk. In 2012, he died in hospital at the age of 33.

United Response was one of many organisations involved in Richard’s care and the one providing his day to day support. His death was a preventable one, and we all made mistakes which led to his death.

The inquest into Richard’s death concluded on Thursday 8 February 2018. The coroner found that, while all agencies involved in his care acted in good faith to assist him at all times, together we failed Richard.

As well as playing a part in the inquest process, we have been following it and the broader discussion online and in the press since it began. We felt it wouldn’t be fair to comment on any specific details of Richard’s death raised during the inquest.

Now that the inquest has concluded, we wish to be clear and open about our role in his care, and to address some of the questions we have been asked.

We are incredibly sorry for Richard’s death. It can only have been devastating for his family and friends, and the long road to the inquest and hearing must have been deeply painful and frustrating for them.

The families and friends of those we support deserve every assurance that we have learned from Richard’s death. I hope to regain their confidence and trust, and to reassure them that we have made changes to improve the quality of our support across the country as a result.

I want to be honest about the lessons we have learned following Richard’s death and what we need to do now in the light of what the inquest has found.

I will do this by sharing what we have learned, what we have done, and what we will do next. I will provide public updates on this work in the coming months, and I will show that my words are backed up with concrete actions.

What we have done

People with learning disabilities and their families must be confident that the care and support provided by all professionals is the very best. Richard’s death has been the catalyst for many changes in the way that we work at United Response.

We have improved our training and guidance across the board

We enlisted the support of Greenwich University to improve our staff guidance and training on health conditions. They created bespoke guidance for our staff, prioritising bowel management.

We updated our policies and practices for supporting people with other health conditions, including how to recognise when the interaction of physical health, mental health and a learning disability means that the support required becomes more complex.

Guidance on common health conditions is now a mandatory part of our induction for all staff.

We also provide training in health advocacy to all our managers to support staff to access the right healthcare at the right time. This training also gives them the knowledge and skills to overcome any barriers to people we support getting the right diagnosis and treatment.

We have changed our approach to documentation

The way we document the health conditions and needs of people we support is more robust following Richard’s death and includes health action plans which specify how we manage health conditions.

We have changed our approach to make sure we maintain high-quality support for everybody through accurate, consistent documentation.

We have changed our policies and training on mental capacity

We have developed a new ‘capacity to consent’ policy to strengthen our existing Mental Capacity Act guidance.

Training on mental capacity is now part of mandatory training for our support workers.

What we will do

We will develop an independent review mechanism

We are proud to say that over 90% of our services are rated ‘good’ by the CQC. While that is a testament to the hard work and dedication of our staff, we must ensure the same good standards across all our services.

The inquest into Richard’s death has made us consider how all of our support work is monitored. As a result, we are reflecting on how we can create a robust external review process. For the past 18 years we have had an annual external review of our services led by the Tizard Centre at the University of Kent. We are now thinking about how we can extend this.

We are at the start of this journey and we will need to call upon families, our staff and other professionals to create a model that works.

What we have learned

We all need to get better at communicating

The inquest into Richard’s death showed that communication between the agencies responsible for his health was not good enough. Clearer responsibilities, coordination and communication between us, the local council and the healthcare providers involved could have prevented his death.

We are strongly in favour of a system that enables health and social care to work in a much more joined up way and will do all we can to make this happen.

We must listen to families and work with them more closely

Richard’s family knew him best when it came to his care, but we and others failed to make the most of their knowledge and experience. I sincerely hope that we will be able to work with the Handley family to make sure that we are able to avoid another situation like Richard’s. We want to get better at collaboration with those closest to the people we support.

We are firmly committed to making sure that the knowledge and expertise of family members is listened to and acted upon wherever possible. Strong engagement with the people who knew Richard best should have been at the heart of the support he received, and I am committed to making this the case for every person we support going forward.

We must acknowledge our mistakes and learn from them

We must get better at talking about our mistakes. We will start more open conversations about the aspects of support that are hardest to get right.

I welcomed Steve Scown’s (CEO at Dimensions) recent blog on constipation as a step in the right direction towards more transparency on difficult topics.

We will share our learning with our colleagues across the sector, all of whom share our goal of creating healthy, nurturing environments in which the people we support can thrive.

While it has been an uncomfortable period for United Response, I welcomed the wide-reaching press coverage that Richard’s inquest received. The live twitter feed during the inquest enabled many to follow the proceedings in detail. It is right that the sector considers how it can facilitate such openness and transparency for the future, and we will work with others to do this.

For too long, the untimely deaths of people with learning disabilities have been ignored by wider society. As an organisation that cares deeply about the lives and the rights of every person we support, we hope that the increased public attention to deaths of this kind will push all agencies, including our own, to improve.

I am committed to making United Response a true learning organisation, and to be open and honest about the challenges we face. The more we speak about these challenges and the work we do to meet them head on, the closer we will be to a world in which people with learning disabilities are no longer at risk of tragic, preventable death.

Tim Cooper, chief executive