Newcastle City Council (08 003 256)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 23 Nov 2011


An investigation by two Ombudsmen highlighted significant failings in the care provided to a man in Newcastle who had Down’s syndrome.

The complaint

Their report describes how Mr J’s basic human rights were ignored after he was detained unnecessarily in hospital for months and was then moved into inappropriate locked accommodation until his death.

The Health Service Ombudsman and Local Government Ombudsman conducted a joint investigation into complaints made by Mr J’s brother about the care and treatment provided by Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle City Council and the Coquet Trust.

Mr J had been an active, outgoing and sociable man, living independently in rented accommodation with his wife. He had day-to-day support from the Council, and his family, who he was close to, supported his wish to be as independent as possible. When health professionals became concerned about a significant deterioration in his skills and health, Mr J was admitted to hospital for a short assessment. He was diagnosed with dementia and epilepsy, but in spite of being declared ready for discharge, he was kept in hospital for a further five months. Rather than returning home, which was now considered to be unsuitable accommodation, Mr J and his wife were moved to a self-contained flat at a care home for older people. The flat was kept locked to restrict Mr J’s access to the outside, for safety reasons. Although this was supposed to be temporary accommodation, Mr J and his wife were still living there ten months later when Mr J became ill with a chest infection. He was admitted to hospital, where he sadly died. He was 53.

The Ombudsmen found significant failings by both the NHS Trust and the Council. Mr J’s basic human rights, to liberty and to family life, had not been given appropriate consideration when decisions were being made about his care needs. The importance of Mr J’s family in his life was not appreciated and as a result they were not fully involved in plans for his care. Opportunities to ensure that Mr J’s wishes and best interests were fully taken into account were therefore missed. There was a lack of any properly co-ordinated and documented health and care plan for Mr J, and no-one from either the NHS Trust or the Council took a leadership role and had responsibility for co-ordinating his care and representing his interests. Action was not taken quickly enough to find permanent suitable accommodation for Mr J and his wife, and contact with his family had been restricted.

Following the Ombudsmen’s investigation, the NHS Trust and the Council agreed to provide Mr J’s family with a full acknowledgement of the serious mistakes they made, together with an apology. They also agreed to pay £2,000 in recognition of the distress caused, which the family have said they will donate to charity. The Ombudsmen have also asked the Trust and the Council to prepare, and report progress on, an action plan setting out what they have done (or will do) to ensure that these mistakes are not repeated in future.

Health Service Ombudsman, Ann Abraham, said:

‘Mr J’s rights, best interests, and family relationships were not taken into account when the Trust and the Council made plans for his care. This was highly likely to have had some impact on the quality of his life, and hence his well-being, in the last 18 months or so of his life. Mr J’s family were also wrongly denied the opportunity to be involved and will never know if they could have made a difference to his quality of life in those last months, which must be a cause of significant and ongoing distress for them. It is shocking that the events described in this report happened in the 21st century. I hope the lessons from Mr J’s story will be understood by public bodies and thereby help to drive improvements in public services.’

Local Government Ombudsman, Anne Seex, said:

‘The failures in Mr J’s case show how public authorities can neglect a vulnerable person’s wishes and basic human rights to liberty and family life. The Ombudsmen’s joint investigation brought serious service failures to light. As a result, the authorities concerned will make changes so that other families are not treated this way.’

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