Section 4: Final remarks
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In this report we have set out the evidence we have considered, the advice we have obtained and our findings, conclusions and decisions with regard to the service Mr B received from the Council and the Trust.
We have not found that the Trust’s psychiatrist failed to provide appropriate care to Mr B, or that the Council failed to support Mr B in claiming appropriate benefits. However, we found that the Trust and the Council failed in their joint responsibility to manage and implement care plans for Mr B and to take adequate account of developing signs of risk. This was service failure, which contributed to the injustice of unnecessary pain and neglect experienced by Mr B and to the distress and trouble for his cousin, Ms A. Therefore, we uphold the complaint about the Trust and the Council.
We have proposed remedies including apologies and financial compensation and action to improve matters for future service users. We are satisfied that these proposals will be a satisfactory resolution of the complaint. The Trust and the Council have agreed to our recommendations.
We hope this report will provide Ms A with the explanations she seeks. We can reassure her that lessons will be learnt and the learning shared as a result of her complaint so that others are now less likely to suffer the same experiences. We also hope that this report will draw what has been a long and complex complaints process to a close.
Ann Abraham
Health Service Ombudsman
Anne Seex
Local Government Ombudsman
