The Ombudsman's final decision:
Summary: We consider East Sussex County Council, Change Grow Live, Sussex Partnership NHS Foundation Trust and Old School Surgery missed the opportunity to meet and discuss Ms E’s worsening alcohol misuse and mental health before she died. That has caused Ms E’s family uncertainty. They will not know if a joint meeting would have changed the outcome. The organisations should apologise for that fault.
- Mrs X complains about East Sussex County Council (the Council), Change Grow Live (CGL), Sussex Partnership NHS Foundation Trust (the Trust) and a GP at Old School Surgery (the Surgery).
- Mrs X says the organisations did not work together, share information, or take responsibility for her daughter’s (Ms E) mental health and alcohol misuse before she died under their care. Specifically:
- A Psychiatrist at CGL did not chase responses from the GP after seeking information about Ms E’s mental health diagnosis, treatment plan and discharge letter from The Priory.
- After The Priory discharged Ms E, her physical and mental health issues meant she could not engage with preparation work toward residential rehabilitation.
- The Council and CGL should have fast-tracked Ms E for urgent support.
- Despite the family highlighting concerns before Ms E died, no organisations acted to support her.
- The Trust did not agree with the families view that Ms E’s mental health issues were significant.
- CGL did not carry out a home visit the day before Ms E died, because it had the wrong address on its system.
- No one told the family The Priory were going to discharge Ms E in May 2017.
- No one offered to be a single contact for the family.
- The Council and CGL did not tell the family Ms E had been given funding for residential rehabilitation before she died.
What I have investigated
- I have investigated paragraphs two and three. The final section of this statement contains my reason for not investigating paragraph four.
The Ombudsmen’s role and powers
- The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
- If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
- The Ombudsmen cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Health Service Commissioners Act 1993, sections 3(4)- 3(7), and Local Government Act 1974, section 34(3), as amended)
- The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies.
- If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- I have considered information Mrs X has provided in writing and spoke to her. All parties have had the opportunity to comment on a draft of this statement. I have considered Mrs X’s comments on the draft statement before reaching my final decision.
What I found
- CGL provided support for Ms E’s alcohol misuse since 2016.
- CGL updated Ms E’s recovery plan in March 2017. She wished to abstain from alcohol and attend residential rehabilitation. She would achieve that by attending appointments and groupwork in preparation.
- Later that month, Ms E’s previous Surgery referred her to the Trust’s community mental health team (CMHT). Ms E’s family were concerned her mental health was worsening. The CMHT referred Ms E for short-term support from the crisis resolution and home treatment team (CRHT). The CRHT supported Ms E until late April.
- After the CRHT discharged Ms E, her mental and alcohol misuse worsened again, and she started having suicidal thoughts. Ms E’s family raised those concerns to the CRHT and CMHT. In early May, the CRHT reviewed Ms E again and arranged for Ms E to attend The Priory for detoxification (detox). That included stopping her alcohol intake with support for the withdrawal symptoms. Ms E stayed at The Priory for two weeks. During her stay, the CMHT and CGL assessed her.
- When The Priory discharged Ms E:
- She agreed to have weekly appointments with a mental health nurse, part of the CMHT. But Ms E needed to work with CGL to treat her alcohol misuse.
- CGL’s psychiatrist amended Ms E’s medication and encouraged her to attend groupwork. While Ms E’s anxiety impacted her ability to engage, the longer she abstained from alcohol, her anxiety would improve. CGL agreed to request certain information from the CMHT about Ms E.
- The Council’s Substance Misuse Service (the SMS) agreed to support Ms E with CGL to work toward residential rehabilitation.
Care and support for Ms E’s alcohol misuse and mental health
- Since 1 April 2013, local authorities have been responsible for improving public health through provision of drug and alcohol treatment services. This is funded by a Government public health grant. Local authorities can commission NHS trusts, private organisations and/or not-for-profit sector organisations to provide the care. Care and treatment can include care from psychiatrists and other clinicians as well as support workers, and can happen in the community or in residential placements. Local authorities remain responsible for the quality of care people receive. This means that complaints about alcohol and drug treatment services commissioned by a local authority are within the Ombudsman’s jurisdiction.
