London Borough of Havering (07A10429)

Adult care services            No maladministration

11 March 2010

This case involves complaints about the London Borough of Havering and North East London NHS Foundation Trust (formerly known as North East London Mental Health Trust), in a joint investigation carried out by the Local Government Ombudsman and the Health Service Ombudsman.

Mr S complained about the care and treatment of his late wife, who had dementia and who he cared for at home. Mrs S was compulsorily detained under the Mental Health Act for treatment. While in hospital, Mrs S fell out of bed and broke her hip. She was transferred to a different hospital (not part of this investigation), where she died.

Local Government Ombudsman, Tony Redmond, said:

“We find that the way the Council provided services for Mrs S, and the procedure its staff followed in applying for her compulsory detention, did not fall below a reasonable standard in the circumstances.”

Ann Abraham, Health Service Ombudsman, in partly upholding the complaint about the NHS Foundation Trust (FT), said:

“We conclude that there were some clear failings including a lack of appropriate risk assessment before the fall which led to an injustice to Mrs S, in that if she had had an appropriate assessment her fall might have been prevented. Also, the failures in the Trust’s communication with Mr S about Mrs S’s fall caused Mr S distress. There were other failures which did not directly lead to injustice to Mr or Mrs S. These other failures were: an inadequate examination immediately after the fall; an adequate investigation by the Trust into the fall; and the Trust’s record keeping was generally poor."

The Foundation Trust has agreed to accept the Ombudsmen’s recommendations to apologise to Mr S. The report outlines the actions the Trust have implemented since the time of the events complained about.

Date Updated: 12/03/10