Summary: Ms X complains about the lack of support provided to her late sister to meet her mental health needs. Ms X says her sister would not have taken her own life had she been provided with proper support. We will not investigate this complaint as there is an inquest pending and an investigation may interfere with the inquest.

The complaint

1. Ms X complains Cornwall Partnership NHS Foundation Trust, (the Trust), failed to provide mental health support to her late sister, Ms Y. Ms X also complains Cornwall Council, (the Council), and the Trust failed to provide Ms Y with aftercare services under section 117 Mental Health Act 1983 (section 117 aftercare).
2. Ms X says Ms Y would not have taken her life had she received services. Ms X says the circumstances around Ms Y’s death, and her death itself, have caused long term emotional damage to her and others close to Ms Y.

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The Ombudsmen’s role and powers

3. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
4. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start an investigation if they believe it would be reasonable to wait for the outcome of investigations or reviews by other organisations before considering a complaint. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

5. I considered evidence provided by Ms X and the Trust, as well as relevant law, policy and guidance.
6. Ms X had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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My assessment

7. Ms Y lived independently and had long standing mental health difficulties. She was supported by the community mental health team. Ms Y complained to the Trust in 2023 about the lack of support and the failure to provide section 117 aftercare services. The Trust responded saying it would not investigate the complaint as it was late under its complaints procedure. This is because the events Ms Y complained about related to her hospital admission in 2007.
8. Ms X says there were several serious flaws from health agencies, including the mental health and home treatment team, which resulted in Ms Y taking her own life in 2024. Ms X considers Ms Y should have been receiving section 117 aftercare services and that her death was preventable. The NHS completed a Patient Safety Incident Investigation (PSII) which identified multiple failings in the support provided to Ms Y. It concluded with recommended actions. Ms X does not consider this is sufficient to challenge the systemic failures she has identified.
9. A coroner will be conducting an inquest which will look at the circumstances of Ms Y’s death.
10. The Ombudsmen will not start an investigation where there is a potential overlap with another organisation, in this case the Coroner. This is to prevent duplication and possible interference in the Coroner’s investigation. Ms X can resubmit her complaint to the Ombudsmen if she has outstanding concerns after the conclusion of the inquest.

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Decision

11. We will not investigate this complaint at this stage because it is reasonable to wait for the outcome of the inquest.

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Investigator's decision on behalf of the Ombudsman