Buckinghamshire County Council (03A04618) & Oxfordshire & Buckinghamshire Mental Health Partnership Trust (HS-2608)
Adult care services Maladministration causing injustice
17 March 2008
The complaint
Mr P’s parents complained to the Local Government Ombudsman and the Parliamentary and Health Service Ombudsman about the care their severely disabled adult son received while he was living for two years in a residential care home run jointly by the County Council and the Health Trust. Mr P needed one-to-one attention for about 95 per cent of his waking time.
What happened
While he was at the care home, Mr P’s care needs were never properly assessed, and a number of significant failings in the level of care he received were identified. Although Mr P’s parents voiced their concerns to the Trust and the Council, there was delay in responding to these concerns and a great deal of confusion as to which body should address the separate aspects of the complaint. While at home during a Christmas break, Mr P suffered from anxiety and depression and refused to leave the house. His parents accommodated him at home without any external support for three months, until he was returned to the Council’s care. When his needs were finally assessed, and a care plan prepared, he was moved to a residential home that provided the level of care and support that an adult with his complex needs required.
The Ombudsmen’s joint investigation
The Ombudsmen’s report said Mr P and his parents had a right to expect that the care home would provide him with appropriate care in an environment conducive to his development, but sadly that did not happen. His needs were not assessed properly. This absence of a proper assessment and, in turn, a proper care plan, led to a failure to ensure his physical or emotional wellbeing was protected. The Council failed to provide appropriate residential services to Mr P on transfer from the local Mental Health Trust. The accommodation provided did not meet his needs, and support and other services fell well short of what was necessary and appropriate for a person with such complex needs. As a result, Mr P’s parents paid for various outgoings which should have been paid for by either the Trust or the Council.
Outcome
The Ombudsmen found that there had been fault by both the Council and the Health Trust that caused adverse effects for Mr P and his family, including acute anxiety, distress and some financial loss. The Ombudsmen recommended that the Council and the Health Trust pay £32,000 compensation.
Joint working
This was the first time that the Local Government Ombudsman and the Parliamentary and Health Service Ombudsman had collaborated on an investigation in this way. Although they had separate jurisdictions over different parts of the complaints, many aspects of the complaints were inextricably linked. The Ombudsmen reported jointly using new powers under the Regulatory Reform (Collaboration etc. between Ombudsmen) Order 2007 to work together more effectively in investigating and reporting on complaints which cross their jurisdictions.
The Local Government Ombudsman said:
“Collaborating with the Parliamentary and Health Service Ombudsman in this way … is an important step forward. One of the outcomes of this case has been identifying the need for robust and transparent governance arrangements to be in place in order to provide clear accountability for the actions of authorities. A complainant can then be more readily signposted to the body that can better deal with a complaint.”
‘Injustice in residential care: a joint report by the Local Government Ombudsman and the Health Service Ombudsman for England’ was laid before Parliament on 26 March 2008.
Date Updated: 13/01/09