The deaths of six people with learning disabilities who suffered prolonged discrimination and neglect by health and social services was "an indictment of our society", an investigation found.
The deaths of the five men and one woman involved "distressing and significant failures" on such a wide scale that others may be at similar risk, according to a report by the Health Service and the Local Government Ombudsmen.
The cases included a 30-year-old man with a broken leg, Mark Cannon, who died of pneumonia despite being admitted to hospital three times, and 43-year-old Martin Ryan who went without food for 26 days after suffering a stroke. The Ombudsmen found Mr Cannon's death was a "consequence of public service failure", and Mr Ryan's death would probably have been avoided if his care "had not fallen so far below the relevant standard".
Awarding £40,000 to the families of Mr Cannon and Mr Ryan for the distress caused, the Ombudsmen called on NHS bodies and councils to check urgently that they had the "correct systems and culture" in place to protect people with learning disabilities from discrimination.