An utterly horrific and profoundly disturbing case has emerged in the UK where Adrian Poulton, aged just 56, and living with Down syndrome, was starved for nine days while he was being treated in Poole Hospital in September 2021 for a broken hip. By the time his family realised what was happening he was “too unwell to recover”.
“His hip was on the mend, but he was incorrectly listed as ‘nil by mouth’ by doctors during his time in hospital and was fed nothing for nine days,” according to an investigation by ITV.
Adrian had lived with his family for most of his life but, after moving to a care home, he fell and broke his hip and was then admitted to hospital. What the family told ITV makes for harrowing reading – and the Down syndrome Research Foundation believed his horrific death was “euthanasia by default”.
Daniel Hewitt, the ITV reporter who wrote about this shocking case, said that almost 40% of people who died with a learning disability in 2023 died avoidably – double the rate of the general population.
His father, Derek Poulton, told ITV News: “Not being medical, we just naturally thought he was having nutrition, a feed. But as it turns out, they were starving him.”
Lesley Bungay, Adrian’s sister, said: “We were just so worried. He was really poorly. He did look at me and dad… He said to me, ‘Lesley, I don’t want to die’.”
“He knew he was going to die. It was just awful.”
By the time Adrian’s family realised he wasn’t being fed, he was too unwell to recover. He died on September 28, 2021, two weeks after being admitted to hospital.
That last line from the ITV report is simply terrifying. Adrian’s family, like most families, relied on the capability and expertise of the medical team caring for their beloved son and brother. Most of us, in that situation, would likely make exactly the same presumption – we would presume that our loved one was being given nutrients through a drip.
Medical experts have long cautioned that ‘nil by mouth’ should be “a last resort for all patients” and a 2010 report from Royal College of Physicians and British Society of Gastroenterology spelled out to medical professionals that “learning disability in itself does not normally produce difficulty in oral feeding” – and that “people with learning disability associated with oral feeding difficulties are at risk of becoming dehydrated and undernourished”.
The report added that “in two recent reports from MENCAP, people with learning disabilities were said to suffer from institutional discrimination and receive worse healthcare.”
“An independent inquiry found evidence that people with learning disabilities had a higher level of unmet needs, less effective treatment and that organisations did not make reasonable adjustments to support delivery of equal treatment. Most often, the best care will be maintained by careful oral techniques and support as described elsewhere.”
Usually ‘nil by mouth’ applies before surgery or if a therapist has confirmed that a patient has difficulty swallowing, or has reduced consciousness – and in every case the decision should be clearly documented and communicated and a plan usually put in place to provide nutrition and hydration often through drips or feeding tubes.
But the family say that no-one told them Adrian had been listed ‘nil by mouth’, and are now looking back in horror and grief at that time when they believed he was being cared for but he was actually being starved. By the time they realised he wasn’t being fed, it was too late. But surely they should have been expected to rely on the health service to feed their son after a hip operation?
It’s the stuff of nightmares. The decency and love of Adrian’s family shines through in the ITV film below, as does the compassion and determination of other families who are also seeking answers.
An “official hospital report into Adrian’s death found that a lack of nutrition contributed to his death, and recommended education across the Trust on learning disability specialist care”, ITV noted in their investigation which also looked at the deaths of other patients with disabilities within the healthcare system. Campaigners say there deaths “are part of a pattern”, ITV heard.
The education on ‘learning disability specialist care’ referred to aims to “save lives by ensuring the health and social care workforce have the right skills and knowledge to provide safe, compassionate and informed care”, according to the NHS.
But surely it doesn’t take specialist knowledge to understand that a patient with a broken hip shouldn’t be placed on ‘nil by mouth’ for nine days? And ITV’s investigation found many other cases where people with a learning disability had died because they didn’t receive the right care. While campaigners have called for the “sharp decline” in specialist nurses to be addressed, is there an underlying issue here that is being overlooked?
Has a culture developed where presumptions are made about people with disabilities and the life-saving interventions to which they should be entitled? Are their lives sometimes considered less worthy and healthcare measures therefore applied which otherwise would not be considered? Does an impaired ability to communicate lead some professionals to make judgments regarding quality of life? The high rate of abortion after a diagnosis of disability is inevitability leading to a less visibility for the communities: is it also leading to a distorted view of their human rights or an increased misunderstanding of their needs? These are questions we urgently need to consider.
Dr Elizabeth Corcoran of the Down Syndrome Research Foundation (DSRF) said that “the appalling case” of Adrian Poulton “tragically exposes the vulnerability of people with intellectual disabilities in end-of-life decision-making across the NHS.”
She offered the Foundation’s “deep condolences to Adrian’s family regarding his wrongful death” – and said they resolved “to fight for equity and adequate safeguards to protect the rights of people with Down syndrome, particularly the fundamental right to life”.
And she pointed to the dangers present in assisted dying measures for vulnerable patients. “It is clearer than ever that Kim Leadbeater’s proposed Assisted Dying Bill tramples on these
Prof. Irene Tuffrey-Wijne, Professor of Intellectual Disability & Palliative Care at Kingston University, said that it was “deeply shocking that after so many years of reports and inquiries into avoidable deaths of people with learning disabilities, these horrific avoidable deaths still happen.”
“This terrible story should be headline news. Compulsory staff training on how to support people with learning disabilities should be a priority for hospital trusts everywhere, but they also need to look at their systems for communicating between staff and services involved in the care of people with learning disabilities.”
Her colleague at Kingston University, Research Assistant Richard Keagan-Bull, who has a learning disability, said that news of Mr Poulton’s death was “absolutely disgraceful, horrible and upsetting. He came in for a broken hip and then he didn’t get any food. It doesn’t matter how old or young you are or whether you have disabilities, you should be treated with respect and given all the right care. We keep hearing those stories. When will they stop?”
The DSRF said that the most recent LeDeR report (Learning from lives and deaths – people with a learning disability and autistic people) shockingly recounts that people with learning disabilities in the UK continue to die decades earlier than the general population.”
“The 2023-2024 LeDeR report was only released a month ago on 2nd September 2025, after a delay of more than a year. This holdup contributes to a lack of transparency and absence of updated data on mortality rates among people with intellectual disabilities.,” they added.
“It has also taken four years for the current story on Mr Adrian Poulton to break. The full extent of existing problems of discrimination, neglect, communication issues, and vulnerability to coercion affecting people with intellectual disabilities, including those with Down syndrome, is likely to be more widespread than we know.”
During the Covid crisis, it was reported that people with learning disabilities were given do not resuscitate orders “during the second wave of the pandemic, in spite of widespread condemnation of the practice last year and an urgent investigation by the care watchdog”. That’s seems more like a broken culture than series of mistakes.
We would be foolish to assume that that these issues, and a shifting mindset and culture which may be exacerbating the problem, could not arise here in Ireland. The rush to abort Baby Christopher – mistakenly diagnosed with a life-limiting disability, while his parents were made to feel there was no hope – revealed the shocking consequences of a culture where some lives are considered less valuable than others.
Many families where a loved one has a disability will read the heartbreaking case of the starvation of Adrian Poulton and hold their children closer. If a pattern of starving and medically neglecting people with Down syndrome and other vulnerabilities is, in fact, emerging, then we need to urgently ask why that is happening.