Ombudsmen publish joint report on two cases
12 Mar 2010
Press release 10/05
12 March 2010
The findings of investigations into complaints about the provision of services by two councils and by NHS trusts, partly concerning the actions of staff working in mental health services, are published today. The joint report by Ann Abraham, Health Service Ombudsman, and Local Government Ombudsman, Tony Redmond is called, Report of two investigations by the Local Government Ombudsman for England and the Health Service Ombudsman for England. The report details the investigations into two unrelated cases – one complaint was not upheld; the other partly upheld about the Trust involved.
Complaints about the London Borough of Enfield, the Barnet, Enfield & Haringey Mental Health NHS Trust, and the Barnet and Chase Farm Hospitals NHS Trust. Mr I had schizophrenia and lived in sheltered accommodation managed by Enfield Council. In December 2006 after his medication was changed he said he experienced back pain and shortness of breath. An ambulance was called and he was taken to A&E. He was examined and discharged home where he died four days later of pulmonary embolus and deep-vein thrombosis.
Mr I’s sister complained that failings in her brother’s care and treatment at A&E, thechanges to his psychiatric medication, and a lack of support at the sheltered housing all contributed to his death, and that sheltered housing staff should have informed her about what was happening.
Health Service Ombudsman, Ann Abraham, said:
"Our investigation into the Mental Health Trust and the Hospital Trust led us to conclude that their care and treatment of Mr I was reasonable. He received a reasonable standard of care in both A&E and in his discharge".
Tony Redmond,Local Government Ombudsman said:
"The service provided to Mr I by the Council’s staff fell below a reasonable standard and this amounted to maladministration. The Council failed to follow its internal policies: to record if a hospital form accompanied Mr I to A&E and update the tenant risk assessment."
But he did not criticise Council staff for not informing Ms I of her brother’s illness, as he had specifically asked them not to do so.
The Local Government Ombudsman said: "I consider that it was appropriate for staff to respect Mr I’s autonomy by accepting his decision at that time."
The Ombudsmen did not uphold the complaint as they could not conclude that maladministration led to the injustice that Ms I had claimed.
Complaints about the London Borough of Havering, and North East London NHS Foundation Trust (formerly known as North East London Mental Health Trust).Mr S complained about the care and treatment of his late wife, who had dementia and who he cared for at home. Mrs S was compulsorily detained under the Mental Health Act for treatment. While in hospital, Mrs S fell out of bed and broke her hip. She was transferred to a different hospital (not part of this investigation), where she died.
Local Government Ombudsman, Tony Redmond, said:
"We find that the way the Council provided services for Mrs S, and the procedure its staff followed in applying for her compulsory detention, did not fall below a reasonable standard in the circumstances."
Ann Abraham, Health Service Ombudsman, in partly upholding the complaint about the NHS Foundation Trust (FT), said:
"We conclude that there were some clear failings including a lack of appropriate risk assessment before the fall which led to an injustice to Mrs S, in that if she had had an appropriate assessment her fall might have been prevented. Also, the failures in the Trust’s communication with Mr S about Mrs S’s fall caused Mr S distress. There were other failures which did not directly lead to injustice to Mr or Mrs S. These other failures were: an inadequate examination immediately after the fall; an adequate investigation by the Trust into the fall; the Trust’s record keeping was generally poor. ".
The Foundation Trust has agreed to accept the Ombudsmen’s recommendations to apologise to Mr S. The report outlines the actions the Trust have implemented since the time of the events complained about.
Notes to editors
- Ann Abraham holds the post of Health Service Ombudsman for England and is also UK Parliamentary Ombudsman. She is appointed by the Crown and is completely independent of Government and the NHS. Her role is to provide a service to the public by undertaking independent investigations into complaints that government departments, a range of other public bodies in the UK, and the NHS in England, have not acted properly or fairly or have provided a poor service.
- There are three Local Government Ombudsmen in England and they each deal with complaints from different parts of the country. They are appointed by the Crown and are completely independent of local government. Their role is to investigate complaints of injustice arising from maladministration or service failure by local authorities and certain other bodies. Tony Redmond is the Local Government Ombudsman who published this joint report with Ann Abraham.
- The Regulatory Reform Order 2007 provides that with the consent of the complainant the Parliamentary and Health Service Ombudsman and the Local Government Ombudsman are able to share information, carry out joint investigations and produce joint reports in respect of complaints that fall within the remit of both Ombudsmen.
- There is no charge for using the Ombudsmen’s services.
- Visit our websites, www.lgo.org.uk and www.ombudsman.org.uk
- Contact details
Press copies of the report are available from the Communications Team, Parliamentary and Health Service Ombudsman, Millbank Tower, Millbank, London SW1P 4QP, telephone: 0300 061 4996, email: email@example.com or the Local Government Ombudsman, telephone: 020 7217 4686/4734, email: firstname.lastname@example.org
Download the full report (532kb)