Mark Cannon
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Summary report of a joint investigation by the Health Service Ombudsman and the Local Government Ombudsman of a complaint made by Mencap on behalf of Mr Allan Cannon and Mrs Anne Handley in relation to their late son, Mr Mark Cannon.
Complainants:
Mr Allan Cannon and Mrs Anne Handley
Aggrieved:
Mr Mark Cannon (late son of Mr Allan Cannon and Mrs Anne Handley)
Representative:
Mencap
Complaint against:
London Borough of Havering (the Council)
Barking, Havering and Redbridge Hospitals
NHS Trust (the Trust)
The New Medical Centre, Romford (the Practice)
Healthcare Commission
Introduction
Background
The complaint
What should have happened
How the Ombudsmen investigated
What the Ombudsmen found and concluded
The Ombudsmen's recommendations
The complainant's response
Introduction
This complaint was investigated jointly by the Local Government Ombudsman for England and the Health Service Ombudsman for England in accordance with the powers conferred by amendments to their legislation due to The Regulatory Reform (Collaboration etc. between Ombudsmen) Order 2007. With the consent of the complainants, Mr Allan Cannon and Mrs Anne Handley, the two Ombudsmen agreed to work together because the health and social care issues were so closely linked. A co-ordinated response, consisting of a joint investigation leading to a joint conclusion and proposed remedy in one report, seemed the most appropriate way forward.
Background
Mr Cannon was a 30 year old man with severe learning disabilities. He also suffered from epilepsy. He had very little speech but was able to communicate with his family and he was particularly close to his sister. He was able to walk unaided but often needed support when he was feeling unsteady on his feet. Mr Cannon was smiling and ‘mischievous’ with a fine sense of humour. He enjoyed participating in activities, social events and outings with his family and carers, but he also liked lazing around and relaxing in an easy chair or bean bag. Mr Cannon lived at home with his mother, stepfather and sister. He attended a day centre five days a week with occasional stays at the Grange (the Care Home) owned by the Council.
In June 2003 Mr Cannon was at the Care Home and he broke his thigh bone, in circumstances which remain unclear. He was admitted to the Trust, the broken bone was repaired and he was discharged to his mother’s home. However, four days later his GP arranged for him to be readmitted to the Trust because he was in pain and it was difficult to persuade him to eat or drink. After about a week, Mr Cannon was discharged again.
In early August 2003 Mr Cannon’s GP made a home visit, diagnosed an infection and prescribed antibiotics. Despite this treatment, Mr Cannon’s condition deteriorated and a few days later he was taken to the Accident and Emergency Department (A&E) at the Trust. He was admitted to a medical admission ward but he deteriorated further and was transferred to the Intensive Therapy Unit (the ITU). A couple of days later his condition had stabilised and he was transferred to the High Dependency Unit (the HDU). However, Mr Cannon collapsed, suffered a cardiac arrest and returned to the ITU. Around a fortnight later, almost three weeks after he had been admitted as an emergency, Mr Cannon’s family agreed with doctors that there was no hope of recovery and Mr Cannon died.
The Coroner found that Mr Cannon’s broken leg was caused by a fall and that his death was as a result of bronchopneumonia. He recorded a verdict of accidental death.
The complaint
Mr Cannon’s parents complained that their son should not have died. They said that if staff at the Care Home, the Trust and the Practice had acted differently, he would have survived. They believed their son had been treated less favourably for reasons related to his learning disabilities.
Mr Cannon’s parents were also dissatisfied with the way their complaint against the NHS had been handled by the Trust and the Healthcare Commission, and with the way the circumstances of Mr Cannon’s injury had been investigated by the Council. They felt the NHS and Council complaints processes had failed them, and they asked for answers to their questions about the service provided for their son.
What should have happened
The staff who looked after Mr Cannon should have been mindful of the overall standard governing their work. This standard is made up of two components: the general standard which is derived from general principles of good administration and, where applicable, public law; and the specific standard which is derived from the legal, policy and administrative framework, and the professional standards relevant to the events in question.
In Mr Cannon’s case, legislation and policy about disability and human rights, in particular the Disability Discrimination Act 1995, the Human Rights Act 1998, Valuing People: A New Strategy for Learning Disability for the 21st Century (2001) and Once a Day: A Primary Care Handbook for people with learning disabilities (1999) were especially relevant to the overall standard.
Mr Cannon’s care should have been organised within the legal and policy framework for integrated health and social care as set out in key documents including the National Health Service and Community Care Act 1990, the National Assistance Act 1948 and the Care Standards Act 2000.
