LeDeR Annual Report


The LeDeR Programme is the national programme which reviews the deaths of people with learning disabilities across the country. It was established in response to the recommendations made in the Confidential Inquiry into the Premature Deaths of People with Learning Disabilities (2013) with the aim of supporting local areas to review the deaths of people with learning disabilities, identify learning and areas of both good practice and where service improvement is required. There is a national and regional governance framework which the Surrey System feeds into.

The Surrey LeDeR Mortality Review Annual Report covers the period between January and December 2019 and this reflects the period reported by the national team in the National Annual LeDeR Report. It gives an overview of the LeDeR programme and how this has been implemented across Surrey Heartlands, Surrey Heath and North East Hampshire and Farnham CCG areas. It provides an overview of the number of deaths that have been reported to LeDeR for these areas throughout 2019 and summaries the learning that has come from the completed reviews.

You can view the LeDeR Annual Report here:  pdf LeDeR Annual Report 2019 (551 KB)


At the time of the report, there was a backlog of notifications waiting to be reviewed with only 26 reviews completed. However, since September, 2019, there has been a full time Co-ordinator in post and this has improved the local process and timeliness of reviews. The national expectation is that all CCGs will, by the 31st December 2020, have completed all of the reviews notified to them before the 30th June 2020 and will continue to manage the flow of referrals following that and Surrey Heartlands expects to fully meet this commitment.

Within this report, there was a lot of evidence of reasonable adjustments being made for individuals to support their care and good practice that also helped improve their experience of care. These included areas such as: Communication of need, specialist equipment provided, good multi-professional liaison, End of Life Care and responsive medical care.

Recommendations from reviewers for improvement in practice included Communication, the provision of Annual Health Checks, Application of the Mental Capacity Act and DoLs, Discharge from hospital and Do Not Attempt Cardio Pulmonary Resuscitation decision making. These recommendations are detailed in Section 9 of the report.

The overall recommendations that are made within the report are:

  • Raise awareness and improve compliance with the Mental Capacity Act.
  • Improve compliance with annual health checks and ensure the benefits of these are understood by our local Primary Care Networks and Care Providers.
  • Work with partner organisations to address access to screening and ensuring the principles of the Mental Capacity Act are applied in decision making.
  • Focus on improved communication between services to provide information in relation to reasonable adjustments required in advance of appointments / attendance. 
  • Identify gaps in service provision and make recommendations to commissioners to address any gaps in services.  


These recommendations will be taken forward by the Surrey LeDeR Steering Group and progress reported within future reports.

More information on the LeDeR programme can be found at http://www.bristol.ac.uk/sps/leder/




Review Date: 2020-11-03
Review Due: 2021-11-03
Model Publication Scheme Class: Class 5: Priorities and How we are Doing