Investigation into a complaint made by Ms I about: Barnet and Chase Farm Hospitals NHS Trust, Barnet, Enfield and Haringey Mental Health NHS Trust and Enfield Council

Section 1: Introduction

Ms I’s complaints span the remits of the Health Service Ombudsman and the Local Government Ombudsman. Using provisions in their respective statutes, both Ombudsmen agreed that a joint investigation leading to the production of joint conclusions in one report seemed most appropriate. Ms I agreed to this approach.

The complaints

Ms I has complained about care and treatment provided to her late brother, Mr I. Mr I lived in sheltered housing and had schizophrenia which was treated with medication. On 11 December 2006, some time after the medication had been changed by his consultant psychiatrist (who was employed by Barnet, Enfield and Haringey Mental Health NHS Trust – the Mental Health Trust), an ambulance was called for Mr I as he was experiencing back pain and shortness of breath. The ambulance took him to the Accident and Emergency Department (A&E) of Chase Farm Hospital, part of Barnet and Chase Farm Hospitals NHS Trust (the Hospital Trust). The staff from his sheltered housing complex did not accompany him. He was examined and then discharged home where sadly, on 15 December 2006, he died. Mr I died of a pulmonary embolus and deep vein thrombosis.(2)

Ms I has said that failings in the care and treatment her brother received at A&E, the changes to his psychiatric medication and a lack of support from staff at the sheltered housing all contributed to his death. She also complained that she was not told about her brother’s admission to A&E until after his death and that staff from the sheltered housing should have informed her about what was happening to her brother; Ms I says that if she had known that her brother was unwell she could have intervened to help – especially as the nature of his schizophrenia meant that he would have had difficulties communicating his needs.

Ms I wanted to know what happened to her brother and to find out if the family’s belief – that failures by Enfield Council’s (the Council’s) sheltered housing staff and the actions of the Hospital Trust and the Mental Health Trust contributed to his death – were correct. She complained to the Mental Health Trust, the Hospital Trust and the Council but was dissatisfied with their responses.

She then complained to the Healthcare Commission, who did not uphold her complaint that Mr I should have been admitted to hospital from A&E.

Ms I has said that she found the complaints process difficult to follow and unsatisfactory in explaining what had happened to her brother.

The Ombudsmen’s remit, jurisdiction and powers

General remit of the Health Service Ombudsman

By virtue of the Health Service Commissioners Act 1993, the Health Service Ombudsman is empowered to investigate complaints about the NHS in England. In the exercise of her wide discretion she may investigate complaints about NHS bodies such as trusts, family health service providers such as GPs, and independent persons (individuals or bodies) providing a service on behalf of the NHS.

When considering complaints about an NHS body, she may look at whether a complainant has suffered injustice or hardship in consequence of a failure in a service provided by the body, a failure by the body to provide a service it was empowered to provide, or maladministration in respect of any other action by or on behalf of the body.

Failure or maladministration may arise from action of the body itself, a person employed by or acting on behalf of the body, or a person to whom the body has delegated any functions.

The Health Service Ombudsman may carry out an investigation in any manner which, to her, seems appropriate in the circumstances of the case and in particular may make such enquiries and obtain such information from such persons as she thinks fit.

If the Health Service Ombudsman finds that service failure or maladministration has resulted in an injustice, she will uphold the complaint. If the resulting injustice is unremedied, she may recommend redress to remedy any injustice she has found.

Health Service Ombudsman – premature complaints

Section 4(5) of the Health Service Commissioners Act 1993 states that the Health Service Ombudsman may not generally investigate any complaint until the NHS complaints procedure has been exhausted. However, section 4(5) makes it clear that if, in the particular circumstances of any case, the Ombudsman considers it is not reasonable to expect the complainant to have followed the NHS complaints procedure, she may accept the case for investigation. This is a matter for the Ombudsman’s discretion after consideration of the facts of the case.

Here, the Health Service Ombudsman noted that Ms I had experienced considerable difficulties in trying to follow the complaints process for each of her complaints; and also that, as the complaints were all interrelated, in order to provide a seamless response that would fully address them, a joint investigation with the Local Government Ombudsman would be appropriate.

General remit of the Local Government Ombudsman

Under the Local Government Act 1974 Part III, the Local Government Ombudsman has wide discretion to investigate complaints of injustice arising from maladministration by local authorities (local councils) and certain other public bodies. He may investigate complaints about most council matters, including Social Services and the provision of social care.

If the Local Government Ombudsman finds that maladministration has resulted in an unremedied injustice, he will uphold the complaint and may recommend redress to remedy any injustice he has found.

Local Government Ombudsman – premature complaints

By section 26(5)(a) of the Local Government Act 1974 (as amended), the Local Government Ombudsman may not generally entertain a complaint unless satisfied that it has been brought to the notice of the council concerned and that the council has had a reasonable opportunity to investigate the complaint and reply to the complainant.

However, section 26(5)(b) makes it clear that if, in the particular circumstances of any case, it is not reasonable to expect the complainant to take the complaint to the council, the Local Government Ombudsman may accept the case for investigation.

In this instance (where Ms I’s complaint had been treated as an enquiry by the Council) the Local Government Ombudsman exercised that discretion and accepted the case for investigation, in order to carry out the investigation jointly with the Health Service Ombudsman.

Powers to investigate and report jointly

The Regulatory Reform (Collaboration etc. between Ombudsmen) Order 2007 clarified the powers of both the Health Service Ombudsman and the Local Government Ombudsman, with the consent of the complainant, to share information, carry out joint investigations and produce joint reports in respect of complaints which fall within the remit of both Ombudsmen. In this case, the Health Service Ombudsman and the Local Government Ombudsman agreed to work together because the health and social care issues were so closely linked.

This investigation

During this investigation we have considered comments and papers provided by the Hospital Trust and the Mental Health Trust, including their complaints files and copies of Mr I’s medical records, and policies on the prescribing of medication. (The papers did not include a prescription or administration record for Mr I’s psychiatric medications which would have provided detailed evidence of the dosages and frequency of administration of the medications.) However, the Council provided copies of papers relating to the day‑to‑day care of Mr I, copies of assessments and copies of its policies and procedures. We have also considered comments provided by Ms I and her son.

We obtained specialist advice from two professional advisers: Dr T Malpass FRCP DCH, a consultant in emergency medicine (the A&E Adviser), and Dr N J R Evans MA BM Bch FRCPsych, a consultant psychiatrist (the Psychiatric Adviser). The Professional Advisers are specialists in their field and in their roles as our advisers they are completely independent of any NHS body. The draft report was shared with Ms I, the Hospital Trust, the Mental Health Trust and the Council. Their comments on the provisional findings were considered.

In this report we have not referred to all the information examined in the course of the investigation, but we are satisfied that nothing significant to the complaint or our findings has been overlooked.

Summary of our decisions

Having considered all the available evidence related to Ms I’s complaint, including her recollections and views, her comments on the draft report and the comments of the bodies under investigation, and having taken account of the clinical advice we have received, we have reached the following decisions.

The Health Service Ombudsman does not uphold Ms I’s complaints about the Mental Health Trust or the Hospital Trust.

The Local Government Ombudsman finds that there was maladministration by the Council but that it did not result in injustice in this instance.

In simple terms, when determining complaints that injustice or hardship has been sustained in consequence of service failure and/or maladministration, we generally begin by comparing what actually happened with what should have happened.

Section 2: The basis for our determination of this complaint

So, in addition to establishing the facts that are relevant to the complaint, we also need to establish a clear understanding of the standards, both of general application and which are specific to the circumstances of the case, which applied at the time the events complained about occurred, and which governed the exercise of the administrative and clinical functions of those bodies and individuals whose actions are the subject of the complaint. We call this establishing the overall standard.

The overall standard has two components: the general standard which is derived from general principles of good administration and, where applicable, of public law; and the specific standards which are derived from the legal, policy and administrative framework and the professional standards relevant to the events in question.

Having established the overall standard we then assess the facts in accordance with the standard. Specifically, we assess whether or not an act or omission on the part of the body or individual complained about constitutes a departure from the applicable standard.

If so, we then assess whether, in all the circumstances, that act or omission falls so far short of the applicable standard as to constitute service failure or maladministration.

The overall standard which we have applied to this investigation is set out below.

The general standard

In February 2009 the Health Service Ombudsman republished three sets of principles outlining the approach public bodies should adopt in order to deliver good administration and how to respond when things go wrong. The Ombudsman’s Principles comprises of: the Principles of Good Administration, Principles for Remedy and Principles of Good Complaint Handling.

The same six key Principles apply to each:

• Getting it right
• Being customer focused
• Being open and accountable
• Acting fairly and proportionately
• Putting things right, and
• Seeking continuous improvement.

We have taken these Principles into account in our consideration of Ms I’s complaint.(3)

Specific standards

National guidance and good practice

British National Formulary

The British National Formulary (BNF) reflects current best practice as well as legal and professional guidelines relating to the use of medicines. It details all medicines that are generally prescribed in the UK, with special reference to their uses, cautions, contraindications, side‑effects, dosage and relative costs. It is intended for use by prescribers in the NHS as well as by pharmacists, nurses and other healthcare professionals and is compiled with the advice of clinical experts. It is an essential reference providing up‑to‑date guidance on prescribing, dispensing and administering medicines.

Modecate is listed in the BNF as an antipsychotic medication; the recommended dose range falls between 12.5mg and 100mg to be given at intervals of 14 to 35 days. Artane is an anticholinergic drug commonly prescribed in dosages of 5mg, 2 or 3 times daily. The BNF advises against abrupt withdrawal of anticholinergic drugs.

The British Thoracic Society guidelines

These guidelines(4) set out the practical approach to the management of suspected pulmonary embolus. Of significance to this complaint the guidelines say that a negative D‑dimer test (a type of blood test) reliably excludes the possibility of pulmonary embolus in patients with a low or intermediate pre‑test probability.

Local guidance

Relevant extracts from Enfield Council’s Sheltered Housing Manual

Section 4 (8): Hospital Admission Forms (Home blocks only)

‘The forms should be completed when the tenant moves in, checked and regularly updated. The forms should be kept in the Blue Bag in the office.

‘These forms should be sent with the tenant if they have to go to hospital, ensuring the hospital has the full information on the tenant.

‘In extra care schemes, carers also have copies of the hospital forms.’

Section 4 (10): Tenant Risk Assessments

‘Needs and Risk Assessments are carried out for all Sheltered Housing tenants. The assessments are carried out using the following guidelines … 6. If a critical incident occurs the Risk Assessment must be revised within 24 hours, if a tenant is experiencing a general decline in health.’

Section 4 (14): Outside Agencies

Part 5: ‘Relatives – contacted for issues relating the following areas. Any relevant change in circumstances, for example well being of tenant. All contact must be recorded.’

In‑house Home Care Service Staff Handbook (Enfield Council, January 2005)

This handbook provided guidance to extra care staff who assisted tenants in their own homes. Section 2.2 of the handbook stated that staff were ‘to encourage and assist service users [tenants] to achieve an optimum level of independence’ and section 3.2, entitled Autonomy and Independence, said that ‘service users must be enabled to make decisions in relation to their own lives, providing information, assistance and support where needed’.

Section 3: The investigation

Background and key events

Mr I was under the care of his local mental health team, where he was seen regularly by his Community Psychiatric Nurse (CPN) and reviewed by his Consultant Psychiatrist. Mr I was prescribed medication to treat schizophrenia in the form of long‑acting injections of an antipsychotic (depot Modecate) and a daily anticholinergic tablet (Artane) to relieve side‑effects of the antipsychotic.

As part of Mr I’s care and treatment, he received support with activities of daily living via sheltered housing. The sheltered housing complex provided a service to older adults which had two components: ‘housing’ (matters connected with tenancy and maintaining tenancy); and ‘extra care’ (care staff to assist tenants with activities of daily living). Mr I received both types of service and required assistance with daily living activities. Staff were available on site during the day and a member of staff slept on site at night and was available to tenants in an emergency. Tenants also had access to the Enfield Community Alarm, a system for triggering an alarm to seek emergency support via a call centre.

Mr I’s CPN wrote a letter to his GP which was received on 26 January 2006. The CPN said that Mr I’s mood tended to deteriorate a week before his depot was due and asked whether his medication could be reviewed, suggesting that the time interval between each depot be reduced from four to three weeks.

On 28 March 2006 a review meeting was held at the sheltered housing complex, attended by Mr I’s CPN, his Consultant Psychiatrist, staff from the sheltered housing complex, Ms I and another of Mr I’s sisters.

On 8 April 2006 the Consultant Psychiatrist wrote to Mr I’s GP with details of the review meeting. She explained that Mr I was generally settled but had some difficulties sleeping. She suggested a new management plan: to stop Artane and start Zopiclone (a sleeping tablet) and to continue his depot medication at 25mg every three weeks. She also said that she would arrange for Mr I’s care to be transferred to another mental health team, as the sheltered housing was not in her catchment area.

GP records indicate that a prescription for Zopiclone was first issued for Mr I on 1 June 2006 and that the last prescription for Artane was issued on 2 August 2006.

Mr I’s care was transferred to another community mental health team within the same Trust. His new consultant psychiatrist wrote to the GP on 11 September 2006 saying that he had been doing extremely well and that he remained stable on his depot injections, which should continue.

In the early morning of 11 December 2006 Mr I was experiencing back pain that was affecting his breathing. He was with a carer from the sheltered housing complex when the emergency alarm was pulled at 3.27am; an operator from Enfield Community Alarm called an ambulance and Mr I was taken to Chase Farm Hospital’s A&E department.

Mr I was seen by a triage nurse at 4.10am who took details of his condition and prioritised his care. He then underwent a series of tests including temperature, pulse, respirations and oxygen saturation and his urine was also tested. He was given oxygen and sent to have a chest X‑ray.

At 7.00am Mr I was admitted to the Observation Ward where further tests and examinations were carried out. These included taking a medical history and repeat tests of those noted in the previous paragraph. Additionally, an examination of the cardiovascular system was also carried out which included a D‑dimer test.(5) Other examinations of the respiratory and neurological systems and the lower limbs were carried out.

The examinations carried out in A&E and the Observation Ward did not show that Mr I had a pulmonary embolism or deep vein thrombosis – the D‑dimer test returned negative. It was considered that Mr I was suffering with back pain and worsening of his shortness of breath caused by chronic obstructive pulmonary disease (COPD).(6) He was discharged home with painkillers and a letter to his GP requesting a lung function test.

Mr I returned to the sheltered housing complex; he had some painkillers and a carer took the letter to the GP Practice.

On Tuesday 12 December 2006 carers reported that Mr I was still experiencing back pain. He was asked whether he would like to see his GP but declined saying that he would carry on taking his painkillers. The carer negotiated with Mr I that if he was no better by the Thursday then they would see the GP.

On 14 December 2006 Mr I was still in pain and he agreed to see his GP. The GP carried out a home visit and prescribed more painkillers and lactulose (a laxative). Mr I was advised to stop taking Paracetamol and Zopiclone for a few days and if he was still no better, to call the GP again.

On 15 December 2006 at approximately 2.30pm carers documented that Mr I was sitting on his bed resting and that he spoke to them. The carers documented that they returned to the flat at 3.30pm but did not see Mr I. At 4.00pm the carers went back to the flat where they discovered that Mr I had died.

Ms I’s complaint about the Mental Health Trust

Ms I complained that:

• Mr I’s long‑acting antipsychotic medication (depot Modecate) was administered at incorrect time intervals; and
• Mr I’s anticholinergic medication (Artane) to control the side‑effects of his depot (Modecate) was abruptly stopped and that without it, her brother would shake, his speech would be slurred and he would have a ‘panic attack’.

Ms I believed that these factors affected her brother’s health and contributed to his death.

The Mental Health Trust’s comments

We offered the Mental Health Trust the opportunity to comment on Ms I’s complaint at the outset of the investigation. We also shared the draft report with the Mental Health Trust to provide them with an opportunity to comment on the provisional findings of our investigation.

The Mental Health Trust provided comments from the Consultant Psychiatrist who said that she recalled that she had discussed the medication changes with Mr I and his two sisters and that they had all been in agreement with the changes at the time. She also said that prescribing practice had changed since Mr I had first been diagnosed, and that she had stopped Artane as it was not indicated in elderly patients and should only be used in cases of severe extra‑pyramidal side‑effects (EPSE).(7)

The Mental Health Trust also said that they had offered to meet Ms I after she complained but that she had not taken up this offer, and that this was unfortunate as they might have been able to allay her concerns.

The Mental Health Trust were unable to tell us who was responsible for prescribing or administering Mr I’s depot medication; the Mental Health Trust said that they thought that Mr I’s GP had been responsible for administering the depot. They could not locate any prescriptions or evidence of administration of the depot. (Mr I’s GP provided us with records of all medication that had been prescribed by the GP Practice in the twelve months prior to his death. The GP informed us that the Mental Health Trust had been responsible for the prescription and administration of the depot and therefore her records did not contain any information about this.)

The advice of our Psychiatric Adviser

Our Psychiatric Adviser has studied the medical records provided by the Mental Health Trust. He commented that they show that, overall, the care and treatment given to Mr I by the Mental Health Trust seemed appropriate and reasonable. Our Adviser added that Mr I was looked after by community psychiatric nurses and consultant psychiatrists in a standard scheme of care and that his transfers between services, such as from adult to geriatric, and from one catchment area to another, were smoothly managed.

On the issue of medication our Psychiatric Adviser has said that the mainstays of psychiatric treatment are antipsychotic drugs, often continued through life, but that this did not imply that the dose would remain fixed. The psychiatric medication that Mr I was taking was within a range that was reasonable for his condition and age (according to BNF guidance, paragraphs 35 and 36).

Our Psychiatric Adviser reviewed out‑patient letters from 1984 onwards, and noted that Mr I normally and sensibly self‑medicated his Artane: meaning that he took the medication as and when he experienced the side‑effects that it was prescribed to counteract. The Adviser noted that Mr I had been taking a relatively low dose – 5mg daily. He could not find any evidence that Mr I was experiencing side‑effects that required Artane in the months leading up to his death and so considers that it was appropriate and correct to stop the medication. He said that it is safe to stop this medication immediately, and that he would not have expected there to be any relevant physical consequences to this other than that which was desired – improved sleep – where the dosage was low. He also noted that Mr I had been accustomed to adjusting his own dose, including stopping it altogether, in the past.

Turning to the complaint about the time interval between the depot medication, as explained in paragraph 62, neither the GP nor the Mental Health Trust were able to provide prescription or administration records and therefore our Psychiatric Adviser was unable from these sources to establish the dose and interval between depots at the time of Mr I’s death. However, documents provided by the Council show that Mr I’s CPN visited him to administer his depot and our Adviser has also seen out‑patient records where dose and frequency of medications are detailed. These records suggest that the dose and time interval between Mr I’s depot medication were altered on occasions according to psychiatric signs and symptoms. So, for example, in 1984 when his mental state was considered to have deteriorated the records state that he was given 25mg of Modecate every three weeks and that he remained on this dose. However, as his mental state improved and he was considered to be ‘consistently stable’ in July 2004, this was reduced to 12.5mg every four weeks. Again in January 2006, when his CPN noted that Mr I’s mood deteriorated in the week before the depot was due, it was increased to 12.5mg every three weeks.

Our Psychiatric Adviser has said that with any medication, doctors should not continue with something that is no longer required or with a larger dose than is necessary and that all doctors should be vigilant for opportunities to stop or reduce medications. On the basis of Mr I’s medical records and the other evidence obtained in this investigation, our Adviser considered that the prescribing practice was reasonable and fell within the appropriate dose range as outlined in the BNF (paragraphs 35 and 36).

The Health Service Ombudsman’s findings in relation to the Mental Health Trust

Having considered the available evidence and after taking account of the advice provided by the Psychiatric Adviser, I am satisfied that the changes to Mr I’s medication were reasonable. The adjustments to his medication (including the most recent one) were appropriately considered and there is no evidence to connect the changes in his medication, or other aspects of his psychiatric care, with his sudden death. Therefore, I find that there was no service failure in this regard.

Ms I’s complaint about the Hospital Trust

Ms I complained that:

• Mr I was not able to communicate his health problems effectively due to his chronic schizophrenia and therefore staff at the A&E department should not have relied upon his statements; and
• had Mr I been admitted to hospital then he might not have died.

The Hospital Trust’s comments

We offered the Hospital Trust the opportunity to comment on Ms I’s complaint at the outset of this investigation. We also shared the draft report with the Hospital Trust to provide them with an opportunity to comment on the provisional findings of our investigation. The Hospital Trust did not provide any comments, but produced all the evidence and papers requested. These included copies of medical records and papers relating to the attempted local resolution of Ms I’s complaint.

The advice of our Accident and Emergency Adviser

The A&E Adviser has studied the medical records provided by the Hospital Trust and the complaint file which accompanied it. She has advised that the documented history taken from Mr I and the examinations and investigations that were carried out on him were ‘impressively thorough’.

The A&E Adviser has commented that staff working in A&E departments are usually trained to deal with patients who may not be able to give a clear history and that, as the sheltered housing staff had not accompanied Mr I to hospital, this probably would have been taken as an indication of his ability to cope independently. She noted that a detailed history was taken and staff would have had no particular reason to doubt the accuracy of what Mr I had said to them.

The A&E Adviser has commented that it is clear that A&E staff were aware that Mr I was taking Paracetamol and Zopiclone; however, there is no reference in the medical records to his psychiatric medication. She said that the psychiatric medications were unrelated to and would not have been influenced by his presenting complaint (breathlessness and back pain).

The A&E Adviser has also clarified the basis of Mr I’s admission to the Observation Ward; this was not a general ward but an acute assessment ward designed for admission of patients whilst initial investigation and assessments are made. The Adviser said that Mr I was seen by an orthopaedic team for his back pain; they could find no serious cause for his pain and considered that he could be discharged. He was also seen by the physicians and a physiotherapist who, in addition to the tests carried out (which included a negative D‑dimer test), also considered Mr I’s suitability for out‑patient management. The A&E Adviser noted that this represented a thorough and efficient clinical care pathway in line with British Thoracic Society guidelines and that Mr I’s clinical management at A&E was reasonable. The A&E Adviser said that it was reasonable for Mr I to be discharged from the Observation Ward, based on the results of the examinations and investigations, at that time.

The Health Service Ombudsman’s findings in relation to the Hospital Trust

Having taken into consideration the A&E Adviser’s comments, I conclude that the care and treatment that Mr I received at the A&E department was reasonable. Staff at A&E were able to take a full and appropriate medical history from Mr I, which demonstrates that he was able to communicate effectively to them. Appropriate tests and examinations were carried out, including a negative result of a D‑dimer test, which ruled out pulmonary embolus/deep vein thrombosis at the time. On that basis, it was considered that Mr I could be discharged to the care of his GP and his symptoms managed as an out‑patient, and there was no need to keep him in hospital any longer. I am satisfied that the care and treatment provided to Mr I did not fall below a reasonable standard. I therefore find no service failure in this regard.

Ms I’s complaint about the Council

Ms I complains that:

• the staff at the sheltered housing scheme should have accompanied her brother to attend A&E; and
• the staff at the sheltered housing scheme should have informed Mr I’s family that Mr I had been taken to A&E in an ambulance.

Ms I told our Investigator that she visited her brother at the sheltered housing scheme every week and that the staff there would telephone her and her husband ‘all the time for silly little things’; yet, she complained, although her brother had been unwell and taken to A&E by ambulance, the staff did not inform her of this important news until after his death. Ms I said that had she known about his ill health, she and her husband would have taken Mr I to A&E and helped him to explain his difficulties.

The Council’s response to our enquiries

We wrote to the Council to offer it the opportunity to comment on Ms I’s complaint at the outset of the investigation. The Council provided all the evidence and papers requested. We noted that the sheltered housing service aimed to secure the independence and autonomy of individuals in its care. We also noted the Council’s initial response to Ms I’s complaint, in which it had said that Mr I had asked staff not to contact his family when he was taken by ambulance as it was too early in the morning.

The Council was sent a draft copy of this report, and its comments on our provisional findings have been taken into account.

The Local Government Ombudsman’s findings in relation to the Council

I have noted that the sheltered housing staff worked with tenants to maintain their independent living skills and their autonomy by encouraging them to achieve an optimum level of independence in accordance with assessed care needs. Within this context, I consider that it was not unreasonable that a carer did not accompany Mr I to A&E as he was considered to be independent to mobilise and access facilities. I also note that the records show that Mr I specifically asked staff not to call his family as he did not wish to disturb them. In the Council’s response to the draft report it said relevant staff had been interviewed and they confirmed that Mr I said he did not want his family contacted. I consider that it was appropriate for staff to respect Mr I’s autonomy by accepting his decision at that time. There may have come a point when Mr I’s wishes would have been overridden, but I am satisfied that it was reasonable for staff not to have contacted Ms I and the Council was not at fault.

There are no records to show that two relevant policies were adhered to. The sheltered housing complex’s form for hospital admissions did not go to A&E with Mr I (paragraph 38). In addition, the sheltered housing complex’s Tenant Risk Assessment was not completed (paragraph 39).

In commenting on the draft report of this investigation, the Council said that the staff were aware of the Hospital Admission Form procedure and that all those interviewed said the form would have been sent to the hospital with Mr I. There is no record of the form being sent.

I cannot say for certain that the form was sent, but that there is no record of this is a fault in itself. However, as the fault is in relation to record keeping I find that this did not cause any injustice to Ms I.

In response to the draft report of this investigation, the Council accepted that the Tenant Risk Assessment should have been completed. It refers to other documents – the FACE Overview Assessment, the Sheltered Housing Support Plan and the Living Skills Assessment – where Mr I’s risks and health and safety issues were considered. But I note that these documents do not refer to any new potential risks after his visit to hospital. He was still unwell after he came back to the home and an assessment of this new risk should have been undertaken. Having said all that, however, based on the Advisers’ comments, and the Health Service Ombudsman’s findings about the Hospital Trust and the Mental Health Trust, I acknowledge that even if these procedures had been carried out, there is no reason to believe that the eventual outcome would have differed.

I consider that the Council’s failure to record sending a Hospital Admission Form with Mr I to A&E and its failure to update risk assessments amounts to maladministration.

Ms I’s comments on our findings

After we had sent her a copy of this report in draft form, setting out our provisional findings, Ms I, with her son, expressed her dissatisfaction with a number of our conclusions. In particular:

• she suggested that her brother’s symptoms were indicative of a rare condition known as Neuroleptic Malignant Syndrome. Having taken professional advice we concluded that there was no evidence to support that hypothesis;
• she maintained her view that there was a failure to diagnose Mr I’s condition which stemmed from the Council’s staff’s failure to complete appropriate paperwork, accompany him to hospital or inform his family; and
• she suggested that the main consequence of failing to inform her at the time was that concerns which she would have had about his symptoms could not be taken into account. In response to these last two points, we have concluded that reasonable medical oversight at the time did not point to an imminently fatal condition.

Injustice

Having taken into account the advice provided by our Professional Advisers in relation to the care provided by the Mental Health Trust and the Hospital Trust, we do not consider that the failings identified here in respect of the Council contributed to Mr I’s death. We conclude, therefore, that the specific injustice claimed (that an opportunity for his family to intervene to help ensure that Mr I received appropriate care was missed) did not result from the maladministration identified.

The complaints about the Mental Health Trust, the Hospital Trust and the Council: our joint conclusions

Our investigation into the Mental Health Trust and the Hospital Trust leads us to conclude that their care and treatment of Mr I was reasonable. The psychiatric medications that Mr I was taking, including the changes in dosage and time intervals, were reasonable for his age and condition: the medication (including the cessation of Artane) would not have contributed to his death. The investigations carried out by the Hospital Trust were thorough and included a test to diagnose deep vein thrombosis and at the time there was no indication to admit Mr I. We find no service failure by the Mental Health Trust or the Hospital Trust. The Health Service Ombudsman therefore does not uphold the complaints about the Mental Health Trust or the Hospital Trust.

We have found that the service provided to Mr I by the Council’s staff fell below a reasonable standard and that this amounted to maladministration. The Council failed to follow its internal policies: to record whether a hospital form accompanied Mr I to A&E and to update the tenant risk assessment. However, we found that no serious injustice resulted directly and so the Local Government Ombudsman finds that there was maladministration by the Council, but that it did not result in injustice.

Section 4: Concluding remarks

In this report we have set out our investigation, findings and conclusions with regard to the care, treatment and service Mr I received from the Mental Health Trust, the Hospital Trust and the Council. We are aware that our findings about the care and treatment provided by the Trusts will be disappointing for Ms I, who, in her comments on our draft report, expressed her disagreement with our findings, and her firm view that Mr I might have survived had she been informed of his ill health in time. We would like to assure her that her complaints have been thoroughly and impartially investigated and that our conclusions have been drawn from careful consideration of detailed evidence, including the opinion of independent professional advisers.

We therefore hope that this report will provide Ms I and her family with at least some of the explanations they were seeking and assure them of our firm view that the clinical care and treatment that Mr I received was of a reasonable standard and would not have contributed to his death.

Ann Abraham
Health Service Ombudsman for England

Tony Redmond
Local Government Ombudsman

March 2010

2 Deep vein thrombosis is a blood clot in a vein, usually a leg vein. The common cause is immobility. A complication occurs in some cases where part of the blood clot breaks off and travels to the lung; this is known as a pulmonary embolus.

3 The Ombudsman’s Principles is available at www.ombudsman.org.uk

4 British Thoracic Society guidelines for the management of suspected acute pulmonary embolism. Thorax 2003; 58:470–484
http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pulmonary%20Embolism/Guidelines/PulmonaryEmbolismJUN03.pdf 

5 D-dimer test: a blood test that is used to screen for abnormal clot formation such as deep vein thrombosis and pulmonary embolus. Combined with a risk assessment, a negative result signifies that a deep vein thrombosis/pulmonary embolus is highly unlikely to be present.

6 COPD: a long-standing disease in which lungs have been damaged, often associated with smoking, and free flow of air into the lung passages is restricted. It may produce coughing, wheezing and breathlessness.

7 EPSE – these are side-effects of antipsychotic medication which cause movement disorders such as stiffness and shaking or other abnormal involuntary movements.