In terms of professional standards, the doctors and nurses should have followed the standards set out by their regulatory bodies. Mr Cannon’s care and treatment at the Trust should have met national and professional standards regarding nursing care and discharge arrangements.
The responses to Mr Cannon’s parents’ complaint about the Trust should have followed the procedures set out in the Directions (1996 and subsequent amendments) produced by the Secretary of State for Health, and the Healthcare Commission should have reviewed that complaint in line with the National Health Service (Complaints) Regulations 2004. The complaint about the Council should have been handled in line with the Complaints Procedure Directions 1990.
How the Ombudsmen investigated
The investigator met Mr Cannon’s parents to gain a full understanding of their complaint. It was important to carefully consider their recollections and views. Evidence about what happened to Mr Cannon and how his parents’ complaints about NHS and Council services were handled was considered. Enquiries were also made of the Coroner who conducted the inquest into Mr Cannon’s death. All the bodies complained about provided additional information in response to specific enquiries.
Several professional advisers provided expert clinical advice to the Ombudsmen. They were: an A&E nurse; a community nurse; an orthopaedic nurse; a learning disability nurse; an A&E consultant; an ICU consultant; an orthopaedic consultant; and a GP.
Mr Cannon’s parents, their representative and the bodies complained about had the opportunity to comment on the draft report, and their comments were carefully considered before the final report was issued.
What the Ombudsmen found and concluded
The Local Government Ombudsman’s investigation of the complaint against the Council
Mr Cannon broke his leg when he was in respite care at the Care Home. His parents complained that their son was provided with inadequate care by the Council and this led to his injury and death. They said the Council failed to keep their son safe as a result of poor planning, poor supervision, weak management and inadequate staffing. They also said the Council repeatedly failed to properly investigate the circumstances of Mr Cannon’s injury or take responsibility for the part their failings played in his injury and subsequent death.
The Local Government Ombudsman concluded that the Council failed to provide and/or secure an acceptable standard of care for Mr Cannon and, as a result, his safety was put at risk. That failure constitutes maladministration.
The Local Government Ombudsman also concluded that there was maladministration in the way the Council investigated Mr Cannon’s parents’ complaint. He found complaint handling during the early stages of the complaints process was extremely confusing, the complaints were poorly considered, responses were unsympathetic and the whole process was unreasonably delayed.
Therefore, the Local Government Ombudsman upheld the complaint against the Council.
The Health Service Ombudsman’s investigation of the complaint against the Trust
Mr Cannon was admitted to the Trust three times between June and August 2003. During the first admission he underwent surgery to repair his broken leg. Subsequent admissions were because his condition deteriorated while he was at home.
Mr Cannon’s parents complained that on each occasion that Mr Cannon was admitted the Trust failed to provide him with adequate care and treatment or to plan and put in place proper arrangements for his discharge. They were happy with his care in the ITU but they said failings elsewhere at the Trust led to a decline in his condition and his death. They were also dissatisfied with the way their complaint was handled.
The Health Service Ombudsman found failings in key aspects of the care and treatment provided for Mr Cannon.
- Management of Mr Cannon’s pain was inadequate. His urgent need for pain relief was not met and assessment and planning for ongoing pain management was not of a reasonable standard. This failure meant Mr Cannon was left in severe pain and great distress for prolonged periods of time.
- Assessment, observation, monitoring and recording of Mr Cannon’s condition was inadequate particularly during his three admissions to A&E, during the days immediately following his operation and when he was admitted to a ward on his third admission.
- Management of Mr Cannon’s epilepsy was inadequate because his seizures and medication levels were not properly monitored and his medication was not always given as prescribed. This failure may have increased the frequency of Mr Cannon’s seizures and increased his agitation.
- On two occasions discharge arrangements did not meet the standards set out in national guidelines. Mr Cannon was discharged without due concern for his safety and community healthcare providers were not fully aware of his condition or the level of support he would need. Staff did not properly consider his needs and his mother was left to care for him and arrange help as best she could.
- On one occasion junior doctors made a decision that Mr Cannon should not be resuscitated if he collapsed. Their decision was not appropriate and did not conform with legal and professional guidance.
The Health Service Ombudsman found shortcomings in the way in which the Trust handled Mr Cannon’s parents’ complaint. For instance, the Trust failed to properly investigate the complaint and failed to take opportunities to offer full explanations and appropriate apologies.
The Health Service Ombudsman concluded there was service failure in the care and treatment provided for Mr Cannon by the Trust and that this was at least in part for disability related reasons. She also found maladministration in the way the Trust handled his parents’ complaint.
