Summary: Mrs X complains about the way in which Charity B (funded by the Council) dealt with her husband, Mr X, prior to his death by suicide. Charity B has taken appropriate steps and action to improve its services has a result of Mrs X’s complaints. The Council also monitors the Charity’s handling and performance with sufficient regularity to identify and help address any issues.

The complaint

1. Mrs X complains about the way in which an alcohol and substance abuse charity (Charity B) funded to provide this service by the Council dealt with her husband, Mr X, prior to his death by suicide. Mrs X says Charity B has accepted faults in its handling of her late husband’s case, but not provided details of the steps it has and will take to improve its services as a result of her complaints. Mrs X wants the Council to ensure learning from her husband’s case is used by Charity B to make meaningful improvements to help prevent other families experiencing the distress caused to her and her daughter.

Back to top

The Ombudsman’s role and powers

2. We cannot investigate a complaint if it is about a personnel issue. (Local Government Act 1974, Schedule 5/5a, paragraph 4, as amended)
3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)

4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

6. I have spoken to Mrs X and considered the information she has provided in support of her complaints.
7. I have considered information the Council has provided in response to my enquiries. This includes information obtained from Charity B, some of which is confidential and cannot be shared with Mrs X or detailed within this decision statement.
8. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

What happened

9. At the end of June 2021, Mr X referred himself to Charity B following advice from his doctor. Mr X had issues with alcohol misuse. Charity B provides support services for alcohol and substance misuse within the Council’s area. This service is available Monday to Friday from 9:00 to 17:00 and on Saturdays from 9:00 to 13:00. Charity B also provides 24-hour support through a crisis team.
10. Charity B allocated a Recovery Worker to Mr X following an initial assessment. The Recovery Worker completed a comprehensive assessment with Mr X in late July 2021, in which they set out a plan to help Mr X reduce his alcohol intake safely and to obtain support through group sessions. Most of Mr X’s contact with his allocated Recovery Worker was by telephone and text message.
11. On 10 August 2021, the Recovery Worker had to cancel their planned telephone appointment with Mr X at short notice. Mr X sent messages to the Recovery Worker expressing his frustration as he was struggling and feeling suicidal. The Recovery Worker contacted Mr X the following day to apologise for cancelling their appointment and offered to reschedule for 18 August 2021. The Recovery Worker also provided contact details for the Crisis Team and Samaritans to Mr X.
12. Mr X sent a further text message to the Recovery Worker outside of their working hours on 17 August 2021. Mr X said he was really struggling and feeling suicidal. He asked for help and expressed his frustration at being unable to get support by using expletives in his messages. Mrs X also contacted Charity B the following morning to ask for help as Mr X was struggling.
13. Mr X had his scheduled appointment with the Recovery Worker on 18 August 2021 and apologised for his language in text messages. The Recovery Worker explained they were trying to help but could not tolerate abusive language. They also discussed Mr X attending group sessions, having fortnightly face to face appointments with the Recovery Worker and other plans to help Mr X slowly and safely reduce his alcohol intake.
14. Mr X contacted the Recovery Worker by text message on 25 August 2021 to say he was really struggling and feeling suicidal. The Recovery Worker offered to call Mr X later that day, but Mr X declined as he was busy at work and already had an appointment scheduled with the Recovery Worker the following day.
15. Mr X had a telephone appointment with the Recovery Worker on 26 August 2021, in which he reported feeling better. They discussed the support available for Mr X to access with the Crisis Team and the Samaritans when the Recovery Worker was not available. A face-to-face appointment was scheduled between Mr X and the Recovery Worker on 8 September 2021.
16. Mr X sadly died by suicide a few days before this appointment. He had been speaking to the Charity’s Crisis Team just before he died.

Mrs X’s complaints to Charity B

17. On 10 November 2021, Mrs X made a complaint about Charity B’s handling following receipt of its report to the Coroner regarding Mr X’s death.
18. Charity B allocated investigation of Mrs X’s complaint to a senior manager who has a telephone discussion with Mrs X on 29 November 2021 about her complaints. The Senior Manager sent Mrs X their minutes of the telephone meeting to confirm the complaints they would be investigating.
19. Mrs X’s complaints were summarised as follows:
1. Mr X should have been offered an earlier appointment following cancellation because he had indicated feeling suicidal;
2. Mr X’s text messages were inappropriately treated as abusive rather than from someone in crisis needing help;
3. Mr X’s text message to his Recovery Worker on 3 September 2021 was not responded to;
4. Mr X’s text messages to his Recovery Worker on evenings or non-working days were not forwarded to another Recovery Worker and there was no out-of-hours provision for the Charity’s alcohol and substance misuse service;
5. Mr X’s Recovery Worker should have taken further steps following his disclosure of suicidal thoughts and behaviours; and,
6. There were at least three inaccurate dates within the Charity’s report to the Coroner about Mr X’s interaction with it.
20. The Investigating Manager undertook interviews with the Recovery Worker assigned to Mr X and their line manager, who had compiled the report to the Coroner. They also examined the case files held about Mr X, together with the Charity’s serious incident report, completed 72 hours after Mr X’s death and a case review undertaken by Senior Managers from the alcohol and substance misuse service and crisis teams to identify any wider learning. Mrs X also provided copies of Mr X’s text messages to his Recovery Worker to the Investigating Manager.
21. Charity B sent its stage one complaint response to Mrs X on 23 December 2021. It upheld complaints a and b listed in paragraph 18 above, partially upheld complaints e and f, and did not uphold complaints c and d. The response explained the action taken by the Recovery Worker and their wider team to learn from the handling of Mr X’s case, including further training and the importance of quick responses to concerns about suicide ideation and attempts, including overriding a client’s declined consent to share information with their GP or other health services.
22. Mrs X remained dissatisfied with Charity B’s complaint response. She escalated her complaint to appeal on 22 September 2022. Charity B completed its final review of Mrs X’s outstanding complaints and issued its final response to her on 7 November 2022.
23. While Charity B’s stage two review maintained the findings reached at stage one, it provided further details of the steps it had taken to improve practice and services as a result of Mr X’s death and Mrs X’s complaint.

Analysis

24. Mrs X’s complaint is essentially that Charity B failed to provide proper support to Mr X and this in part led to his death by suicide.
25. I have a great deal of sympathy for Mrs X, her daughter and the rest of Mr X’s family. Mr X’s death has clearly been very distressing for everyone involved. I can appreciate Mrs X and her daughter’s desire to know more about what happened and the Charity’s actions since Mr X’s death.
26. In response to my enquiries, the Council has shared information about the action Charity B has undertaken specifically with the Recovery Worker assigned to Mr X and their direct line manager. It has also provided details of the wider work Charity B has completed as a direct result of its learning from Mr X’s death. Because this information relates to the personnel records of individual employees, I am unable to describe in detail the nature of this activity. I am however satisfied that Charity B has taken appropriate action in respect of this matter and Mrs X’s complaints.
27. I am also reassured that the Council, which funds Charity B’s alcohol and substance misuse service, has appropriate oversight of its work. The Council has monthly meetings with Charity B to monitor performance and has appropriate reporting procedures in place to ensure it is swiftly notified of serious incidents such as Mr X’s death.
28. I realise none of this alleviates the grief and distress Mrs X and her daughter have and are still experiencing. I hope however, that my independent review gives Mrs X some reassurance that Charity B took her concerns seriously and has taken appropriate steps and action to learn from its handling of Mr X’s case.

Back to top

Final decision

29. I have completed my investigation and do not uphold Mrs X’s complaint.

Back to top

Investigator's decision on behalf of the Ombudsman