This report provides an overview of the lessons learnt from more than three years of reviewing disability service provision to people who have died.

The reviews tell us that some people do live good lives, and their disability services enhance and empower them to engage meaningfully in all aspects of their community. However, while some people’s deaths may be ‘expected’, the quality of service provision may not have been good enough.

Sadly, the majority of deaths reviewed are ‘unexpected’ and raise significant concerns about the quality of service provision, possible preventable early deaths, and teach us that oversight and action must continue to be taken on both an individual and system-wide level.