- In this case, the Council commissioned CGL (previously called STAR) to provide its drug and alcohol treatment service on its behalf. This explains why my recommendations are to the Council, rather than CGL, later in the decision statement.
CGL not chasing the Practice and The Priory
- In response to Mrs X’s complaint, CGL apologised that it did not chase the GP or the CMHT after its psychiatrist sought information about Ms E. CGL recognised that was frustrating for the family.
- I consider CGL acted with fault, but there was no injustice to Ms E. That was because the SMS got the records the psychiatrist needed instead. However, I understand how CGL’s fault would have caused Mrs X and the family frustration.
- CGL should have had a process in place to chase organisations who do not respond to information requests. I asked CGL how it would avoid similar fault in future. CGL told me that in late 2020 it introduced a centralised administration team. That team supports clinical staff, and is responsible for requesting and chasing records, such as discharge and mental health information. CGL noted there has been significant improvements in responsiveness to information requests.
- Overall, I consider CGL has taken appropriate action to remedy the frustration the family suffered. Also, its actions should avoid similar fault happening again.
- The East Sussex Commissioning Strategy of Substance Misuse (2012-2015) is the local vision for treatment services, which CGL worked toward.
- Residential rehabilitation provides structured psychosocial interventions and independent living skills in a safe, drug and alcohol-free environment. The programmes last three to six months, sometimes longer. Before CGL agrees to fund a residential rehabilitation placement, the service user must carry out certain steps first, including group preparation work.
- While CGL did not formalise a pathway until October 2017 (one month after Ms E died), its ‘Referral Pathway for Residential Rehabilitation’ would have been applicable in Ms E’s case. That pathway followed the steps below:
- Service user appeared motivated and attended group preparation work.
- Care Coordinator and Team Leader agree to proceed to assessment.
- Service user booked onto next rehab preparation group
- Service user to complete ‘Get ready for rehab’ workbook and personal statement.
- Complete rehab application form.
- Complete rehab preparation group.
- Email application to rehab inbox.
- Panel meeting held and decision made.
- In response to my enquiries, CGL said:
- The SMS managed rehabilitation referrals.
- The purpose of the group preparation work was to reduce the chance of an unplanned exit, and to maximise the benefit of rehabilitation.
- Ms E needed to attend group preparation work to access residential rehabilitation.
- It followed the relevant pathway.
- In July 2017 it referred Ms E for support to attend appointments for alcohol misuse and her mental health. The Primary Care Pilot supports people who have disengaged from support services.
Lack of support for Ms E despite the families concerns
- In 2016 the National Institute for Health and Care Excellence (NICE) issued guidance Coexisting severe mental illness and substance misuse: community health and social care services for commissioners of recovery services. This provides guidance on how to identify and provide support to people with coexisting severe mental illness and substance misuse.
- Severe mental illness includes a clinical diagnosis of: schizophrenia, schizotypal and delusional disorders, or bipolar affective disorder, or severe depressive episodes with or without psychotic episodes.
- NICE guidance says existing specialist services should be adapted to meet both a person's coexisting severe mental illness and substance misuse needs and their wider health and social care needs rather than the creation of a specialist 'dual diagnosis' service. Whilst guidance recognises the need for joined up working, it also acknowledges that alcohol treatment must take precedence in some situations.
- In 2011 NICE issued guidance Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high risk drinking) and alcohol dependence (CG115) for health professionals and the public. They suggest that service users who have been dependent on alcohol will need to be abstinent, or have very significantly reduced their drinking, to benefit from psychological interventions for any coexisting mental health disorder.
- In response to my enquiries, the Council said:
- It shared the families concerns with the right organisations.
- It followed the NICE guidance. It worked collaboratively with the organisations between May and September 2017. However, a multiagency meeting would have been helpful to understand each organisations approach to treat Ms E. That could have included a more robust care plan and risk assessment.
- It followed the NICE guidance. However, it could have responded better to Ms E’s changing circumstances when her mental and physical health worsened when she relapsed between July and September 2017.
- During that period, it should have reviewed her risk management and support plans. The support plan was not robust.
- Also, it should have considered assessing Ms E’s drinking and suitability for detox because it was a requirement for ANA’s residential rehabilitation.
- It followed the NICE guidance. It encouraged Ms E to engage with CGL to address the alcohol misuse before it could robustly assess her mental health.
- It worked collaboratively with Ms E and CGL to manage her alcohol misuse, which it hoped would stabilise her mental distress.
- Between June and September 2017, Ms E did not attend appointments. It could have considered visiting Ms E at home when she did not attend.
- Improve the experience of people who need access to both mental health services and substance misuse services.
- To meet their needs, through a combined approach.
- To treat the person as a whole, rather than a sub-set of their difficulties.
- In response to my enquiries, CGL told me there was no choice to fast-track Ms E for residential rehabilitation. In November 2017 (after Ms E died), it introduced a fast-track process for detox. However, Ms E was working towards residential rehabilitation. Therefore, CGL did not assess Ms E for detox.
- Ms E’s aim was to work toward residential rehabilitation. Preparation work was clearly fundamental to access residential rehabilitation. As there was no fast-track for that, I cannot say the SMS or CGL missed an opportunity to fast‑track Ms E.
The Trust’s view of Ms E’s mental health
- I have considered the CMHT’s medical records. The medical records show the CMHT was clearly aware of Ms E’s mental health conditions, and I am persuaded it did take those seriously.
- The NICE guidance (paragraph 47) state that someone should be abstinent from alcohol for three to four weeks to assess if there is a significant improvement in their depression.
- From the records I have seen, Ms E could not remain abstinent for three to four weeks. Ms E’s drinking made it difficult for the CMHT to assess her mental health after May 2017. However, I understand the lack of contact between the CMHT and Ms E (compared to the SMS and CGL) led the family to believe the CMHT were not taking Ms E’s mental health seriously. Rather, the CMHT was focussed on Ms E accessing support for her alcohol misuse. I have already decided the organisations were not at fault for focussing on supporting Ms E’s alcohol misuse before her mental health.
CGL’s attempted home visit
- In response to Mrs X’s complaint, it accepted it had the wrong address for Ms E on its system. Therefore, on 14 September 2017 it did not see Ms E at home that day. CGL said it cannot say if the outcome would have been different for Ms E had it reviewed her on that day.
- I have considered CGL’s records from 14 September.
- I agree that CGL should have carried out the home visit on 14 September. That was fault.
- I agree that I cannot say the outcome would have been different for Ms E, had CGL reviewed her that day. Unfortunately, again this leaves the family with uncertainty.
- I am satisfied CGL has recognised that fault and apologised to the family. However, I consider it should take further action to avoid similar fault happening to others.
Organisations communication with the family
The discharge from The Priory
- In response to Mrs X’s complaint:
- The Council and Trust jointly acknowledged it was not ideal when someone is discharged late at night without telling the family. The Trust told The Priory about how important conversations about discharge are with families.
- The Surgery said it was aware Ms E had moved to The Priory on 3 May 2017 and was expected to stay for four weeks. However, the Surgery received Ms E’s discharge summary two weeks later.
- CGL was only aware of Ms E’s admission at The Priory when a Psychiatrist at CGL completed a medical assessment while she was on day release. It acknowledged there was little joint working when The Priory discharged Ms E.
- The Council said the CMHT was responsible for telling the family The Priory would be discharging Ms E in mid-May 2017.
- The CMHT did not receive a copy of the discharge summary from The Priory. While there is no evidence the CMHT told other organisations, The Priory would be discharging Ms E, it was working closely with the other organisations.
- At the time, CGL was not aware of the admission and discharge from The Priory. Therefore, it could not contribute to aftercare planning on discharge.
No single contact for the family
- In response to my enquiries:
- The Council said the SMS explained the roles of the professionals involved to Ms E verbally and in writing in July 2017.
- CGL said each organisation had a point of contact for the family. However, it accepted the organisations did not clearly explain the roles and responsibilities to the family.
- The Trust said it worked collaboratively with CGL to encourage Ms E to attend appointments.
- The Surgery said Ms E’s lack of consent impacted its ability to discuss the families concerns.
- CGL provided clinical treatment and support for her alcohol misuse.
- The SMS supported her to access residential rehabilitation.
- The CMHT supported her mental health.
- The Surgery supported her physical health.
The funding for residential rehabilitation
- Mrs X says the SMS and CGL did not tell the family Ms E had been given funding for residential rehabilitation before Ms E died.
- In response to Mrs X’s complaint, CGL initially said it did not submit a funding request because she had not completed the preparation work for ANA. However, in a later response, it told Mrs X it was not aware the SMS had made a funding request.
- In response to my enquiries, the Council said the SMS told Ms E’s father funding had been declined.
- I have considered the Council and CGL care records.
- I consider the SMS told Ms E’s father the panel declined funding for residential rehabilitation. However, there is no record that the SMS told Mrs X.
- Mrs X and Ms E’s father were not in contact with each other about Ms E. They were raising separate concerns to the SMS.
- I consider when the SMS said he would update the family on the outcome of the funding panel, it should have communicated that to both Ms E’s father and Mrs X. However, I am not persuaded that lack of communication was fault.
- I can see the SMS was very busy on 14 September. They were communicating (or trying to) with CGL, the CRHT, the Surgery, Ms E and her father. Everyone had significant concerns for Ms E’s welfare, which the SMS was trying to address. I understand why communicating the outcome of the funding panel was not a priority on 14 September. The SMS communicated the outcome to Ms E’s father after her father requested a home visit for his daughter. I consider on 14 September, the SMS appropriately prioritised Ms E’s welfare.
- However, I have not seen any evidence the Council told Mrs X funding had been declined after 14 September. That was fault, which caused Mrs X uncertainty. Until now, Mrs X has not known if the panel accepted or rejected SMS’s funding request.
- Also, CGL has not provided a formal record of the panel’s decision. I consider that poor record keeping was fault, which caused Mrs X uncertainty. However, in October 2019, CGL apologised to Mrs X for that fault and agreed to take minutes for panel decisions about residential rehabilitation. It would place a copy of those minutes in the service user’s records. I am satisfied CGL’s actions have remedied Mrs X’s uncertainty.
- Within four weeks, the Council should apologise to Mrs X for the uncertainty caused by not communicating the outcome of the funding panel.
- Within four weeks, the Council and Trust should apologise for the uncertainty caused by not holding a multi-agency meeting in July 2017 to review Ms E.
- Within eight weeks, the Council should ensure CGL reviews its existing service users’ address and contact details to ensure they are correct. The Council should also ensure CGL develops a process to periodically keep them updated.
- I have completed my investigation. There was fault by the organisations causing injustice to Mrs X.
Parts of the complaint that I did not investigate
- I have not investigated how CGL handled Mrs X’s complaint.
- We can only uphold complaints and make recommendations where we find evidence that maladministration or service failure (which we call fault) has caused an injustice. If the actions caused an injustice which has already been put right by the organisation then we would not normally look at the complaint because there is little we could achieve by doing so.
- CGL recognised it handled Mrs X’s complaint with fault, and fully upheld her complaint. It accepted staff did not follow policies when agreeing to respond to Mrs X, and apologised for the additional distress it caused her. It agreed to put improvements in place to avoid similar fault happening to others. I am satisfied CGL has shown good learning from its fault. Therefore, I have decided not to investigate Mrs X’s complaint about how CGL handled her complaint.
Investigator’s decision on behalf of the Ombudsmen
Investigator's decision on behalf of the Ombudsman