The Investigation

Background and key events

26. (A more detailed chronology is provided at Annex F.) Mr J had Down’s syndrome. He was an active, outgoing and sociable man who from 1989 onwards, had lived independently in the community; from 1992 onwards this was with his partner, Mrs N (who also has learning disabilities), whom he married in 1996.
    Day-to-day support to help Mr J and his wife maintain their independence in rented accommodation was provided by the Council; from 1995 onwards this was through a contract with the Coquet Trust, who provided local support workers. Mr J’s mother died in 1998. In 2003 one of the carers who had been providing support for Mr J for a long time, and whom Mr J considered a friend, moved away from his role as Mr J’s carer. Until 2003 Mr J had had a work placement in an office doing photocopying two days a week, but this was terminated when his tenure ended and it was considered that Mr J could no longer cope with it. (No other placements were found for Mr J, other than helping out for a few hours a week in the Coquet Trust’s office, until the autumn of 2005.)

2004-05

27. In April 2004, due to concern about changes in Mr J’s behaviour and a deterioration in his abilities, the Coquet Trust requested funding to increase the support hours being provided to Mr J, which were then 15 hours per week (and 15 hours for Mrs N). During 2004 a consultant clinical psychologist, who had assessed Mr J on several occasions since 1998, concluded that Mr J could be suffering from a loss of skills associated with a process of early ageing.
28. In December 2004 DH issued interim guidance on the Bournewood case, which was intended to protect vulnerable individuals against the risk of arbitrary deprivation of liberty.
29. During the rest of 2004 and much of 2005 social services and the Coquet Trust corresponded about Mr J’s support needs, with the latter pressing social services to fund extra hours in response to the continuing decline in Mr J’s skill levels and functioning. They raised particular concerns about his mobility problems (increasing unsteadiness and his wife had reported that he had had falls), changes in mood and memory difficulties, which meant that many tasks took longer for Mr J to complete and that he needed repeated prompting. In October 2005, after Mr J had recently required police assistance to return home after becoming confused and anxious in public without support, various further assessments of Mr J’s needs and abilities were carried out. This led to a recommendation by an occupational therapist (OT) that Mr J required ground floor accommodation and led to social services agreeing to fund 21 hours support per week for Mr J (and the same for Mrs N).
30. On 2 November 2005 Mr J’s GP made an urgent referral to the NHS Trust because of concern about a significant general decline in Mr J’s health and condition; he noted a recent history of falls and brief spasms (myoclonic jerks) suggesting epilepsy. A Consultant Psychiatrist (Dr A) saw Mr J on 11 November. Her initial assessment was that Mr J was probably suffering from depression, for which she prescribed medication. However, as the changes in Mr J’s condition might be caused by a number of other factors, she also asked for a nurse from the community learning disability team (CLDT) to visit Mr J at home, made referrals for a CT scan and an electroencephalogram (EEG, which tests brain activity). She also requested an application form for Mr J and his wife to be rehoused.
31. On 14 November Dr A wrote to Mr J’s GP. She noted that Mr J’s wife had reported that he had fallen down several times and that at the appointment Mr J ‘looked the picture of misery’. He could not give any account of himself and had ‘marked psychomotor retardation’. Although she noted that Mr J had regular contact with his brother, Mr K, she also commented that because Mr J’s wife had not attended the appointment, she had had to rely on what his carers could report. Dr A said she would see Mr J with his wife in two weeks. She detailed the medication she had prescribed, and said that an EEG would be arranged as soon as possible. If there were urgent concerns an earlier appointment could be arranged. Dr A copied her letter to the Coquet Trust, the CLTD nurse and Mr J’s social worker.
32. Dr A saw Mr J with his wife on 16 November and admitted him that day as an informal patient to Northgate Hospital for a five to six week assessment. She recorded that Mr J and his wife had, after lengthy discussion, agreed to the admission. There was no record of any assessment of Mr J’s capacity to consent to admission being carried out at this time. (Hospital forms completed from 22 November onwards relating to patient consent to share information about their health and treatment all said that Mr J did not have the capacity to consent.) Following admission Mr J had a variety of assessments and tests including a CT scan.
33. A meeting set up in line with the Care Programme Approach (CPA – Annex B, paragraph 29) was held on 1 December; Mr J’s social worker was sick and unable to attend. Mr K and Mr J’s wife attended the meeting. Dr A told the meeting that Mr J had cognitive decline and that she was proposing that Mr J’s care be transferred to Dr B, a different Consultant Psychiatrist. The nursing note prepared for this meeting (and the notes prepared for subsequent meetings) recorded that Mr J wished to be discharged to live with his wife. The meeting noted that social services needed to find appropriate accommodation for Mr J and his wife as soon as possible.
34. On 29 December Mr K raised a large number of concerns with hospital staff about Mr J’s care and treatment on the ward, including the decision to put Mr J on a soft diet (he considered it to be unnecessary and to be causing Mr J’s weight loss); Mr J’s restricted lifestyle and lack of activity, which the family believed was exacerbating his decline and depression (‘the ward was like a prison’); and the lack of communication with Mr J’s family. Mr K asked when Mr J would be discharged and expressed dissatisfaction that social services were not promoting Mr J’s best interests. He complained about the decision that had been taken to stop prescribing antidepressants for Mr J, and said that Dr B had not said why she had not asked him for information about Mr J. The hospital records show that these matters then continued to be raised with the staff over the telephone by Mr K and Mr J’s other siblings, when they called to ask how Mr J was, or
    when visiting.

2006

35. On 10 January 2006 Mr J, Mrs N and the OT visited Mr J’s former home in order to carry out an assessment. The OT completed a detailed assessment in which she noted that not only was the flat on the first floor, reached via a
    14-step stairway, but the interior was also uneven with stepped access into several rooms, which meant that there was a high risk of Mr J falling. The OT considered that it was too dangerous for Mr J to return there.
36. At a difficult CPA meeting held on 12 January⁴ Mr K was told that Mr J had dementia and epilepsy and needed 24-hour care, but that he could leave hospital as soon as social services could provide appropriate support. (Staff did not invite Mr J’s family to subsequent CPA meetings, but it was noted in the files that they should be kept informed of what had been discussed and agreed. Apparently at Mr K’s instigation, Mr J was subsequently assigned an advocate from the advocacy project Skills for People, who attended the CPA meetings from
    9 February onwards.)
37. Around this time, to reduce the impact on patient care on the ward, the NHS Trust introduced some telephone and visiting guidelines for Mr J’s family, which included restricting the number of telephone calls to Mr J’s ward to twice a day, and the family’s time on the ward to two hours a day. However, the NHS Trust did say that the family could take Mr J off the ward for an unspecified amount of time when they wished.
38. On 16 January it was confirmed at a CPA meeting that Mr J could be discharged with support, but that he should not return home and that temporary accommodation was not in his best interests. The meeting also again confirmed that lead responsibility for finding appropriate accommodation rested with
    social services. On 31 January Your Choice Homes (the Council’s local housing provider – Annex B, paragraph 37) sent Mr J a medical priority form to complete regarding his application for housing.
39. On 6 February Mr J’s wife and his new social worker visited him and talked about accommodation; Mr J said that he wanted to leave and live with Mrs N. Later that day the social worker called the housing department to ask how long it was likely to take before appropriate permanent housing would be available, and was told at least six months.
    In the light of that, at the CPA review on
    9 February, it was decided that, given the time that Mr J had already spent in hospital, an interim placement would be more beneficial to him than a lengthy wait for a permanent one. The Coquet Trust staff helped Mr J to complete the housing medical priority form and Your Choice Homes received the completed form on 22 February.
40. Meanwhile, interim accommodation in the form of a first floor flat at the care home (a home for the elderly) had been identified which would become available from 8 March. An OT visited the flat on 16 February and identified the adaptations (grab rails in the bathroom and a shower chair) that would need to be made before Mr J and his wife could move in. (Mr J and his wife were subsequently taken to view the flat on 23 March.)
41. On 3 March Mr K made formal complaints about the NHS Trust, social services and the Coquet Trust (according to Mr K, this was in the hope of accelerating Mr J’s move out of the hospital into permanent appropriate accommodation).
42. Mr K received a response to his complaint from the NHS Trust on 12 April, but remained dissatisfied and entered into further local resolution with the NHS Trust, before putting his complaint to the Healthcare Commission (the body which at the time oversaw the second stage of the NHS complaints procedure). He was also unhappy with the social services’ response and in July, asked social services to carry out a Stage 2 investigation of his complaint (Annex B, paragraph 41). (His complaint about the Coquet Trust was included within that complaint.)
43. On 15 May a further physiotherapy assessment found that Mr J’s balance and mobility had deteriorated significantly over the preceding few months and that he now had a very high risk of falling. The OT found that although Mr J’s physical abilities were fluctuating daily, he would ultimately need full use of a wheelchair and a mobile hoist in the bedroom. (This meant that the permanent accommodation being sought would need to take account of these future needs.)
44. In the meantime, in response to Mr K’s unhappiness with the proposals for Mr J’s future accommodation, Mr J had been allocated an independent mental capacity advocate (IMCA). Her role was to consider Mr J’s best interests and ascertain if his own wishes, feelings and rights were being considered in the decision regarding where he would live following his discharge from hospital. In her report (dated 17 May) she concluded that, although given his diagnosis Mr J’s condition was unlikely to improve, and he would no longer be able to go out independently, he was not benefiting from being in hospital, separated from his wife and unable to lead a life that included enjoying some of his interests in a familiar environment, with support staff that he knew. The IMCA accordingly supported the move to the care home. She said that Mr J should be discharged as soon as possible to temporary accommodation, as this would enable him to live with his wife, but she also stressed that it was important that the search for a ground floor flat continue.
45. On 12 June, once the required adaptations had been completed, Mr J moved to the care home with his wife, where he was provided with 24-hour support by live-in carers provided by the Coquet Trust. Around this time Mr J lost his medical priority for housing because he had not bid for any properties. On 20 July the Coquet Trust wrote to Your Choice Homes explaining that Mr J had been unable to bid for a property because he had been ill and in hospital. They asked for his medical priority to be reinstated.
46. On 21 July Dr B wrote telling Mr J’s GP that Mr J had settled well at the care home and that 24-hour support appeared to be working. Mr J was still able to join in some activities in the community, such as swimming, and he was still able to walk within the grounds but otherwise needed a wheelchair outdoors. No further myoclonic jerks had been recorded. On the whole he slept well. He had lost some weight but was still a healthy weight. He was occasionally doubly incontinent at night.
47. Dr B also noted Mr K’s request that Mr J and his wife stay with him for a few days. She advised that any major changes to Mr J’s then current daily routine would significantly affect his functioning and emotional well-being. Whereas in the past a holiday might have been a stimulating and positive experience, she believed that it was now likely to cause him undue stress. (Social services subsequently wrote to Mr K on 25 August saying that, in the light of that medical advice, they felt that it would be better if Mr J continued to enjoy day trips with the family, but did not at present commit to overnight stays.)
48. In the meantime, on 4 August, Mr J’s social worker wrote to Mr K about his daily contact telephone call with Mr J. He said that the Coquet Trust support staff were concerned that the daily calls (which they initiated in order to support Mr J’s contact with his family and to update them on Mr J’s well-being in the previous 24 hours) often lasted up to an hour, but were in the main not spent with the family talking to Mr J or Mrs N, but with the family making complaints to the staff about past and present support arrangements. That took staff away from caring for Mr J. He asked that any such complaints should be addressed to him, or to the Coquet Trust management. He also referred to Mr K’s request that Mr J should ring at a set time each day, saying that there had to be some flexibility around the arrangements to suit Mr J’s needs.
49. On 8 August Mr J’s medical priority for housing was reinstated.
50. On 18 October another consultant psychiatrist took over Mr J’s care. Mr J’s condition continued to decline, and Mr K continued to express dissatisfaction to the Coquet Trust with Mr J’s care and support, and about the difficulty the family had in reaching Mr J by telephone when they wished to, as the flat had no landline. (Mr K’s home was about 80 miles from where Mr J lived, and of necessity, therefore, their most regular contact was by telephone.)
51. On 27 October and 2 November Your Choice Homes offered properties for consideration for Mr J and Mrs N. Social services and the Coquet Trust staff refused these on Mr J’s behalf, the first because the bedrooms were too small to enable staff to be able to meet Mr J’s care needs (including the use of a bed hoist when required), and the second on the advice of the community nurse and the OT that it did not meet Mr J’s needs and the required adaptations would take too long. Neither Mr J nor Mr K were told about these offers. On 13 November Mr J’s medical priority for rehousing lapsed again because no interest had been expressed in the properties offered. There is no evidence to suggest that Your Choice Homes notified Mr J or anyone else involved in his care of this. No further properties were offered or considered subsequently.

2007

52. Mr J’s GP attended him on 4 April 2007 because the Coquet Trust staff were concerned about noises in Mr J’s chest. Mr J’s chest was found to be clear. The GP considered that the chest noise could be due to Mr J not swallowing his food properly.
53. Mr J became unwell and was admitted to hospital on 7 April for intravenous medication, as his swallowing difficulties prevented him from taking it orally. Sadly Mr J died there from pneumonia on 9 April.

2008

54. The findings of the Stage 2 complaint to social services were issued in January 2008 and on 28 April the Council responded to the Stage 3 findings. Mr K remained dissatisfied with the responses he had received and subsequently complained to us.

Mr K’s comments

55. It is very evident from Mr K’s account in Annex C and in his other representations that there was a strong bond between Mr J and his family. Mr K was clearly passionate in his desire to see that his brother got the most he could out of his daily life, and remains convinced that the family were the only ones who truly knew Mr J, and recognised his full potential, talents, and preferences. The main thrust of Mr K’s outstanding complaints is that he strongly believes that the failure of the relevant service providers to recognise the special relationship that existed between Mr J and his family, and to involve them appropriately in Mr J’s care, caused a chain of events that resulted in a rapid deterioration in the quality of Mr J’s life and health and eventually led to his death. He considers that these important and significant matters have not yet been properly addressed.

The bodies’ responses to the complaints

The NHS Trust’s response

56. We offered the NHS Trust the opportunity to comment on Mr K’s complaint at the outset of this investigation. The NHS Trust told us that they considered that they had followed DH’s interim guidance following the Bournewood case. They were satisfied that their policies and procedures at the relevant time had been in line with the interim guidance.

The Consultants’ comments

57. Dr A and Dr B, the Consultant Psychiatrists at the NHS Trust identified by Mr K as having been responsible for Mr J’s inappropriate admission to, and detention in, the NHS Trust and his misdiagnosis, sent us their own comments on the parts they played in these events. These are set out in detail in Annex D.
58. In summary, Dr A said that she remained convinced that Mr J’s admission to the NHS Trust on 16 November 2005 had been in his best interests. She had witnessed a major deterioration in Mr J’s condition in just a few days. It was unclear what had caused that. There were a number of possibilities which had needed to be investigated urgently and could not be carried out effectively on an outpatient basis, and although she had considered contacting Mr K beforehand, her chief concern had been to find Mr J a place of safety that evening.
59. Dr A said that when the options had been discussed with Mr J, his wife and his carers, it had seemed that the best option had been for the community nurse to take Mr J and his wife to view the hospital, meet the staff and see whether he would be prepared to stay. The admitting officer had subsequently documented that Mr J had said that he was happy to stay. It was the admitting officer’s duty to contact the next of kin; and Dr A had assumed that this would include not just Mr J’s wife, but the wider family.
60. On the matter of whether Mr J had capacity to consent to his admission, Dr A said that guidance said that there should be an assumption that a patient possessed capacity until shown otherwise. Mr J had been so distraught when she saw him that she would not have been able to assess capacity at that time, but she felt that the fact that Mr J had said that he was happy to stay once he had seen where he would be sleeping and meeting the staff at the hospital supported the view that Mr J did have the capacity to consent. Dr A acknowledged that she should have documented in her notes that, had Mr J expressed a will to leave the hospital rather than be admitted, he should be assessed
    under the Mental Health Act 1983 (Annex B,
    paragraph 22), but that she had not done so at the time because of the urgency of the situation.
61. Dr A went on to say that she had not made any definite diagnosis as to what was causing the deterioration in Mr J’s functioning. However, as the information she had indicated the possibility that he might be severely depressed, she had prescribed antidepressants. However, Mr J had subsequently become very sleepy and had low blood pressure, which were both possible side effects of the medication, and so she had discontinued it so that baseline assessments of Mr J’s blood pressure, mental state and fit frequency could be carried out. Dr A concluded that she believed that she had made strenuous efforts to ensure that Mr J had not been discriminated against; she had done all she could to exclude any underlying physical and treatable cause of his deterioration.
62. Dr B said that it was sometimes difficult to determine whether symptoms were a consequence of depression or dementia, but it had been established that Mr J’s symptoms were due to dementia. Given that diagnosis, there had been no clinical reason to restart the antidepressant medication. The speech and language therapist (SALT) had considered a soft diet necessary to reduce the risk of Mr J choking or aspirating food, which could have been fatal. She concluded that the multidisciplinary team had had Mr J’s best interests in mind, and that his needs had been addressed as they had emerged.

The Council’s response

63. We wrote to the Council at the outset of the investigation to offer them the opportunity to comment on Mr K’s complaint. As the Coquet Trust are a voluntary body, funded by the Council, and were providing services contracted by the Council, the Council responded on behalf of both bodies. The Council told us that the complexity of Mr J’s needs had made his home unsuitable to live in after his discharge. The decision to use the care home had been taken because there had been an urgent need for Mr J to be discharged and reside with his wife: that decision had been a multidisciplinary decision agreed with health professionals. It was accepted that this was not an ideal solution, but no other accommodation had been available; residential accommodation would not have been appropriate because Mr J had been married and wished to live with his wife.
64. The flat at the care home was on the first floor and, although normally accessed by a lift, there were stairs close by: the flat was kept locked because there was a risk of Mr J falling and wandering.
65. Mr J’s family had had to sign in and out when they visited because of fire regulations. Mr K’s unhappiness with this was known, and Coquet Trust staff had done what they could to mitigate his dissatisfaction. In a letter to Mr K of 4 August 2006 the Council had stated that they were ‘committed to working constructively to ensure the maintenance of positive communication’.
66. With regard to Mr J’s care, the Council said that a side effect of his medication had been weight loss, which had been monitored by health professionals. Coquet Trust staff had been given appropriate training to manage the situation. Mr J’s condition had also made him susceptible to infections, such as pneumonia. Mr J had received extensive support from the Council, and appropriate services such as occupational therapy had been called in when necessary. During Mr J’s stay in hospital the Council had continued to commission eight hours of care per week from the Coquet Trust to promote Mr J’s emotional well-being by enabling his wife to visit him. Following his discharge from hospital, 112 hours of care, plus waking nights (that is, 24-hour) care had been provided.
67. Turning to the handling of Mr K’s complaint, the Stage 2 investigator had not interviewed Mr K or his sister because there had been extensive communication with them between April and September 2006 about the arrangements for the investigation. Mr K had sent a substantial amount of documentation and comments, and had spoken by telephone; therefore a meeting would further have delayed matters. Mr K had made no complaint at the time about the lack of a face-to-face meeting.
68. There had been delays with the complaint, partly due to the sick leave of two social workers who had provided support to Mr J, neither of whom returned to work.
69. The Council went on to say that, in line with the Stage 3 panel recommendation, their team had met staff of the council for social care inspection (CSCI) on 29 April 2008. The agenda had included the discussion of individual (serious) cases, including Mr K’s complaint.
70. The Council had also taken action in response to the other Stage 2 and Stage 3 recommendations. This had included:
    • carrying out significant training across the learning disability service;
    • continued work with the CLDT, Dr B and the NHS Trust to develop individual support plans for all users of services with a diagnosis of dementia; and
    • a review of policies and procedures.
71. The Council said that team managers and social workers had been working in partnership with housing associations, private landlords and housing providers on Mr J’s accommodation needs. All had been aware of Mr J and his wife’s housing requirements (‘ground floor flat or bungalow with a maximum of one or two steps on entry, preferably with a level access shower in situ and that two bedrooms were essential’) and had been asked to report to managers if suitable properties came up. This was normal practice. Social workers were seeking housing solutions and would contact housing providers. If a solution arose that was not suitable for a particular service user, the details would be shared with the rest of the team to ensure that other users’ needs were taken into account.
72. The Council said that Mr J’s particular needs had restricted the number of housing options. This was not inactivity, or missed opportunity on the Council’s part and great effort had gone into trying to support Mr J and his wife at the care home, particularly given that Mr J’s health was fluctuating so much, leading at times to the need for an increase in staffing. That had meant, however, that at those times the focus had been on meeting Mr J’s immediate health needs, rather than on actively pursuing permanent housing. The Council commented that Mr J had not nominated a specific individual to make housing bids on his behalf.
73. In response to our subsequent enquiries, the Council told our staff that 41 two-bedroom ground floor flats had been allocated in the Heaton and Byker areas between February 2006 and April 2007, of which eight had been adapted; the remaining properties had had the potential to be adapted. There would also have been other properties advertised throughout the city during this time. However, the majority of these properties, even those that had been adapted, were unlikely to have been regarded as a suitable environment to meet Mr J and Mrs N’s needs, some, for example, were within a large multistorey block. Nevertheless, if Mr J or his representatives had expressed an interest in a property, the Your Choice Homes OT would have assessed whether it was adaptable, prior to an offer being made.
74. When an adapted property became empty a housing officer would obtain a list of potential tenants. This was how two offers were made to Mr J. Regarding the first, it was recorded that housing staff had met staff from social services and the Coquet Trust who advised that the bedrooms were too small. Regarding the second, the records indicated that staff and the OT had concluded that it was unsuitable. The Council said that although they were declined, the two properties had appeared to meet the basic requirements.
75. Regarding the DH interim guidance
    following the Bournewood case (Annex B, paragraphs 32 to 34), the Council said that they had no evidence of issuing their own separate guidance to staff. However, from January 1998 social services had held discussions, including representatives of local NHS bodies, about the implications of the ruling. The NHS Trust had asked regional medical officers to review all existing cases and new admissions to establish if informal patients should be sectioned. In March 1999 social services held joint training which dealt with the implications for mental health teams, the CLDT and NHS Trust staff. In May 2005 approved social workers had attended training, and discussions had continued in the Council’s approved social work forum. Thereafter approved social workers had been alerted to advice from Newcastle, North Tyneside and Northumberland Mental Health NHS Trust, which dealt with the Bournewood case and its implications. The Council said that they were satisfied that they had followed the DH guidance.

Professional advice received

76. The Psychiatric Adviser’s detailed comments (in Annex E) identify the following key points. With regard to Mr J’s admission to hospital, Dr A had faced a difficult situation and, although the admission had not been documented in line with the relevant guidance, and Mr J’s family had not been contacted and consulted as they should have been (both before and throughout his admission), which were both serious matters of concern, nevertheless the decision to admit, in itself, seemed reasonable on the available evidence. The Psychiatric Adviser went on to say that the records indicated that Mr J had been admitted because of his distress and because of the concern that he might have a life-threatening condition. In those circumstances it would have been poor practice to have sent Mr J home. He also confirmed that it was appropriate for Dr A to suggest that a successful and timely scan was more likely if Mr J was supported from within a specialist learning disability unit; any other urgent assessments would also be easier to arrange.
77. The Psychiatric Adviser also noted that Mr J had been judged ready for discharge on 12 January 2006, just eight weeks after admission. The assessment process had therefore taken just two weeks longer than Dr A had originally anticipated. The key difficulty had been the further five month period it had taken to find and equip suitable accommodation. It was during that delay that serious problems had begun to arise for Mr J in terms of his restricted contact with his wife and family, which would have been distressing for him. Against that background the decision not to allow Mr J (after his discharge) to visit his brother for a short period was unsatisfactory.
78. However, the overall level of clinical treatment that Mr J had received from the NHS Trust had not fallen below acceptable standards, and there was no evidence to suggest that Mr J had been discriminated against because of his disability in the way described by Mr K. Namely, there is nothing to show that assumptions had been made about Mr J’s symptoms, or that no account had been taken of his communication difficulties. Appropriate investigations had been carried out to identify possible causes of Mr J’s deteriorating condition, and there was enough evidence in the medical notes to confirm that he was suffering from dementia.
79. The Nursing Adviser, although concerned about the poor record keeping of the Coquet Trust’s staff, said that she had found nothing to suggest that, in the days immediately preceding Mr J’s death, that they had failed to pick up on indications that a serious or fatal decline in his health was imminent.

Findings

Overall

80. It is not at all surprising that, even though their complaints have previously been investigated in some depth, Mr J’s family should remain convinced that something must have gone badly wrong in the care and treatment provided to their brother, which has not yet been fully addressed. If any individual who was admitted to hospital for a few weeks’ assessment subsequently remained there for seven months, some five of those after they had been declared ready for discharge, and was then released into inappropriate locked accommodation which they only left due to their death some 10 months later, it would raise serious questions. Where the individual concerned is a highly vulnerable adult, with deteriorating health, whose quality of life depends heavily on being in a suitable environment with the care and support of his family and carers, those serious questions demand answers.
81. The major failure we have identified was the lack of any properly co-ordinated and documented health and care plan for Mr J, with an identified key worker to monitor and co-ordinate those services and to ensure, not just that information was shared fully and appropriately between all of those involved, but also that Mr J’s and his family’s voices were clearly heard. That did not happen – with worrying consequences for both Mr J and his family.
82. The fact that no one had taken that key leadership role meant that not only was there no one individual with an overall view of Mr J’s character and abilities, his family background, his needs and the services he was receiving, but also no one to represent Mr J’s interests and wishes appropriately by driving matters forward when these were clearly not being served. This was demonstrated in the CPA meetings, where it was recognised that the NHS Trust was not a normal living environment and could not provide Mr J with the opportunities and activities available in the community, as well as the importance to Mr J of living with his wife, and yet then simply noting that it was social services’ responsibility to find the required accommodation. That lack of leadership might also explain why the CPA meetings were not carried out in line with the DH guidance and the records were so poor – including the failure to complete the ‘service user/carer’ section (Annex E, paragraph 8).
83. That does not, however, mean that we agree with Mr K’s view that the NHS Trust, the Council and the Coquet Trust should be held responsible for the deterioration in Mr J’s health and abilities leading to his death. There can be no doubt that the change in Mr J’s condition over a relatively short period came as a shock to his family; and the distress this caused them comes across clearly in Mr K’s complaints, and indeed in the family’s dealings with those involved in Mr J’s care. It is also very evident that they remain convinced that Mr J was suffering from depression, which could, if treated appropriately, have been managed so that his skills and daily functioning did not decline. But it is very clear from the notes of the professionals caring for Mr J that his condition had not only been fluctuating but also generally deteriorating for some time; indeed concerns had been raised about this by the Coquet Trust staff in the two years before Mr J was admitted to hospital. We are satisfied from the clinical evidence we have seen (including the EEG and CT scan results), and the professional clinical advice we have received, that this very sad course of events had physiological origins, in other words, it had its roots in the onset of dementia and epilepsy, and was not simply due to a lack of appropriate opportunities being provided for Mr J to use and practise his skills. Further, that deterioration clearly escalated quite suddenly in the latter half of 2005, and the causes of that needed investigating. It is against that background that we have reached the conclusions below.

The NHS Trust

84. We are satisfied that the initial decision to admit Mr J to the NHS Trust was a reasonable one in all the circumstances. It is clear that Dr A, when dealing directly with Mr J, was striving to take all of his circumstances into account including his marriage, his underlying Down’s syndrome, his preferences and, especially, his safety. Whilst we appreciate that Mr K does not believe that Mr J would have consented to admission, we find Dr A’s comments in this respect (paragraph 59) persuasive. In particular, we do not see that discrimination against Mr J (on the grounds of his Down’s syndrome) came into play here. Rather, we note that Dr A was careful not to make assumptions and rush to a diagnosis of dementia linked to Down’s syndrome, but was open to a variety of possible reasons for the deterioration, and had tests carried out to look into those possibilities.
85. We also cannot conclude that Mr J was misdiagnosed. As we have already indicated above, whilst we appreciate Mr K’s strong view that Mr J was simply depressed, we find it reasonable, on the basis of the clinical evidence we have seen, to conclude that Mr J did indeed have dementia and epilepsy; and that his medication was therefore appropriate. Similarly, we take note of the Psychiatric Adviser’s comment that it was reasonable to adjust Mr J’s diet to take account of potential risks such as choking.
86. We have also found no fault with the NHS Trust’s overall handling of Mr K’s complaints. They responded to Mr K’s initial complaint within a reasonable time frame; they then entered into further local resolution, changing Mr J’s consultant psychiatrist as requested and drawing up an action plan with social services. They set out in their final response the outcome of the local resolution meeting (held in October 2006), as well as apologising again for identified shortcomings, and advising Mr K correctly on what further action he could take. In essence, we have seen that the NHS Trust went some way to try to resolve the complaint and we do not conclude in all the circumstances, and with the difficult relationship which they at that stage had with Mr K, that the process followed by the NHS Trust in dealing with his complaints was inherently unreasonable.
87. However, that does not mean that the NHS Trust were fault free – far from it. We find that the NHS Trust failed Mr J in two important respects. First, there is the question of Mr J’s continuing capacity to consent to staying in the hospital. Dr A has acknowledged that she should have documented her views on Mr J’s capacity to consent to admission, but had failed to do so because of the urgency of the situation. Whilst we would observe that it is precisely when making urgent decisions that it is most important to document the reasons for them, we do not believe this would have made any difference on the day of admission.
88. What it might, however, have done is to prompt others, in the coming months, to review and document Mr J’s capacity to consent and the reasons for his continued inpatient status, in line with the guidance issued following the Bournewood case. That did not happen – despite the fact that that guidance was specifically designed to protect those in a similar position to Mr J and ensure that they were not inappropriately kept in hospital against their wishes – even if with the best of intentions. We consider that failure to be a major breach of guidance and therefore maladministration.
89. We note that the NHS Trust have contended that there was no overt sign that Mr J wished to leave the hospital, and that he had made no attempt to do so. They deny that he was unhappy there, and claim that there is no evidence that he was being kept there against his will. Mr K, on the other hand, tells a different story and talks of Mr J’s distress on being returned there, and says that Mr J’s right to liberty under the Human Rights Act 1998
    was thereby denied. We note that the
    European Court was of the opinion (Annex B, paragraph 32) that the fact that an individual might not have tried to leave did not mean they were not being ‘detained’. But in any event, there is clear documentary evidence of Mr J’s expressed desire to leave the hospital, both in the nursing reports prepared for the CPA meetings, and in the social worker’s note of his visit on 6 February 2006 (some three weeks after the CPA meeting had said Mr J was ready for discharge).
90. It seems to us that, whether it was the NHS Trust’s intention or not, they had clearly given Mr J and his family the impression that only they (the NHS Trust) could say when Mr J could leave the hospital. Indeed, the fact that the NHS Trust had overall control in this matter appeared to be reinforced when Mr K was told in August 2006 that Mr J would not be allowed to visit him for a few days on the advice of Dr B, despite the fact that Mr J was by then living in the care home. We would add that we also find it surprising, given the limited number of such specialist beds available for patients, and the fact that it was generally recognised that it would be better for Mr J’s well-being to be discharged and be with his wife, that the NHS Trust did not do more, once Mr J had been judged ready for discharge, to urge social services to find suitable accommodation as quickly as possible. Instead they were apparently content to let him wait for the next five months in hospital.
91. As we have indicated (Annex B, paragraph 18), it is not for us to determine whether the law on human rights has been breached. What we can, however, say is that the relevant DH guidance (Annex B, paragraph 32) was clearly intended to ensure that those rights were appropriately protected. We conclude that by failing to follow that guidance, the NHS Trust have failed to show that they had due regard to those rights in their dealings with Mr J.
92. The NHS Trust’s second key failing was in their failure to involve Mr K and Mr J’s other siblings appropriately in Mr J’s care planning, both in line with the relevant guidance and good practice. It is evident that there were lapses in communication, and gaps in the knowledge which the NHS Trust had, and shared, about Mr J. For example, Dr A pointed out that when she first saw Mr J in November 2005 she had not been told about the community nurse’s previous extensive involvement with Mr J, nor been aware of the multidisciplinary assessment in October 2005 (Annex D, paragraph 4).
93. In particular, however, there does seem to have been a failure to appreciate the full importance of Mr J’s family in his life and, potentially, in his future. As a result, not only were the family not consulted before Mr J’s admission, but decisions were made which did not take any account of the family’s previous involvement in Mr J’s life. The suggestion, for example, by Dr B in August 2006 that Mr J would be caused undue stress by the unfamiliar environment if he went to stay with his brother for a few days took no account of the many successful visits Mr J had enjoyed there previously. That decision not only deprived Mr J of a potentially pleasurable break, after a very long time away from his family, but clearly caused great distress on all sides. (We note, however, that that issue was later resolved as Mr J and Mrs N did subsequently spend several weeks visiting Mr K and his wife, both over Christmas 2006 and then again in early 2007.)
94. It is evident that, after Mr J’s admission, the NHS Trust were generally aware of the family’s involvement and intended to include them in the discussions about Mr J’s care and treatment. Accordingly, the family was initially invited, in December 2005 and January 2006, to the CPA meetings considering Mr J’s care needs. What is also clear is that Mr K disagreed with, and was distressed by, both the NHS Trust’s diagnosis and the prognosis given for Mr J, and made that very clear. In such circumstances it is not, perhaps, surprising that feelings ran high at the second meeting; Mr K acknowledges that he spoke out of turn and was asked to leave. However, he was not then invited to any further meetings. That was simply not acceptable. Regardless of how difficult the relationship was to manage, it did not provide the NHS Trust with carte blanche to disregard the guidance and best practice and exclude the family from contributing their extensive personal knowledge and experience of Mr J into his future care planning. We note that the family were in daily contact with those caring for Mr J on the ward, and took those opportunities to press their views as to Mr J’s care needs, indeed so much so that their contact had to be restricted (paragraph 37). Nevertheless, we think it reasonable for Mr K to argue in these circumstances that, had the family’s views been taken into account at subsequent CPA meetings, a different outcome, or at least a more urgent solution to Mr J’s accommodation needs, might have been sought.
95. That does not, of course, mean to say that Mr J’s basic needs were being overlooked; nor did it mean that his family’s views were being completely ignored. (The NHS Trust did, for example, get a second SALT opinion regarding Mr J’s diet, and changed Mr J’s consultant at the family’s request.) But it did mean that important opportunities to ensure that all relevant information necessary to achieve the best possible outcome for Mr J were lost. We have accordingly concluded that communication with Mr J’s family in this respect was inadequate and must be regarded as a significant service failure.

