Summary: A support service commissioned by the Council failed to update its risk assessments and share key information about Ms X’s son, Mr X, in the weeks before he died. The NHS Trust that jointly provided the service then failed to include some key information about Mr X’s case in its internal review and made mistakes in its submissions to the coroner. As the Council commissioned the service, the Council was at fault. These faults caused Ms X avoidable uncertainty, frustration and distress. The Council has agreed to apologise, pay Ms X £800 and provide evidence of service improvements made by the NHS Trust and the support service.

The complaint

1. Ms X’s son died due to an overdose. In the months before he died he was attending a support service. This service was commissioned by the Council and delivered for it by an NHS health trust and a private company.
2. Ms X complained that the support service failed to properly record and review her son’s risk of harm in the weeks before his death and if not for these faults, her son may not have died.
3. Ms X also complained that the service’s internal review of the circumstances leading up to her son’s death was flawed and it failed to provide key information to the coroner as part of its investigation.
4. Ms X said the actions of the service avoidably left her son at risk of harm and caused her uncertainty and distress.

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The Ombudsman’s role and powers

5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. 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)
7. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of poor care or service on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
8. 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, sections 24A(1)(A), and 25 (7) as amended)
9. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
10. As a publicly funded body we must be careful how we use our resources. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. This means we do not try to answer every single question a complainant may have about what the organisation did.
11. We will not investigate certain parts of a complaint if we decide there is another body better placed to consider parts of a complaint. (Local Government Act 1974, section 24A(6) as amended, section 34(B)
12. 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)

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What I have and have not investigated

13. Ms X has raised complaints about events which happened more than twelve months before she complained to us. I have decided to investigate these despite them being late, as Ms X has provided good reasons for not complaining to us before now.

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How I considered this complaint

14. I considered the information provided by Ms X and the Council.
15. I considered the relevant law and guidance as set out below.
16. I considered our Guidance on Remedies.
17. I considered all comments received from Ms X, the Council and the NHS Trust on a draft decision before making a final decision.

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What I found

Law and guidance

Coroners

18. Coroners are appointed by councils but they are independent judicial office holders. In most cases, complaints about coroners cannot be investigated by the Local Government and Social Care Ombudsman.
19. Coroners investigate deaths that have been reported to them if they have reason to think that the death was violent or unnatural, if the cause of death was unknown or if the death was in prison, police custody or state detention.
20. If the coroner believes action should be taken to prevent deaths in the future, it will issue a ‘Report to Prevent Future Deaths’ and these are usually made publicly available. A challenge to a coroner’s decision is by Judicial Review only.

Risk assessment policy (NHS Trust)

21. The following excerpts are from the risk assessment policy that was in force during the period I have investigated, at Cumbria, Northumberland, Tyne and Wear NHS Trust. This policy applied to its support service.
22. The policy said that risk assessments are required at various points, including:
• when admitting and discharging a person from hospital, and as part of planning and agreeing leave; and
• when there are major changes to presentation or personal circumstances, or following an incident.
23. The policy also said risk management, and or safety plans, should be developed where possible with the service user and their family members and should be shared as part of multi-agency working. (“Care Programme Approach Policy”, Cumbria, Northumberland, Tyne and Wear NHS Trust, 2020)

What happened

Background

24. Ms X’s son, Mr X, was living in supported accommodation and had a keyworker at a support service.
25. The support service is run jointly by an NHS Trust and a private company and is commissioned by Northumberland County Council. I refer to it as ‘the service’ below.

Key events

26. Mr X was admitted to hospital twice in one month for accidental overdoses. Both times his service was made aware. The service did not update his risk assessment in response to these admissions to hospital.
27. At the end of that month, Ms X called the service herself. She said she was worried about Mr X due to changes in his behaviour and because he had been spending nights away from his supported accommodation. Ms X asked the service to increase the support being provided to him. The service responded with options for support for Ms X but she declined these and said it was her son that needed help.
28. The service did not contact Mr X following this phone call, contact his supported accommodation provider or update Mr X’s risk assessment.
29. The service next attempted to contact Mr X around two weeks later but did not receive a response. The following day the service called Ms X to carry out a welfare check due to not having heard from him.
30. Ms X told the service her son had died due to an overdose the day before. She said the exact cause of death was not yet known but was thought to be accidental.
31. The NHS Trust carried out an internal review of the support it provided Mr X in the period before he died. It considered evidence including the notes from Ms X’s call to the service. It concluded that its standard of care towards Mr X, including his risk assessments, was classed as “good”.
32. The NHS Trust submitted this information to the coroner as part of the coroner’s investigations. The coroner concluded several months later that Mr X had died by “misadventure” and decided not to issue a Report to Prevent Future Deaths.
33. At the coroners hearing, Ms X raised concerns about the standard of care Mr X received from the service and outlined what she said were flaws in the Trust’s internal review of her son’s death. The coroner advised the NHS Trust to have a meeting with Ms X to go over these concerns.
34. Representatives from the NHS Trust met with Ms X, as advised by the coroner, but Ms X did not feel that the meeting addressed her concerns. The NHS Trust later accepted that its officers were not fully briefed before this meeting.
35. Ms X made a formal complaint to the NHS Trust about her disappointment with the recent meeting. She also complained that:
• The Trust sent incorrect information to the coroner, including an incorrect date of birth and date of death for her son;
• The Trust’s internal review into her son’s death was flawed, as it failed to invite her to contribute and failed to include key information, including that she felt her son’s risk was not properly assessed and responded to in the weeks before his death.
36. The Trust met with Ms X several times in relation to the complaint and sent a final response several months later.
37. It upheld that according to its policy, the service should have updated Mr X’s risk assessments after his admissions to hospital and it should have shared updated risk assessments with other services such as his supported housing provider, in the weeks before he died. It accepted it failed to do this and apologised. It said it was working with the supported accommodation provider to improve communication procedures.
38. The Trust upheld that the service should have contacted Mr X sooner, following Ms X’s call outlining concerns and requesting further support. It apologised that it did not do this.
39. The Trust apologised for its errors in submissions to the coroner and for failing to invite Ms X to contribute to its internal review. It said it had now changed its processes, so that family members are consulted as part of these reviews.
40. The Trust also sent a letter to the coroner, at Ms X’s request, setting out its complaint findings and explaining that it had amended its internal review decision, changing several areas to be marked only as “satisfactory” and not as good, largely in relation to its changed findings on the risk assessments.
41. Ms X complained to the Ombudsman as she felt the Trust’s response was insufficient to remedy the injustice caused.

My findings

42. The Ombudsman cannot make findings on causes of death. Only the coroner can make this decision. We also do not award compensation in the same way as a court can. So in these findings, I have not commented on, or considered whether any of the faults identified could have contributed to Mr X’s death. This is because these were matters that were able to be considered by the coroner.
43. I have used my general discretion to restrict my investigation to only look at whether the support service commissioned by the Council had due regard to its own policies in its care of Mr X. Where it did not, I have made findings on the injustice caused to Ms X and recommended remedies in line with our own guidance. This includes service improvements aimed at preventing reoccurrence of the faults I have identified.
44. The service has accepted that in the weeks before Mr X died, it failed to update Mr X’s risk assessments in response to new information and failed to ensure the updated risk assessments and information were shared as part of multi-agency working. The Trust failed to have regard to its own risk assessment policy here and this was fault. This fault has led to uncertainty for Ms X about whether her son could have accessed more, or different, support during this time.
45. The service has also accepted that the information it sent to the coroner contained inaccuracies, including incorrect dates and it failed to record as part of its internal review, that it had at times, not adhered to its own standards for assessing risk. These flaws in administration and investigation were fault. These faults caused Ms X avoidable distress and frustration.
46. Ms X said if not for these faults, the coroner may have come to a different conclusion and issued a Report to Prevent Future Deaths. The coroner has been made aware of the changes to the Trust’s findings and has not taken any further action. Coroners have wide powers to seek whatever evidence they need to reach their findings. The Ombudsman cannot say, even on the balance of probabilities, what would have happened if not for the fault by the service.
47. The service has also accepted that it should have consulted Ms X as part of its internal review into the care and support Mr X received before he died. This failure to obtain important information as part of the review was fault and caused Ms X frustration at an already distressing time. We welcome the change the Trust says it has made to its policy so that family and carers are now consulted as part of these types of internal reviews.

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Agreed action

48. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we found fault with the actions of the organisation providing the support service and so we have made the following recommendations to the Council.
49. Within one month of the date of the final decision, the Council has agreed to:
1. Apologise to Ms X for the injustice caused by the faults in this case; and
2. Pay Ms X £800 to reflect the uncertainty, frustration and distress caused by the Council’s faults in this case.
50. Within three months of the date of the final decision, the Council has agreed to demonstrate that:
1. the risk assessment policy has been sent to all staff supporting service users at the support service, along with the Ombudsman’s final decision in this case;
2. the importance has been reiterated to staff at the support service, of sharing information as part of multi-agency working and updating risk assessments in response to key information including hospital admissions and updates from family and carers;
3. staff at the support service have been reminded about the importance of following up promptly on contact which indicates an increased risk to a service user, such as reports from concerned family members;
4. the NHS Trust and support service has considered how to improve processes for double checking information sent to coroners, to ensure against mistakes in documentation during sensitive proceedings; and
5. it has received evidence from the NHS Trust that the Trust has changed its policy, as agreed in its complaint response to Ms X, so that family members and carers are now routinely consulted as part of the Trust’s internal reviews of cases where a service user has died.
51. We publish Guidance on Remedies which sets out, at section 3.2, our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended.
52. The Council should provide us with evidence it has complied with the above actions.

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Final decision

53. I have completed my investigation. I have found fault leading to injustice and recommended an apology, a financial remedy and service improvements.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman