Summary: We found fault in the way a Council, Mental Health Trust and GP Practice supported a vulnerable man in the community for over two years. Each of the organisations has accepted its failings and the impact of them and has taken steps to prevent recurrences, so we have not recommended any further action. We also found a Hospital Trust failed to properly assess the man’s mental capacity while he was an inpatient. This has left the man’s family with uncertainty which is an injustice to them. The Hospital Trust has agreed to provide an apology and to offer a small financial payment to address this.

The complaint

1. Ms A complains about the care and treatment of her late brother, Mr B, between 2017 and 2019. She complains about actions by:

• Northumbria County Council (the Council),
• The Coquet Medical Group (the Practice),
• Cumbria, Newcastle, Tyne & Wear NHS Foundation Trust (CNTW Trust),
• North East Ambulance Service NHS Foundation Trust (the Ambulance Trust), and
• Northumbria Healthcare NHS Foundation Trust (Northumbria Trust).

The Council

2. Ms A complains the Council:
1. Failed to provide appropriate support for Mr B between 2017 and 2019.
2. Failed to properly manage safeguarding processes about Mr B between 2017 and 2019. In particular, Ms A complains the Council failed:

• To ensure there was adequate and consistent attendance at safeguarding meetings and failed to hold any professionals or organisations to account for their lack of attendance or engagement in the process.
• Failed to hold professionals and services to account for failing to follow through with actions that had been agreed at previous meetings. Ms A said there was no rigour and no challenge at the meetings.
3. Failed to ensure that all services had access to Mr B’s safeguarding records in order to help understand his needs and vulnerabilities. Ms A said it was evident that none of the services who interacted with Mr B toward the end of his life had access to this information and, as such, did not have a full and proper understanding of his needs.

The Practice

3. Ms A complains the Practice:
1. Failed, on several occasions, to arrange appointments or home visits for Mr B at times of crisis.
2. Failed to arrange suitable assessments and support for Mr B between 2017 and 2019.
3. Failed to implement its own policies and procedures for the treatment of vulnerable adults – including a failure to ‘code’ Mr B as such in its records.
4. Failed to attend regular safeguarding meetings about Mr B.
5. Failed to complete a review of Mr B’s long-term medication, as requested at safeguarding meetings.
6. Failed to respond appropriately to Mr B’s father’s request for a home visit for Mr B on 13 November 2019. Further, Ms A complains she was unable to get through to anyone at the Practice on this day despite repeated calls.

CNTW Trust

4. Ms A complains CNTW Trust:
1. Failed to provide timely or adequate support for Mr B between 2017 and 2019. As part of this, Ms A said that when CNTW Trust eventually assigned a Community Psychiatric Nurse (CPN) to Mr B’s case, the CPN failed to properly engage and build a rapport with Mr B. She said CNTW Trust then unfairly ended its support of Mr B on the basis that he would not engage.
2. Wrongly put Mr B on a standard care package rather than an enhanced care package.
3. Provided incomplete and unreasonable advice to Northumbria Trust on 16 November 2019 not to implement Deprivation of Liberty Safeguards (DoLS) to keep Mr B on the ward when he said he wanted to leave.

Ambulance Trust

5. Ms A complains a paramedic crew from the Ambulance Trust:
1. Failed to follow its own policies about contacting other professionals or a manager when Mr B refused to go to hospital on 13 November 2019.

Northumbria Trust

6. Ms A complains Northumbria Trust:
1. Inappropriately allowed Mr B to discharge himself from hospital on 16 November 2019, including that it failed to appropriately act on its assessment that Mr B was unlikely to have the capacity to decide to leave.
2. Inappropriately authorised emergency services to force entry to Mr B’s father’s home on 17 November 2019.
3. Failed to treat her with compassion of basic courtesy when she visited a ward to collect Mr B’s death certificate on 22 November 2019.

Claimed impact and injustice

7. Ms A said services – through day-to-day contact with Mr B and through the safeguarding process – failed to produce any positive changes for Mr B. Ms A said the poor management of the safeguarding process also meant that “pieces of the jigsaw were [not] being put together and as a result [Mr B] was let down by services”. Ms A said this made Mr B bitter and angry and frustrated by professionals. Ms A said she felt that if more effective support had been offered to Mr B earlier he might not have got into such a grave situation, and would have enjoyed a better quality of life.
8. Ms A said that, overall, “some of the errors and inefficiencies [in Mr B’s care throughout 2017 to 2019] are highly significant and led to a serious lack of appropriate provision for [Mr B] within his lifetime and also contributed to his untimely and tragic death”.
9. Mr B said that because of these events Mr B lost out on a better quality of life. Further, she said she and her father had been caused significant trauma and distress. Ms A said these events have left her life “severely damaged”.
10. Ms A complains the organisations’ responses to her complaint failed to consider matters in the round and, crucially, failed to properly consider the impact on Mr B and his family. Ms A said, because of this, the organisations have not acknowledged the impact of their failings and have not provided a satisfactory remedy.

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What I have investigated

11. I have investigated issues (a), (b), (f), (g), (h), (j), (k), (l), (m), (n) and (o).
12. I have explained why I have not investigated issues (c), (d), (e), (i) and (p) at the end of this statement.

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The Ombudsmen’s role and powers

13. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
14. 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.
15. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
16. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
17. It is the Ombudsmen’s role to consider complaints in relation to the information that was known to the bodies at the relevant time, and not within the benefit of hindsight. This principle was highlighted by a High Court Judge during a judicial review in 2015. (Paragraphs 38 and 39 of: R (on the application of Rapp) v Parliamentary and Health Service Ombudsman [2015] EWHC 1344 (Admin); Queen's Bench Division, Administrative Court (London))
18. 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)

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How I considered this complaint

19. I read the correspondence and supporting evidence Ms A sent to the Ombudsmen. I also spoke to Ms A on the telephone. I wrote to all the organisations to explain what I intended to investigate and to ask for their comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance.
20. I shared a confidential copy of this draft decision with Ms A and all the organisations and invited their comments on it. I considered all the comments I received in response.

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What I found

Outline of events

January 2017

21. In January 2017 Ms A called CNTW Trust due to concerns that Mr B was in a mental health crisis and needed support. Staff from a crisis team visited Mr B then:

• referred him to adult social care,
• referred him for an autism assessment, and
• contacted the Practice to ask it to review his anti-epileptic and antidepressant medication.

22. The Council did not act on the referral it received. The Autism Diagnostic Service placed Mr B onto its standard waiting list. In the middle of January 2017 a GP at the Practice recorded in Mr B’s records “Medication review done”. There is no further detail including about whether Mr B was present or consulted, or what decisions were made.

October 2017 to October 2019

23. Between October 2017 and October 2019 there were three periods when Mr B’s case was ‘open’ to Adult Care Services (ASC) and when active safeguarding procedures were in place. The referrals to the Council and safeguarding related to Mr B’s vulnerability to abuse and threats in the community and the impact this was having on his mental health and wellbeing.

• October 2017 to June 2018. The ASC involvement resulted in the development of a Care and Support Plan for Mr B. The safeguarding process led to recommendations for actions by the police and a referral to a CNTW Trust Community Treatment Team for support to manage Mr B’s anxiety.
• October 2018 to April 2019. The safeguarding process asked for more work by the police, for housing services to be involved to see what support they could provide, and for a Social Worker to assess Mr B’s capacity to make decisions to keep himself safe. Safeguarding closed its case in December 2018 on the basis that ASC and mental health services would continue to offer support to Mr B. ASC closed its case in April 2019 on the basis that Mr B had refused care.
• April 2019 to October 2019. The safeguarding process recommended action to look into Mr B moving to a different property. It also recommended a Social Worker undertake further work with Mr B, including assessing his capacity and liaising with mental health services. There were plans for Mr B to move to a different area but, in August 2019, Mr B said he no longer wanted to leave his current area. In September 2019 the safeguarding case remained open with plans to review the situation in two months’ time.

24. In June 2018 ASC referred Mr B to CNTW Trust for support. Later in the month the Autism Diagnostic Service assessed Mr B (in response to the referral it received in January 2017). It determined Mr B did have an autistic spectrum disorder (ASD). Staff from the Community Asperger’s Support Team (CAST) and staff from the Community Treatment Team jointly assessed Mr B in December 2018. They felt he did not need support for the features of ASD but that he needed support for emotional regulation, problem solving and mood management. In the first instance it referred Mr B to a Consultant Psychiatrist for further assessment.
25. The Psychiatrist assessed Mr B in March 2019. They agreed that a CPN should offer some support to Mr B. They also noted they were very concerned that Mr B had not attended for a review of his anticonvulsant medication or management of his seizures for more than ten years. They noted they had recommended to Mr B that he should visit his GP about this.
26. CNTW Trust allocated a CPN to Mr B in May 2019. They visited Mr B at various points to look at helping him to manage his anxiety. In October 2019 Mr B said he felt their meetings were pointless and not achieving anything. The CPN offered a further appointment which Mr B cancelled. The Community Treatment Team closed its case in October 2019 on the basis that Mr B would not engage with the CPN.

November 2019

27. Mr B’s father visited Mr B on 13 November 2019 and was concerned about his health. In the late evening an ambulance took Mr A to the Emergency Department at Northumbria Specialist Emergency Care Hospital (the Hospital).
28. Doctors felt Mr B probably had flu and a lower respiratory tract infection, but also had concerns that he may have a problem with his heart. It planned to do more tests. However, in the early hours of 14 November, Mr A discharged himself against medical advice.
29. Ms A arranged for Mr B’s Social Worker to visit him on 15 November to try to persuade him to go back to hospital. A GP from the Practice also went to Mr B’s home they arranged for an ambulance to take him back to hospital in the afternoon.
30. Again, doctors noted concerns about problems with Mr B’s heart. Mr B did not want staff to insert cannulas into his arm. This led to concerns about Mr B’s capacity to make decisions about his care and treatment. In the evening of 16 November a doctor recorded that it was likely Mr B lacked capacity. At this point Mr B was willing to stay in hospital and Hospital staff did not take any further action.
31. At around 10pm on 16 November Mr B left the Hospital and told a member of staff he was going to his father’s house. The hospital called for an ambulance to go to Mr B’s father’s home. They arrived at around 4.30am and forced entry to Mr B’s father’s home shortly before 5am. Mr B was not there and Mr B’s father said he had not seen him.
32. Shortly before 9am the police found Mr B at home. An ambulance attended. Both services reported that Mr B did not want to come back to hospital and had the capacity to make that decision.
33. Mr B’s social worker went to Mr B’s home on 19 November 2019. They found Mr B had died and paramedics confirmed this shortly after midday. One of Mr B’s neighbours called Ms A around 4pm and told her that Mr B had died.

Analysis

Complaint that the Council failed to provide appropriate support for Mr B between 2017 and 2019

34. In its response to a complaint from Ms A the Council acknowledged significant failings in its care of Mr B, including that:

• It failed to act on the referrals it received about Mr B in January 2017.
• It failed to consider using the support of an enabler for Mr B at the initial assessment.
• Before April 2019 it did not consider what support was available to Mr B in the community and, instead, over-relied on the plan for support from CAST without checking what support CAST would offer and whether Mr B would accept it.
• It failed to formally assess Mr B’s capacity to make decisions about his care (following a request for this at a safeguarding meeting in 2018).
• There were several times when there were delays in contacting Mr B within a reasonable timeframe.
• Before closing its case in April 2019 (on the basis that Mr B had declined support), it did not do enough to consider Mr B’s reasons for not engaging and did not do enough to promote his engagement. The report said there was some evidence the allocated Social Workers attempted to engage with Mr B, but there was evidence of drift which meant ‘reachable’ moments were not acted upon.
• When it closed its case in April 2019 it did so without checking if the safeguarding actions had been fulfilled, and despite ‘protection’ issues continuing to be in evidence.

35. In its response to our enquiries the Council reiterated there had been missed opportunities to provide consistent support. It also accepted that when it did record Mr B’s desired outcomes and meaningful activities it did not fully explore them. It acknowledged that it should have. However, the Council said it could not sure that, even if it had, Mr B would have participated in any activities.
36. I agree with the conclusions the Council reached during the local resolution process and have not identified any further failings. Viewed together, these are notable shortcomings in the Council’s care of Mr B.
37. When there were Social Workers allocated to Mr B’s case there is evidence of some good practice. Staff adjusted their approach to contacting Mr B to account for his needs. There is also evidence of staff building a rapport with Mr B by showing an interest in his collections, art and hobbies. The Council also encouraged Mr B to report incidents to the police. It was for the police alone to determine how it responded to incidents, including the ones which preoccupied Mr B for a long time. When the Council produced Care and Support Plans for Mr B it provided draft versions in the first instance and invited comments and amendments to them. I have not seen evidence to suggest it failed to respond to any suggestions for additions to these plans. There is also evidence to show the Council liaised with external professionals about Mr B and looked at ways of improving his situation, including via a house move.
38. On balance, had the delays in the Council’s handling of Mr B’s case not occurred, and had more been done to consider and counter Mr B’s non‑engagement, there would have been a greater opportunity to build a better relationship with Mr B. However, from our independent perspective, we cannot do any more than speculate about what may have been different if the failings had not occurred. There is a possibility that, even with better engagement from the Council, it would not have been possible for it to have provided any practical support that Mr B would have considered suitable or adequate. The Council also may not have been able to provide support which would have been able to resolve the practical problems Mr B faced from other members of the community.
39. Overall, there was fault in the Council’s support of Mr B but the Council has acknowledged this. We cannot say, even on the balance of probabilities, that Mr B missed out on support that he would have found beneficial and which would have resolved his long-running issues. However, the failings have left doubt and uncertainty about missed opportunities. I will return to this impact at paragraph 72.

Complaint that the Council failed to properly manage safeguarding processes about Mr B between 2017 and 2019

Safeguarding guidance

40. If a council thinks someone might be at risk of neglect or abuse, and cannot protect themselves from those risks, it must make any necessary enquiries. The council must also decide whether anyone should take any action to protect the person at risk. This is set out in section 42 of Care Act 2014. The Care and Support Statutory Guidance guides professionals on how to fulfil this duty.
41. The purpose of the enquiry is to decide whether or not the local authority or another organisation, or person, should do something to help and protect the adult. (Section 14.78 of the Care and Support Statutory Guidance)
42. There is no set enquiry process, and ‘The scope of [each] enquiry, who leads it and its nature, and how long it takes, will depend on the particular circumstances’. (Section 14.93 of the Care and Support Statutory Guidance)

What happened

43. During the local resolution process the Council acknowledged failings in the safeguarding proceedings:

October 2017 to 28 June 2018

• Safeguarding policies and procedures were not followed by the Community Social Work Team:
• The threshold tool was not used,
• Timeframes were not adhered to,
• There was no evidence of management oversight,
• No interim safety plan established,
• Relevant partner agencies were not contacted for further information.
• There was no evidence of a safety plan when a meeting was cancelled due to severe weather.
• There was a delay in agreed actions being carried out.
• The safeguarding and Adult Social Care involvement were closed even though Mr B still felt unsafe in the community.
• There was no safety or contingency plan when the case was closed.
• Communication about the closure of the case did not take account of Mr B’s communication preferences.

4 October 2018 to 2 April 2019

• Safeguarding triage was not completed correctly as no one requested information from partner agencies.
• There was a delay in initiating safeguarding procedures.
• Invites to the initial strategy meeting were not sent to the relevant partner agencies.
• The ‘Making Safeguarding Personal’ agenda was not followed at the initial meeting as neither Mr B nor his family were there.
• Invites to the safeguarding planning meeting were not sent to the police.
• The safeguarding case was closed without the knowledge of the Safeguarding Adults Team or the Chair, and while protection issues still existed.
• Not all actions were completed.
• There was no safety or contingency plan on closure.

15 April 2019 to September 2019

• No decision was recorded about alerts raised on 15 and 24 April 2019.
• There was a delay from 3 to 8 May 2019 in deciding what to do about another referral.
• Details of a planning meeting in June 2019 were not recorded according to policy and procedures.
• A review meeting in July 2019 did not give timeframes for actions.
• A review meeting in September 2019 did not request an enquiry report or update and did not discuss suggested actions from a Senior Manager and the legal team (namely, to assess Mr B’s capacity).

All episodes

• Notifications were not always recorded correctly and did not demonstrate the manager’s rationale and an interim safety plan.
• Interim safety plans were not established or agreed.
• There was sometimes poor attendance at meetings and this impacted on Mr B’s experiences and safety plans that might have been agreed with him.
• Enquiries were closed by community teams without agreed actions being completed, and without discussions with the Safeguarding Team.
• Cases were closed twice while protection issues were still evident.
• There was no professional curiosity about why engagement with Mr B was limited and inconsistent, and ‘reachable moments’ were not acted upon.
• Mr B’s mental capacity was not assessed despite there being some factors suggesting it would be appropriate.
• Agreed actions within safeguarding meetings were not referred to.
• The report said it was up to the Chair to ensure actions were properly recorded and understood, with clear actions and timescales. It said it was also up to the Chair to follow-up on previous actions to ensure the plan remained effective.
• The report also said there was a lack of professional challenge within meetings about actions not being completed.

44. In its response to our enquiries the Council said:

• The complaints process had led to it identifying flaws in the invite process and taking steps to improve matters.
• It had made changes to the safeguarding process to ensure action plans are sent out within 48 hours of the meeting and with clear timeframes.

45. Overall, the Council said it accepted the safeguarding process appeared ineffective for Mr B as there did not appear to be any positive changes in his situation. The Council said it would be difficult to determine whether Mr B would have enjoyed a better quality of life had been more effective support been offered. The Council said Mr B had a history of refusing support and mistrusting professionals and there was a chance Mr B would have found the interventions intrusive. However, it accepted that if the failings had not occurred all avenues could have been explored and this might have given Ms A greater confidence in the process.
46. The safeguarding processes did lead to some practical steps aimed at improving Mr B’s situation. Meetings asked for a variety of actions by the police. It seems evident these did not satisfy Mr B, but the actions of the police are beyond the scope of this investigation. The safeguarding process also involved housing services which actively sought alternative properties for Mr B.
47. As with the support ASC provided to Mr B, these were significant failings in Mr B’s and Ms A’s experience of the safeguarding process. As before, it is likely this undermined Mr B’s trust of professionals and had a detrimental impact on his engagement. This has left uncertainty about whether a more effectively led process would have helped Mr B more, although we cannot say this would definitely have been the case. There were limits to what professionals could do to affect the actions of other members of the public, or Mr B’s own choices, or to persuade Mr B to move properties. As such, the impact of these failings is that they left uncertainty. I have considered the issue further at paragraph 72.

Complaint that the Practice failed to implement its own policies and procedures for the treatment of vulnerable adults – including a failure to ‘code’ Mr B as such in its records

48. During the complaints process the Practice acknowledged it did not recognise quickly enough that Mr B was a vulnerable adult, and did not record this status in his notes. The Practice said that during an initial consultation on 9 December 2014 Mr B described himself as “vulnerable”. The Practice acknowledged that this, and other information shared during that consultation, was sufficient to note that he was a vulnerable adult and to code his records as such. The Practice also acknowledged that it failed to record that Mr B needed additional support to access health services, and failed to put measures in place to help Mr B with this.
49. The Practice said if these failings had not occurred the ‘vulnerable adult’ coding would have been visible to all clinical and administrative staff in the Practice who accessed Mr B’s notes. It also said it would have allocated a named GP to Mr B. The Practice said this would have helped to improve Mr B’s continuity of care as he would have been given, wherever possible, appointments with the named GP. Further, any incoming correspondence about Mr B would have been forwarded to the named GP.
50. The Practice said this, in turn, would have helped the named GP to build a professional relationship with Mr B and build an understanding of him and his social circumstances and medical problems. Further, the Practice said Mr B’s increasing familiarity with the named GP may have been helpful to Mr B in terms of his interactions with the Practice.
51. The Practice said a Significant Event Analysis of this complaint had let to actions to improve its practice. It said these changes should lead to quicker recognition of vulnerable adults; either through direct consultations or via incoming correspondence about them. The Practice said ‘coded’ vulnerable adults would be discussed at monthly multidisciplinary Supporting Families meetings. Further, the Practice said it would ask new patients who need extra support if they would like to nominate an advocate. In addition, the Practice said it will take steps to share learning from the case in the local region and would audit the notes of patients classified as vulnerable adults.
52. There was fault here, which the Practice has clearly acknowledged and accepted. The Practice has been open in acknowledging that this is likely to have had a detrimental impact on Mr B’s relationship with its service. As with the failings in the Council’s actions, we cannot say this fault directly led to a specific, personal injustice to Mr B. Throughout this period ASC, mental health services, the police and housing services sought to support Mr B in ways the Practice could not. There would have been limits to what practical support the Practice could have offered to Mr B over and above this. However, I have considered this issue further at paragraph 72.

Complaint that the Practice failed to attend regular safeguarding meetings about Mr B

53. The Practice said the only correspondence it received from the Safeguarding Team were two emails in early 2018 – one on 19 February and one on 6 March. The Practice said it did not know that multiple safeguarding meetings took place as it did not receive any correspondence about them. The Practice did acknowledge that, having been notified of safeguarding enquiries about Mr B, it did not follow up to request minutes of the two meetings it was told about.
54. It said its own interaction with Mr B did not alert it to any issues which needed to be referred to safeguarding. The Practice said that if the safeguarding concerns had been relayed to it, this would have raised its awareness of the problems Mr B was facing. It said this, in turn, would have provided an opportunity for it to proactively try to contact Mr B to see if it could help him.
55. The Practice said it has since reviewed and revised its Safeguarding Adults Policy. It said, under the changes, any notifications it receives about safeguarding meetings should trigger a review of the patient’s notes.
56. As noted above, the Council’s review of its safeguarding processes supports the Practice’s conclusions here. As it was not invited to most of the safeguarding meetings there was no fault by the Practice for not attending.

Complaint that the Practice failed to complete a review of Mr B’s long-term medication

57. In its complaint response the Practice said it had reviewed Mr B’s medication on a number of occasions. It also said it had invited Mr B to further appointments which he had not attended. The Practice said there had been no indication from its reviews for referring Mr B on for a specialist review. The Practice said, in future, it would try to proactively identify the patients who needed more support to access health services, and would try to identify how to best help them.
58. The Practice also advised the Ombudsmen that, since this complaint, it had developed a new policy for Long Term Condition Reviews. It said it will now send three reminders to people. The first two via text (if they have a mobile number) and the third by letter on coloured paper. The Practice said where the patient is coded as a vulnerable adult, if they do not receive a response to the three reminders, the named GP will actively follow up.
59. The Practice records detail that Mr B’s medication was reviewed in January 2017, November 2017 and November 2018. It said at these times a prescribing clinician from the Practice reviewed Mr B’s repeat prescriptions to determine if they should continue or if any other action was required. Mr B was not seen on these dates.
60. When Mr B attended an appointment with a GP in September 2017 they discussed his antidepressant medication but decided against increasing it.
61. The records also show that in May 2017, September 2017 and August 2018 administrative staff wrote to Mr B to invite him to call the Practice to make an appointment to discuss his epilepsy.
62. Therefore, the records support the Practice’s response to the complaint in showing that Mr B’s medication did not go completely unreviewed. As the Practice has suggested, if it had identified that Mr B needed more help to access its services, it may have been able to arrange more face-to-face appointments with Mr B (possibly accompanied by Ms A) to discuss his needs and medication.
63. We do not know whether, had Mr B’s medication been reviewed any further, it would have led to any changes in his prescriptions. Further, we do not know whether any possible changes would have led to a notable improvement in Mr B’s health and wellbeing. In this context, the Practice’s response to this issue is a proportionate one and there is no further action for the Ombudsmen to recommend.

Complaint that CNTW Trust failed to provide timely or adequate support for Mr B between 2017 and 2019; and

Complaint that CNTW Trust wrongly put Mr B on a standard care package rather than an enhanced care package

The Care Programme Approach

64. The Care Programme Approach (CPA) is an approach used in secondary mental health care. It helps to assess, plan, review and coordinate treatment, care and support for people with complex mental health needs. The key guidance on this is: Refocusing the Care Programme Approach: Policy and Positive Practice Guidance (CPA guidance). Services should regularly review whether people still need support under CPA (Page 15 of the CPA guidance).

What happened

65. During the complaints process CNTW Trust acknowledged it failed to:

• Action a plan to allocate Mr B’s case to a CPN on 6 December 2018,
• Note the above failure or address it when Mr B saw a doctor on 8 March 2019, and
• Place Mr B on an Enhanced CPA plan. The Trust noted this meant Mr B was:
• Not reviewed by a psychiatrist after six months and
• Discharged without a formal care review involving all the professionals involved in his care.
• Ensure there was consistency in the appointments offered to Mr B by his allocated CPN, with large gaps between appointments.

66. In addition, in its response to our enquiries, CNTW Trust also acknowledged its CPN had not recorded:

• The reasons why they were unable to attend a safeguarding meetings in May and June 2019, or any update(s) they gave to the safeguarding team about their involvement with Mr B,
• Any liaison they had with Mr B’s Social Worker following the safeguarding meeting in June 2019.

67. In terms of the delay in allocating Mr B to a CPN, CNTW Trust said it had reviewed the data for the period. It said, on average, people waited up to 110 days to be allocated to a practitioner. It said Mr B waited 146 days for allocation (going from his assessment on 6 December 2018 and his first appointment with the Community Treatment Team on 21 May 2019). As such, CNTW Trust said Mr B was not subject to a significant delay.
68. CNTW Trust said it has introduced Unallocated Case Guidance for people who are awaiting allocation longer than four weeks. It said this includes instructions to staff to have four-weekly telephone contact with people who are waiting and to offer face-to-face contact on alternative months.
69. CNTW Trust said it accepts that the failings in its care of Mr B “limited opportunity for engagement to build therapeutic alliance and engage with support which could have enhanced quality of life”. It said that since these events its Community Treatment Teams’ approach has changed from providing episodic care (with a focus on specific interventions and treatment) to promoting proactive and assertive engagement. It also said a policy on promoting engagement gave clear guidance to staff. CNTW Trust said it also reviews all unplanned discharges at multidisciplinary team meetings and has enhanced the teams’ safeguarding processes
70. Overall, as CNTW Trust has already acknowledged, there was notable fault in the care and support it provided to Mr B. I have not found evidence of any further fault which CNTW Trust has not already accepted.
71. From our independent perspective we cannot say for certain that the failings in Mr B’s care meant he missed out on support that would have been a significant benefit to Mr B. The evidence from the records shows significant ongoing issues in Mr B’s life related to practical issues which practitioners from CNTW Trust would not have been able to resolve. However, it is possible that with better, more consistent engagement with a mental health professional, Mr B may have felt better able to manage his anxiety and preoccupying thoughts around these issues. I have explored this impact further, below.

Combined injustice of the faults between January 2017 and October 2019

72. As noted in the previous sections, there would have been limits to what each of the services involved in Mr B’s life could have done to improve his situation. He lived independently and, seemingly, had the mental capacity to make his own choices about who he associated with and how he lived his life. However, when viewed together, the combined impact of the failings in Mr B’s care throughout this time it notable. Collectively, had services responded more appropriately to Mr B’s situation, in a more timely manner, he may have responded more positively. This in turn could have led to more regular engagement, better relationships and this could have led to changes which would have reduced the stress, frustration and upset Mr B often experienced. However, there are too many variables and unknowns to be able to do anything more than speculate about this.
73. The combined faults of the Council, the Practice and CNTW Trust have left Ms A with considerable, understandable, uncertainty and distress about lost opportunities. This is an injustice to her. In each of the organisations’ responses to the complaint they have acknowledged this uncertainty, and the possibility that Mr B may have lost out on support which would have been helpful. Viewed alongside the services’ openness about their individual failings, and the steps they have taken to prevent recurrences, these acknowledgements are a proportionate response to the injustice. As such, I have not recommended any further action.

Complaint that CNTW Trust provided incomplete and unreasonable advice to Northumbria Trust on 16 November 2019 not to implement DoLS

74. CNTW Trust said there is no evidence its staff told Northumbria Trust staff not to implement DoLS on 16 November 2019. It said the Psychiatric Liaison Service provided appropriate advice to the ward.
75. Records show hospital staff contacted CNTW Trust’s Liaison Psychiatry team in the morning and evening of 16 November 2019 for advice about Mr B’s capacity. The team encouraged staff to contact a CNTW Trust on-call specialist registrar for guidance and support. The team said it also advised ward staff about using “DoLS if attempting to leave”.
76. Based on this evidence, I have not found fault in CNTW Trust’s actions here.

Complaint that the Ambulance Trust failed to follow its own policies about contacting other professionals or a manager when Mr B refused to go to hospital on 13 November 2019

77. In its response to the complaint the Ambulance Trust acknowledged:

• Its records from 13 November 2019 did not articulate the crew’s findings about Mr B’s mental capacity decide whether to go to hospital. The Ambulance Trust said that evidence from the crew’s radio contact with the control room suggested they had reached a view that Mr B did have the capacity to make this decision.
• On 13 November 2019 the crew did not contact the Clinical Support Desk or Clinical Care Manager before they left Mr B’s home.

78. These were failings in Mr B’s care. They mean Ms A cannot be assured that everything had been done before leaving Mr B. However, when an ambulance went to Mr B around three-and-a-half hours later they were able to persuade Mr B to go to hospital. As such, the failings here did not lead to a significant injustice. As the Ambulance Trust has already acknowledged and addressed its failings there is nothing further the Ombudsmen can add.

Complaint that Northumbria Trust inappropriately allowed Mr B to discharge himself from hospital on 16 November 2019

Mental Capacity and Best Interests

79. The Mental Capacity Act 2005 (the MCA) is the framework for acting and deciding for people who lack the mental capacity to make choices of their own. The MCA and associated Code of Practice (the Code) describe the steps people should take when deciding something for someone who cannot make that decision on their own.
80. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
81. The Code says, at paragraph 2.11, there may be cause for concern if somebody repeatedly makes unwise decisions exposing them to significant risk of harm or exploitation. The Code says this may not necessarily mean the person lacks capacity but further investigation may be required.
82. The Code sets out a two-step test for assessing a person’s capacity. The first step is to consider whether the person has an impairment or disturbance in the way their mind or brain functions. The Code gives significant learning disabilities as an example.
83. The second step is to determine whether the impairment means the person is unable to make a specific decision. A person is unable to make a decision if they cannot:

• understand information about the relevant decision;
• retain the information;
• use or weigh the information to make a decision; or
• communicate the decision.

84. A key principle of the MCA is that any decision, or action, must be in the best interests of the person without capacity. Section four of the MCA provides a checklist of steps that decision makers must follow to determine what is in a person’s best interests. Chapter five of the Code of Practice gives guidance on how to work out a person’s best interests.
85. When deciding whether a decision is in someone’s best interests, the decision makers must consider all the relevant circumstances relating to the decision in question. As far as possible, the decision maker must consult other people where appropriate and take into account their views as to what would be in the best interests of the person lacking capacity. In particular they should consult:

• anyone previously named by the person lacking capacity as someone to be consulted, and
• carers, close relatives or close friends or anyone else interested in the person’s welfare.

86. The MCA Code of Practice notes that “Any staff involved in the care of a person who lacks capacity should make sure a record is kept of the process of working out the best interests of that person for each relevant decision, setting out:

• how the decision about the person’s best interests was reached
• what the reasons for reaching the decision were
• who was consulted to help work out best interests, and
• what particular factors were taken into account.

The record should remain on the person’s file” (Section 5.15 of the MCA Code of Practice).

Deprivation of Liberty Safeguards

87. DoLS are an amendment to the MCA. DoLS provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. DoLS protect people from being deprived of their liberty unless it is in their best interests and there is no other less restrictive alternative.
88. Once there is, or is likely to be, a deprivation of liberty it must be authorised. Without authorisation a deprivation of liberty is unlawful.
89. The ‘managing authority’ (i.e. the hospital where a patient is admitted to) must request authorisation from the ‘supervisory body’ (usually the local council). There must be a request and an authorisation before a person is lawfully deprived of his or her liberty.
90. There are two types of authorisation: standard authorisations and urgent authorisations. Urgent authorisations are made by the managing authority in urgent cases only, for seven days, pending application for a standard authorisation.
91. Section 6.2 of the Deprivation of Liberty Safeguards Code of Practice (the DOLS Code) notes that “Urgent authorisations should normally only be used in response to sudden unforeseen needs…”
92. Section 6.11 of the DOLS Code states that when a managing authority is considering using an urgent authorisation it “must, as far as is practical and possible, take account of the views of anyone engaged in caring for the relevant person or interested in their welfare”. However, section 6.13 notes that “The ultimate decision, though, will need to be based on a judgement of what is in the relevant person’s best interests”.

What happened in Mr B’s case

93. When Mr B was in hospital on 16 November 2019 he resisted treatment and staff had concerns about whether he had the mental capacity to understand the choices he was making. There is evidence to show they sought support to assess this from the Psychiatric Liaison service. However, it remained the responsibility of clinicians on the ward to make the necessary assessments and judgements. A doctor reviewed Mr B in the evening and recorded he had “limited ability to retain, weigh up and communicate information. Likely does not have capacity”.
94. By this point staff had concerns that Mr B had a significant, potentially life‑threatening heart problem. They also knew that he had recently discharged himself against medical advice. In this context it was important the clinical team in charge of Mr B’s care made a clear, well documented decision about whether Mr B had the capacity to make decisions about his care and treatment. And, if not, to properly explore what was in Mr B’s best interests and to document what they concluded. It would only have been appropriate to have requested an urgent DoLS if this had been done properly.
95. In this instance the assessment of Mr B’s capacity was not adequate. There is insufficient information about what information was shared with Mr B, or how the professional tested or measured Mr B’s ability to retain it or weigh it up. There is also no information about whether staff attempted multiple approaches to Mr B to help test his ability to retain information. There is also no information about whether they considered contacting next of kin for collateral information or, potentially, assistance in discussing the situation with Mr B. As such, there was fault in how Northumbria Trust considered Mr B’s capacity to make decisions about his care and treatment.
96. In the days before this, and shortly after it, other professionals also considered Mr B’s capacity when he was felt to be making unwise choices about his physical health:

