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These are the reports of two cases which we have jointly investigated, both of which involve the provision of services by a local council and by NHS trusts – and both, to some extent, concern the actions of staff working in mental health services.
The first complaint, made by Ms I, was that in the period shortly before his death, and while he was living in sheltered accommodation managed by Enfield Council, her brother became ill and, because of failings by the Council’s staff and by staff employed by Barnet, Enfield and Haringey Mental Health Trust and by Barnet and Chase Farm Hospitals NHS Trust, he died. Having considered all the relevant available evidence, and the views of professional advisers about treatment by Accident and Emergency staff, and by Mr I’s Consultant Psychiatrist, we did not conclude that there had been service failure on the part of the two NHS bodies. We found that Council staff had not adhered to their own processes in connection with sheltered housing residents becoming ill, and had not notified Mr I’s family about his illness. To that extent we concluded that there had been maladministration on the part of the Council. However, since we could not conclude that that maladministration led to the injustice which Ms I had claimed (Mr I’s subsequent death) we did not uphold the complaint.
The second complaint, made by Mr S, was about the care and treatment of his late wife, who had dementia. He complained that Havering Council had failed to provide sufficient support for his wife prior to her compulsory admission to hospital under the Mental Health Act which, he claimed, had been inappropriately arranged by a social worker employed by the Council. He also complained about the way the Council had handled his subsequent complaint about these matters. Finally, he complained about the care provided to Mrs S when she was in the hospital, which was managed by the North East London Mental Health Trust (now known as the North East London NHS Foundation Trust). Although we had some concerns about the handling of Mr S’s complaint by the Council, these were not so serious in our view as to amount to maladministration; neither did we find that there had been maladministration by the Council in the substantive aspects of Mr S’s complaint. We did not therefore uphold any part of the complaint against the Council. As for Mrs S’s care in hospital, where she had a fall subsequently necessitating the surgery elsewhere, and following which she died, we had concerns about the assessment of her risk of falling by the Trust staff; there was also a failure to keep Mr S properly informed. Having taken account of the relevant evidence and after taking advice from both Nursing and Medical Advisers, we concluded that these failings did amount to service failure and that they led to injustice: Mrs S’s need for surgery might have been prevented had a risk assessment taken place and safeguarding measures been in place; and Mr S was caused distress about the level of care which his wife received. We therefore partly upheld the complaint against the Trust.
1 The identities of the complainants and their families have been anonymised in the report.