The Council

96. The Stage 2 investigation into Mr K’s complaint to the Council, particularly about the support and communication provided prior to Mr J’s admission, was protracted. We note that the Council accepted that there had been a number of shortcomings in the service which had been provided. It is clear, for example, that the Coquet Trust had been asking for some time for funding for additional support hours in the period before Mr J’s admission. This is understandable in terms of the deterioration which was clearly taking place, given the changes in his physical and physiological condition due to the onset of dementia and epilepsy. The question of how much extra support and funding should have been provided is not a matter for us. However, the Stage 2 investigation confirmed that, given that Mr J’s deterioration was so severe as to require assessment in hospital, not only was it clear that those requests were not considered with appropriate urgency, it could also be argued that it should have been evident that the basis for funding needed to be radically revised. These matters have been dealt with at length in the earlier stages of the Council’s complaints process. Nevertheless, despite the significance of those failings, we do not think it is possible to conclude that Mr J’s increasing depression and dependence on others can be linked directly to a failure to provide appropriate day time and general support over a fairly long period before his admission to the NHS Trust. There can be little doubt, however, that the delay in funding sufficient support must have impacted on Mr J’s quality of life in that period to some degree, as the Coquet Trust’s records show that they were spending increasing amounts of time supporting Mr J with basic tasks, such as feeding and dressing, which meant that there was less time available for them to do anything else, such as to take him out, or to support him in other activities.
97. During the period when Mr J was in hospital, the main responsibility for providing sufficient day-time activity therapy would have rested primarily with the NHS Trust, and not with social services. That is understandable. But the social services’ decision to reduce the support hours available to him to only eight per week during that period had a significant impact on the amount of contact Mr J could have with his wife, Mrs N. It would appear that that was insufficient time to support her to make more than one visit a week, because of the distance of the hospital from their home. Despite the positive impact his wife’s visits were recorded as having on him, no consideration seems to have been given to increasing those hours to allow more frequent contact between them. That omission demonstrated a disappointing and unacceptable disregard for Mr J’s relationship with his wife and his well-being.
98. It is possible that that omission could have in part resulted from the lack of adequate communication during important periods, between social services’ staff and the Coquet Trust’s staff with Mr J’s family, which the
    Stage 2 investigation revealed. In fact, social services’ contact with his family after Mr J’s admission seems to have been very limited. Further, there was not even a social services representative at the first of the CPA meetings (Annex B, paragraph 29) on 1 December 2006. We appreciate that Mr J’s then social worker was sick, but that did not mean that there was not a continuing duty on social services to provide the necessary input into his care planning and provision in order to promote Mr J’s best interests whilst he was in the hospital. They clearly failed to do that.
99. That failing was all the more marked, however, once Mr J had been assessed as ready for discharge in January 2006. It is quite clear from the OT’s detailed assessment of Mr J and Mrs N’s home in January 2006 (paragraph 35) that it would have been inappropriate to suggest that Mr J should return to his former accommodation. Whilst we recognise that Mr J’s family do not agree with that view, given the high risk of Mr J falling there, we do not consider that that was an option realistically open to the Council. In fact the need for rehousing had first been identified by social services in October 2005 (paragraph 29), and reinforced by Dr A in November 2005. However, that then placed the onus squarely on the Council to find appropriate ground floor accommodation for Mr J and his wife as soon as possible. Yet, as we have shown, that never happened. Instead, Mr J spent the next five months waiting in the hospital, and was then discharged into unsuitable, first floor accommodation, where he had to be locked in to prevent him from falling in the lift or on the stairs, and from wandering, and where he was still living when he died ten months later. All of that was simply unacceptable.
100. During all of that time, not only was no sense of urgency brought to bear on the accommodation issue by the Council, but a situation developed which could at best be described as unfortunate, but which was, in reality, both astonishing and absurd. This arose from the fact that the Council took no action to resolve the housing issue, other than to expect Mr J to use the same choice-based bidding system as anyone else. Under that system (Annex B, paragraph 37) Mr J, or someone he had nominated to act on his behalf, was required to bid for advertised properties. This was entirely inappropriate in Mr J’s circumstances and effectively meant that social services had abandoned their clear duty to seek actively to resolve Mr J’s urgent housing need (Annex B, paragraph 24). To add insult to that injury, there is no evidence to show that any efforts were made to ensure that this process was ever properly explained to, or understood by, Mr J and his wife. Nor do the records show that he was invited to nominate someone else to act on his behalf in this matter, or that the process was explained to Mr K or anyone else in Mr J’s family; nor indeed that any of the care professionals working with Mr J had taken on this role. As a direct result, Mr J’s medical priority was first removed in July 2006 because he had not made any bids, and then reinstated a month later, when the Coquet Trust explained to the housing agents that Mr J had been in hospital. Then two offers were made and refused without any discussion with Mr J or his family, and even, in the second instance, apparently without the involvement of Mr J’s social worker. Further, the second property was refused on the grounds that it would take ‘too long’ to make the required adjustments, without any attempt to establish exactly how long it would take, or indication whether another property was likely to become available in that period. The housing agency then ceased to make any further offers apparently because of the lack of interest shown in the first two.
101. We note that the Council, in their response to us, have suggested that the difficulties arose because Mr J had not nominated a specific individual to bid for him (paragraph 72) and had shown no interest in any of the potentially suitable properties that were coming up at that time (paragraph 73). The Council also imply (paragraph 74), that it was not surprising that the housing agency made no further offers, as the properties that had been declined had ‘met the basic requirements’.
102. We find that response outrageous and indefensible. It entirely ignores the question of Mr J’s capacity to act on his own behalf and the fact that the process was totally inappropriate for him and his circumstances. It pays no heed to the legal duty on social services to seek the help of the housing and health authorities to resolve the problem, and failing that, to seek to resolve it themselves. It also disregards the fact that Mr J and his family were unaware of the process in place, and that the properties were turned down by social services and the Coquet Trust, and not by Mr J or a nominated representative, as being unsuitable for Mr J’s needs. There is little sign here of social services and the housing agency working in partnership to meet Mr J’s urgent accommodation needs, as the Council say was the case (paragraph 71). Indeed, it seems highly unlikely, in the light of these developments, that had Mr J lived, he and his wife would ever have moved from the unsuitable locked accommodation in the care home.
103. These events are all the more alarming when considered against the background of the national strategy and guidance in place intended to improve the lives of those with learning disabilities, giving them greater choice and control over their lives, and the guidance issued following the Bournewood case, intended to ensure that individual’s human rights were given proper consideration. We find that the Council’s failure to review regularly and record why Mr J was being effectively detained in unsuitable, locked accommodation, and their failure to take appropriate and urgent action to find suitable permanent accommodation, were so serious as to amount to service failure.
104. That same guidance highlighted the importance of involving the family in care planning for service users. The failure to involve Mr J’s family sufficiently in trying to resolve the accommodation issue was particularly serious. Although staying with Mr K might have not been a viable option for Mr J in the long term, Mr K must have viewed, with distress, the fact that this was never discussed with him nor tried as an emergency interim measure, and that he was not given the opportunity to help in the search for appropriate accommodation, which might have led to Mr J being able to spend the last months of his life in relative freedom (although we recognise that he was no longer able to go out independently) and in more congenial surroundings.
105. We turn finally to the investigation of Mr K’s complaint to the Council. This took far longer than it should have to complete (15 months, rather than the 28 days set out in the regulations – Annex B, paragraph 40), and we agree with the Stage 3 panel that Mr K should have been offered an interview. In the main, however, the investigation had been thorough in acknowledging and responding appropriately to many points of detail in the complaint. There was, nevertheless, a key omission, which was the overwhelming failure to recognise that in failing to follow the relevant guidance, and in failing to take timely and appropriate action to find permanent suitable accommodation for Mr J and his wife, the Council were not just failing to act in Mr J’s best interests, but failing to ensure that Mr J’s human rights were adequately safeguarded.

