Foreword
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I am laying before Parliament, under section 14(4) of the Health Service Commissioners Act 1993 (as amended) this report of a joint investigation which I conducted as Health Service Ombudsman for England with the Local Government Ombudsman. The complaint is about Northumberland, Tyne and Wear NHS Foundation Trust (the NHS Trust), Newcastle City Council (the Council) and the Coquet Trust. My reason for laying this report before Parliament is to allow the joint investigation report to be in the public domain.
This report tells the story of Mr J, who was an active, outgoing and sociable man. He had Down’s syndrome. He lived independently in rented accommodation with his wife. The Council, latterly through the Coquet Trust, provided day-to-day support to Mr J and his wife to help maintain their independence. In 2005, owing to concerns about a significant deterioration in his skills and health, Mr J was admitted to hospital for a five to six week assessment. Mr J remained in hospital for seven months, some five of those after he had been declared ready for discharge. Mr J was discharged into inappropriate locked accommodation, which he only left following his death 10 months later. Mr J was 53.
Mr J’s brother, Mr K, complained about the care provided to Mr J. My joint investigation with the Local Government Ombudsman found significant failings on the part of both the NHS Trust and the Council which meant that they were unable to demonstrate that Mr J’s basic human rights, to liberty and to family life, had been given appropriate consideration when decisions were being made as to his care needs. There was no properly co-ordinated and documented health and care plan for Mr J. No one from the public bodies took a key leadership role and so there was no one with an overall view of Mr J’s character and abilities, his family background, his needs and
the services he was receiving. There was no one to represent Mr J’s interests and wishes and drive matters forward.
The NHS Trust failed to review and document Mr J’s capacity to consent and the reasons for his continued inpatient status, contrary to guidance specifically designed to protect those in a similar position to Mr J. The NHS Trust also failed to involve Mr K and Mr J’s other siblings in Mr J’s care planning, so decisions were taken which did not take account of the family’s previous involvement in Mr J’s life.
Whilst he was in hospital, the Council decided to reduce the support hours available to Mr J. This had a significant impact on the amount of contact he had with his wife. The Council therefore demonstrated a disappointing and unacceptable disregard for Mr J’s relationship with his wife and his wellbeing. The Council effectively abandoned their duty to actively seek to resolve Mr J’s urgent housing need for his discharge from hospital. Against published guidance, the Council failed to review and record why Mr J was effectively being detained in unsuitable locked accommodation and they failed to take urgent action to find suitable accommodation. They failed to involve Mr J’s family sufficiently in Mr J’s care planning.
We found that the failings by the public bodies resulted in injustice to Mr J and his family, and we therefore found that Mr K’s complaint about his brother’s care was partly justified. The NHS Trust and the Council have accepted our recommendations to remedy the injustice.
The remedies include an acknowledgement and apology. The NHS Trust and the Council will also pay compensation to Mr K, as the family’s representative. Mr K has told us he will donate the money to charity. Although the Local Government Ombudsman and I recognised that there have been changes in the legislative framework since the events of this case, which if complied with should mean the failings described in this report should not be repeated, we did not see the existence of the framework as sufficient reassurance that lessons will be learnt. Therefore, we recommended that the NHS Trust and the Council prepare, share and update progress on an action plan showing what they have done (or will do) to prevent recurrence of their failings. They have agreed to do this.
It is shocking that the events described in this report happened in the 21st century. By putting this report in the public domain I hope the lessons from Mr J’s story will be understood by public bodies and thereby help to drive improvements in public services.
Ann Abraham
Parliamentary and Health Service Ombudsman
November 2011
