A damning report has warned Northern Ireland's five health trusts are at risk of failing to meet the needs of thousands of adults with learning disabilities if they do not improve how they deliver services.
A review carried out by the Regulation and Quality Improvement Authority (RQIA) criticised all five trusts and the Health and Social Board.
Among the main issues the health watchdog identified was a shortage in community staff leading to "unnecessary and avoidable" hospital admissions.
Health campaigners have described the report as shining the light on a "huge hole" in the standard of services.
And leading charity Mencap also branded the lack of development since the Bamford Review as "shocking and sad".
The 'baseline assessment' of adult services carried out by RQIA also pinpointed:
It also noted pressures on carers leading to a deterioration in their wellbeing.
In Northern Ireland there are approximately 26,500 people with a learning disability– about half are aged 19 and under.
Overall 32 recommendations were made – 23 were to the five health trusts and nine to the Health and Social Care Board (HSC).
It said the current model of service needs to be reviewed and "significant leadership" was required in the planning of change.
However, the report also stated: "If trusts continue to deliver services as they currently do, they risk failing to adequately meet the needs of adults with a learning disability."
The trusts said since the 2011 audit development plans to improve services had been put in place. And in a statement the Health and Social Care Board said: "We will study the findings carefully."
The report also said trusts needed to look at how home treatment and crisis response teams could be developed into a seven days a week service.
The Southern Trust said it would "now consider in detail" the recommendations while the South Eastern Health Trust said it has been working to modernise and improve learning disability services.
The Western Trust said it is committed to providing "high quality services for those with a learning disability in the west".
The Northern Trust said since the audit was undertaken services had developed.
The Belfast Trust said it "will seek to implement recommendations in line with its ongoing review, development and modernisation of learning disability services".