Safety spotlight
A learning disability is a neurodevelopmental condition that affects how individuals process information, often impacting skills such as reading, communication, and memory. While many people with learning disabilities have average or above-average intelligence, they may require tailored support to navigate healthcare effectively.
Maternity care should be responsive to every woman’s needs. For those with a learning disability, evidence highlights opportunities to improve how care is planned, communicated, and delivered. UK research consistently points to risks around clinical safety, inclusion, and the experience of support.
In one investigation, a 34-year-old woman with a documented learning disability accessed maternity care through her GP and local unit. While staff were aware she processed information differently, her needs were never formally assessed or documented. Healthcare professionals assumed her disability was mild and that no additional support was needed because she asked appropriate questions and appeared to understand information given.
The woman gave birth to a healthy baby and was discharged home. Twenty days later, she collapsed and died—likely due to a cardiac event or pulmonary embolism. Her death triggered an MNSI investigation.
The investigation found that although her learning disability was acknowledged, its impact on her ability to access care, recognise warning signs, or escalate concerns was never explored. Her discharge summary lacked detail and omitted her learning needs and social context. The GP practice later recognised gaps in how learning disabilities were flagged and has since improved its systems.
Consider these safety prompts:
- How does your service record that a woman has a learning disability and how it affects her day-to-day care needs?
- What are the barriers to offering every woman with a learning disability the opportunity to complete a health and care passport?
- Could tools such as the health and care passport be used more routinely to capture communication preferences, concerns and support needs?
- How does your service ensure key information about learning needs and social complexities are consistently shared in discharge summaries?
- Have your staff been supported to undertake the government approved Oliver McGowan mandatory training on Learning Disability and Autism?
Further reading
NHS England (2024) Health and care passport.
NHS England (2025) The Oliver McGowan Mandatory Training on Learning Disability and Autism.