The Coquet Trust

106. Mr K complained about the amount and content of the practical day-to-day support provided to Mr J by the Coquet Trust. However, the Coquet Trust were not responsible for planning the care or care management arrangements on behalf of social services: their contract with the Council was specifically for the provision of a certain number of hours of support to assist Mr J and his wife with basic daily living tasks. We have seen that the care provided by the Coquet Trust was considered at all stages of the social services complaints procedure; and the investigation of the issues complained about was generally thorough and the findings reasonable. We have had no reason to repeat those investigations. Mr K has made a number of criticisms of the practical arrangements but it seems to us that Coquet Trust staff did what was reasonably possible within the time allocated to them. We note, for example, that the funding available to maintain contact between Mr J and his wife while he was in hospital was determined by social services, and was insufficient for the contact to be anything other than minimal. After Mr J’s discharge, they were, of course, providing Mr J with 24-hour, live-in support.
107. Further, although we found that the Coquet Trust’s records were sometimes sparse and seemingly incomplete, there was nothing in the available evidence to suggest that Mr J was provided with an unacceptable standard of care in the period before his death. In particular, we do not conclude that Coquet Trust staff failed to observe signs of imminent serious illness – especially as we note that the Coquet Trust asked both the community nurse and his GP to see Mr J three days before his final admission to hospital, and neither the nurse nor GP raised any urgent concerns about Mr J’s health.
108. We turn finally to the complaint that the Coquet Trust staff were a part of the wider failure to communicate adequately with Mr J’s family. We consider that prior to Mr J’s admission, the responsibility for keeping Mr J’s family properly updated rested primarily with Mr J’s social worker (although we note that that would have required the Coquet Trust staff to have kept him informed, which was identified as a failing on their part in earlier stages of the complaints process). We also note that the Coquet Trust staff did not inform Mr K when Mr J’s imminent admission to hospital was being considered in November 2005, although they did call him that evening to tell him of Mr J’s admission. We do not, however, find that the support workers failed to facilitate Mr J’s contact with his family following his discharge. The records clearly show that it was part of the support workers’ recognised duties to call Mr J’s family each day to update them on Mr J’s health and activities in the previous 24 hours and to support Mr J in speaking to his family, and that this was to be done when Mr J was safe and did not need their support in other ways; and that was what happened. We appreciate that Mr J’s family would have preferred there to be a landline in Mr J and Mrs N’s flat in the care home, in order to be able to contact Mr J when they wished. However, that accommodation was meant to be temporary only, and given the daily contact call, we do not see it as a failing on the part of the Coquet Trust staff that they did not press for a landline to be installed in line with the family’s wishes.

Injustice

109. So what was the injustice caused to Mr J by the service failings we have identified above? As we have already indicated, we cannot agree with Mr K that it is possible to conclude that, had all the health and social care staff involved in Mr J’s case carried out their duties in line with the relevant guidance and best practice the outcome for Mr J would have been dramatically different, in the sense that his condition would not have worsened as it did and he would not have died. Mr J’s condition was clearly fluctuating, but it was recognised by a wide range of professional staff involved with Mr J’s care that he had been slowly deteriorating over a long period, and that that deterioration became more rapid with the onset of dementia and epilepsy. Accordingly, even if Mr J had been provided with more support sooner, and suitable accommodation had been found much earlier, there is little possibility that he would have been able to regain his former skills and health, or retain those that he had before entering hospital for much longer. We certainly cannot conclude that he would not have died when he did.
110. It is also not possible for us to determine, with any level of certainty, what level of additional distress was caused to Mr J by his unnecessarily prolonged stay in hospital, and in accommodation that was unsuited to his needs. We accept, however, that this will have been significant, particularly for the period when Mr J was in hospital and he was clearly missing his wife.
111. What we can, however, say with certainty is that those service failings meant that opportunities were not taken to assess Mr J’s needs promptly and appropriately, with due regard to his rights, best interests and wishes, and his relationship with his wife and family. We cannot know precisely what difference that might have made, but it seems highly likely to us that it would have had some impact on the quality of his life, and hence his well-being, in the last 18 months or so of his life. That injustice cannot now be put right.
112. Those service failings also, however, had a negative impact on Mr J’s family in that, had they been properly involved in Mr J’s care planning, they might have been able to represent Mr J’s interests more successfully. They might, for example, have been able to put forward other options to meet Mr J’s accommodation needs, at least on an interim basis, or been able to secure more urgent action by the Council, so that Mr J could spend his last months in more congenial surroundings with easier and more regular contact with his family. The overwhelming injustice to them is that they were wrongly denied those opportunities to contribute to Mr J’s care planning, and will never now know if they could have made a difference to the quality of Mr J’s life in those last months. We have no doubt that that uncertainty is a cause of significant and ongoing distress to Mr K and the rest of Mr J’s family.

Recommendations

113. The NHS Trust and the Council have both previously offered their apologies for the shortcomings identified during previous
     stages of the complaints system, and taken various steps (as set out in their responses in Annex F) to try and prevent a recurrence. We do not, however, consider that those provide sufficient remedy for the injustice arising from the very serious failings identified in this report. We therefore make the following recommendations that the NHS Trust and the Council should:
     • provide Mr K with a full acknowledgement of the serious service failures identified in this report, together with an apology for the distress those failings caused Mr J’s family; and
     • pay Mr K (as the family’s representative) a sum of £2,000 in recognition of the distress caused to Mr J’s family by the failings identified in this report; (with the NHS Trust and the Council contributing an equal share to that sum – namely £1,000 each). Mr K has informed us that he will be donating all of the money to charity.
114. Whilst we recognise that there have been changes in the legislative framework since the events in this case which, if fully complied with, should mean that the failings described in this report should not be repeated, we do not see the existence of that framework as sufficient reassurance in itself that appropriate lessons have been learnt. We therefore additionally recommend that, within three months of the issue of the final report, the NHS Trust and the Council each:
     • prepare an action plan which describes what they have done (or will do) to ensure that they have learnt from the failings identified in this report and which describes what they intend to do, including timescales where appropriate, to avoid a recurrence of those failings;
     • send a copy of the action plan to the Ombudsmen and Mr K. The NHS Trust should also share its action plan with NHS North East (the strategic health authority), Monitor, Newcastle Primary Care Trust (the commissioning body) and the Care Quality Commission; and
     • ensure Mr K is regularly updated on progress against the action plan. The NHS Trust should also ensure that NHS North East, Monitor, Newcastle PCT and the Care Quality Commission are updated.
115. The NHS Trust and the Council have agreed to these recommendations.

Conclusion

116. We 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. As a result, important opportunities were missed to try to ensure that Mr J got the best out of his everyday life in the last 18 months of his life in particular, and significant and ongoing distress was thereby caused to Mr K and the rest of Mr J’s family. We are aware from Mr K’s comments on a draft of this report that, contrary to our findings, he remains convinced that Mr J’s clinical diagnosis was wrong and that the care and treatment that Mr J received was accordingly not only misconceived, but in fact hastened his decline and death, and that this misdiagnosis was the result of discrimination against Mr J. We have considered all of Mr K’s representations very carefully, but on the basis of the evidence we have seen, and the professional advice we have received, we cannot agree with him. Accordingly, we find the NHS Trust and the Council’s agreements to our recommendations to be a suitable outcome to this partly justified complaint.
117. Although we have been unable to reach the conclusions that Mr K was seeking, we hope that this report will provide him and the rest of Mr J’s family with at least some of the explanations they were seeking, and will draw to a close what had been a long and complex complaints process for all those involved.