The Trust told the Health Service Ombudsman about actions it had taken subsequently to address the failures in the service provided for Mr Cannon.
The Health Service Ombudsman concluded that, had the Trust provided appropriate and reasonable care and treatment, according to prevailing standards and guidance, it is likely Mr Cannon’s suffering would have been less and it is possible that he would have survived. Furthermore, his family would have suffered less anxiety and distress. These findings represented unremedied injustice.
Therefore, the Health Service Ombudsman upheld the complaint against the Trust.
The Health Service Ombudsman’s investigation of the complaint against the Practice
Mr Cannon’s parents had not previously complained about the Practice, but to ensure they had a full picture of their son’s care and treatment during the final months of his life, the Health Service Ombudsman used her discretion to investigate their complaint.
Mr Cannon’s parents complained that the Practice failed to provide their son with adequate care and that more could have been done to diagnose his illness following his discharge from hospital. In particular, Mr Cannon’s parents believed that a GP who examined their son only a few days before he was readmitted had not acted properly and should have done more to help him.
The Health Service Ombudsman did find some shortcomings in the actions of the GP who visited Mr Cannon prior to his final admission to hospital. However, she decided that these shortcomings did not amount to service failure.
Therefore, the Health Service Ombudsman did not uphold the complaint against the Practice.
The Health Service Ombudsman’s investigation of the complaint against the Healthcare Commission
Mr Cannon’s parents were dissatisfied with the way their complaint was handled by the Healthcare Commission.
The Health Service Ombudsman found maladministration in the way the Healthcare Commission reviewed Mr Cannon’s parents’ complaint against the Trust because it was not based on appropriate or adequate clinical advice. This meant its decision was unreliable and unsafe. Furthermore, the Healthcare Commission’s review did not cover key aspects of Mr Cannon’s parents’ complaint and the report of the review contained significant factual inaccuracies. The Health Service Ombudsman concluded the Healthcare Commission’s response was superficial, incomplete and not evidence-based. Mr Cannon’s parents were denied a proper independent review of their complaint against the Trust and this caused them unnecessary uncertainty and distress.
Therefore, the Health Service Ombudsman upheld the complaint against the Healthcare Commission.
Was Mr Cannon treated less favourably for reasons related to his learning disabilities?
The Health Service Ombudsman concluded that failures in the care and treatment provided for Mr Cannon by the Trust were in part for reasons related to his learning disabilities. Staff did not make reasonable adjustments to the way in which they organised and delivered care to meet his complex needs. She concluded that in some significant respects the service failures at the Trust were for disability related reasons.
The Local Government Ombudsman concluded that some of the failures by the Council represented failure to make reasonable adjustments to meet Mr Cannon’s needs, and resulted in him being treated less favourably for reasons related to his learning disabilities.
The Ombudsmen concluded that there was no evidence of any positive intention to humiliate or debase Mr Cannon. Nevertheless, by omitting to provide and/or secure proper care for Mr Cannon, public services failed to have due regard to his dignity and status as a person, and the need to observe the principle of equality.
Was Mr Cannon’s death avoidable?
The Ombudsmen considered Mr Cannon’s death could not be attributed to one specific incident or action. That said, they concluded that the Council and the Trust had failed Mr Cannon. The injury suffered by Mr Cannon might well have been avoided. In any event he should not have died as a consequence of that injury. On that basis, the Ombudsmen found that Mr Cannon’s death arose in consequence of service failure and maladministration they identified. Therefore, they concluded his death was avoidable.
The Ombudsmen’s recommendations
The Ombudsmen recommended that Mr Cannon’s parents should receive apologies and compensation totalling £40,000 from the bodies against which complaints were upheld. The compensation was in recognition of the injustice suffered in consequence of service failure and maladministration identified.
In response to these recommendations the Trust acknowledged its failings and apologised to Mr Cannon’s parents. It also agreed to pay its share of the compensation recommended. The Healthcare Commission agreed to apologise to Mr Cannon’s parents. The Council did not accept the recommendations.
The complainant’s response
Mr Cannon’s parents welcomed the Ombudsmen’s report, saying it was ‘tough and hard hitting’. Nevertheless, they were particularly disappointed that the Health Service Ombudsman did not uphold their complaint against the Practice because they believed their son did not receive a reasonable standard of care from the GPs there. Mr Cannon’s father, although welcoming the Health Service Ombudsman’s findings regarding the Trust, expressed continuing concerns about specific aspects of the care and treatment it provided for his son.