• In the early hours of 14 November 2019, while Mr B was in hospital, staff explained to him that they needed to complete more tests to be sure that he had not suffered a heart attack. Mr B said he wanted to go home anyway. The doctor recorded that Mr B had the capacity to make this decision.
• In the morning of 17 November 2019 the police called the Hospital ward and said they had found Mr B at home. They said Mr B did not want to return to hospital and, in their view, he had the capacity to make that choice.
• Also in the morning of 17 November 2019 paramedics called the Practice. They also noted that Mr B did not want to go back to hospital and had the capacity to make that decision.

97. In view of this information, and given the limited nature of the capacity assessment on 16 November, we cannot say from our independent perspective that Mr B lacked the mental capacity to decide whether to stay in hospital on that day. It is possible that, had a more robust assessment been completed, the assessment may have concluded Mr B did have the capacity to choose to leave hospital even though the professionals all felt this to be an unwise decision. Because of this, we cannot say that the Hospital should have put an urgent DoLS in place which would have allowed staff to prevent Mr B from leaving.
98. Nevertheless, the fault in the capacity assessment has still caused an injustice. The fault has left considerable doubt about whether events would have been different without the fault, and whether Mr B may have missed out on inpatient treatment which would have helped him. Just as we cannot say that the Hospital definitely should have kept Mr B in hospital we also cannot say that further inpatient treatment would have saved his life. However, the uncertainty around these events has been a caused of distress and upset to Ms A and this is an injustice to her. I have made a recommendation to address this injustice below.

Complaint that Northumbria Trust inappropriately authorised emergency services to force entry to Mr B’s father’s home on 17 November 2019

99. After Mr B left the Hospital in the late evening of 16 November 2019 ward staff called the police and explained the situation. The police told the ward to call an ambulance. The ward did so. An ambulance arrived at Mr B’s father’s house at around 4.30am on 17 November 2019. No one answered. The crew called staff on the ward at the Hospital and asked whether they needed to force entry into the house. Hospital staff recorded that a nurse said Mr B “was a high risk and needed medical treatment in hospital, so the crew did need to force entry.”
100. The ambulance crew, aided by the fire service, forced entry to Mr B’s father’s home shortly before 5am. Fire officers and paramedics searched the house looking for Mr B. Mr B was not there and Mr B’s father said he had not seen him. The ambulance crew advised the Hospital which then contacted the police again.
101. There is an entry in Northumbria Trust’s records which states Mr B told a member of staff that he was going to his dad’s house as he left the Hospital. In this context it was reasonable for ward staff to believe Mr B may have been at his father’s house. The investigation results the Hospital had were concerning and suggested Mr B had significant problems with his heart. The nature of the clinical findings meant there were understandable concerns about Mr B’s immediate health. In this situation, while the events were clearly alarming and distressing for Mr B’s father, there was an appropriate clinical rationale behind them. As such, I have not found fault with Northumbria Trust’s request that paramedics force entry to the house.

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Agreed actions

102. Within four weeks of the final decision Northumbria Trust should write to Ms A to acknowledge the fault identified in paragraph 95 of this decision statement. Northumbria Trust should also apologise for the impact of this fault, as set out in paragraph 98.
103. Within two months of the final decision Northumbria Trust should offer to pay Ms A £300 as a tangible acknowledgement of the injustice Ms A experienced because of its fault. This payment is not compensation, but is a symbolic payment to acknowledge the impact of the uncertainty Ms A has been left with.
104. Within three months of the final decision Northumbria Trust should produce an action plan to address the fault identified in this statement. The action plan should seek to implement, in a SMART way, measures to prevent similar failings happening again.

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Decision

105. I have completed this investigation on the basis that there was fault which caused injustice which will be addressed through the recommendations of this investigation.

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Parts of the complaint that I did not investigate

106. I did not investigate issue (c) as there is no clear way the Council would have been able to achieve the information sharing Ms A wanted. Each health and social care organisation keeps its own records and would not have access to the Council’s files. As such, if we were to investigate this issue, the only impact we might be able to find would be that Ms A may have been caused avoidable frustration by being given incorrect information. This is not an injustice serious enough to warrant an Ombudsmen investigation.
107. I did not investigate issues (d) and (e) as we did not have enough specific details about when these claimed failings occurred, and what the impact of each was. Without this it would be difficult for an investigation to be able to reach clear, evidence‑based findings about specific failings which caused a personal injustice.
108. I did not investigate issue (i) because, later that day, Ms A was able to call 111 which arranged for an ambulance came to assess Mr B. As such, while Ms A’s frustration about not being able to contact the Practice is understandable, an investigation would not be able to link this incident led to a specific personal injustice.
109. I did not investigate issue (p) because it is unlikely an investigation would be able to achieve significantly more than the apology Northumbria Trust provided in its complaint response.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman