Central and North West London NHS Foundation Trust (19 010 659a)

Statement Upheld Mental health services 26-Jan-2021

Summary: We found fault with the care and support provided by the Council, Trust and CCG to Miss X, a vulnerable young woman with complex needs. We found this placed Miss X at significant risk in the community and caused her and her family avoidable distress. These organisations have agreed to apologise to Miss X and pay a financial remedy in recognition of the impact of this fault on her.

The Selsdon Park Medical Practice (20 004 819b)

Statement Closed after initial enquiries General practice 26-Jan-2021

Summary: Ms A has complained about a care home and GP regarding their response to a fall her mother suffered in March 2020. The care home has already apologised for its delay in communicating with the family and there is nothing more we could achieve. We will not investigate this case as we are unlikely to find any further fault or add to the previous investigation by the care provider.

United Lincolnshire Hospitals NHS Trust (20 000 835a)

Statement Upheld Hospital acute services 25-Jan-2021

Summary: We have partially upheld Mr S’s complaint about his father’s discharge from hospital to a residential care home. The Council and Trust have already apologised to Mr S and we consider this a suitable remedy for distress caused to Mr S. The Council says it has already improved its way of working following Mr S’s complaint. We have asked for evidence of these improvements and recommended further service improvements. The Council and Trust accept our recommendations, so we have completed our investigation.

Lincolnshire East Clinical Commissioning Group (20 000 835b)

Statement Closed after initial enquiries Assessment and funding 25-Jan-2021

Summary: We have partially upheld Mr S’s complaint about his father’s discharge from hospital to a residential care home. The Council and Trust have already apologised to Mr S and we consider this a suitable remedy for distress caused to Mr S. The Council says it has already improved its way of working following Mr S’s complaint. We have asked for evidence of these improvements and recommended further service improvements. The Council and Trust accept our recommendations, so we have completed our investigation.

University Hospitals of North Midlands NHS Trust (20 008 224a)

Statement Closed after initial enquiries Other 22-Jan-2021

Summary: We will not investigate Mr X’s complaint. We most likely cannot achieve the outcome Mr X would like or add anything to University Hospitals of North Midlands NHS Trust’s investigation.

Hertfordshire Partnership University NHS Foundation Trust (19 019 240a)

Statement Not upheld Mental health services 15-Jan-2021

Summary: Mr P complained that the Council and Trust stopped his direct payment without telling him, and did not give him the information he needed about how direct payments worked. The Trust, on behalf of the Council, apologised and paid Mr P a financial remedy. They also made improvements to how direct payments are managed following Mr P’s complaint.

Lancashire and South Cumbria NHS Foundation Trust (19 008 717a)

Statement Upheld Mental health services 13-Jan-2021

Summary: We found faults by a Council and an NHS Trust resulted in delays in providing support for an individual who had recently been diagnosed with Autism. The organisations have already accepted some faults and taken action to improve the services provided to those diagnosed with Autism. However, the injustice to the complainant was not fully addressed. The organisations have agreed to apologise and pay the complainant £500 to recognise the distress caused by the faults.

Gloucestershire Clinical Commissioning Group (20 002 580a)

Statement Closed after initial enquiries Mental health services 04-Jan-2021

Summary: Mr D complained about his adult son’s access to mental health aftercare which should be arranged and provided by the Council and the CCG. He also complained about an error in an NHS Trust’s medical records which was preventing his son receiving the services he was entitled to. We decided not to investigate Mr D’s complaint against the Council and the CCG as the issues have since been resolved. Mr D’s complaint against the NHS Trust can be considered separately by the Parliamentary and Health Service Ombudsman.

Gloucester Health & Care NHS Foundation Trust (20 002 580b)

Statement Closed after initial enquiries Mental health services 04-Jan-2021

Summary: Mr D complained about his adult son’s access to mental health aftercare which should be arranged and provided by the Council and the CCG. He also complained about an error in an NHS Trust’s medical records which was preventing his son receiving the services he was entitled to. We decided not to investigate Mr D’s complaint against the Council and the CCG as the issues have since been resolved. Mr D’s complaint against the NHS Trust can be considered separately by the Parliamentary and Health Service Ombudsman.

Surrey & Borders Partnership NHS Foundation Trust (19 019 904a)

Statement Not upheld Other 21-Dec-2020

Summary: Mrs B complained the Council failed to properly monitor two homecare agencies it commissioned to provide care to her mother, Mrs C. She also said the Trust’s mental health assessment was poor as it failed to record visible bruising to Mrs C’s face. The Council’s safeguarding investigation could not determine the cause of bruising found on Mrs C’s body after she was admitted to hospital in 2019. The Trust said its officer did not notice any bruising when the assessment was completed. The Council accepted there had been systemic failings, but it could not substantiate the allegation of neglect. We cannot say the Trust was at fault in the way it completed the mental health assessment. There was fault by the homecare agencies commissioned by the Council, but we did not find fault in the way the Council monitored the agencies or in the way it completed a safeguarding investigation. The Council agreed to our recommendation and will arrange for a written apology to be sent to Mrs B for the injustice caused by the systemic failings identified.