Allison House (23 018 947c)

Category : Health > Community hospital services

Decision : Not upheld

Decision date : 29 Jul 2024

The Ombudsman's final decision:

Summary: Ms Y complained that professionals failed to understand her mother’s personality and wrongly determined she lacked capacity. Ms Y said this led to a decision to transfer her mother to a nursing home which caused her distress. In addition, she said it led to a hospital and a nursing home placing unnecessary restrictions on her mother. We have not found fault in the way professionals considered Mrs X’s capacity. However, we have found fault in the way a Council considered Mrs X’s best interests before placing her in a nursing home. This caused avoidable distress and we have recommended an apology and a small financial payment.

The complaint

  1. Mrs X went into North Tees Hospital in April 2023. North Tees and Hartlepool NHS Foundation Trust (NTH Trust) is responsible for this hospital. