Ms B's family complained that the Trust failed to give her adequate care and treatment when her mental health declined. They said this led to her avoidable death. They also complained about the Trust's poor communication and complaint handling.
What happened
Ms B had a medical history of schizotypal personality disorder and moderate depression, as well as high blood pressure and cholesterol. During 2011 she was admitted to the Trust for short periods three times, once because of an overdose of blood pressure medication, and twice because she was suffering from stress.
Ms B did not engage with the services on offer during her admissions, or after discharge. When she did not attend an appointment, the Trust wrote to her inviting her to make contact at any time. Ms B was found dead in her flat in summer 2011. She had been dead for several weeks. The Coroner's inquest in autumn 2011 recorded that it was not possible to identify the cause of death because of the time that had elapsed before she had been found.
Ms B's family complained that the Trust did not give her adequate care and treatment. They believed her death could have been avoided. They also said the Trust failed to listen to them when they tried to give Ms B's clinicians information about her, and this caused them great anxiety and distress.
The Trust responded and explained that, because Ms B had declined to give permission for her family to be involved, her clinician was limited as to what discussions he could have had with them. The Trust apologised because it should have called the family back to explain this. The Trust said that Ms B had been given a reasonable standard of care, both psychologically and physically. The family were not satisfied and complained to us.
What we found
We partly upheld this complaint. We found the care Ms B received was in line with recognised quality standards and established good practice, and there were no failings.
However, there were failings in the way the Trust treated Ms B's family when they tried to give information about her to her clinicians. There were also failings in the way their complaint was handled. These failings caused the family great anxiety and distress.
Putting it right
The Trust acknowledged the failings and apologised for them. It also prepared an action plan to make sure it had learned from the failings so that they didn't happen again.
East London NHS Foundation Trust
Greater London
Did not take sufficient steps to improve service
Apology
Recommendation to learn lessons or draw up an action plan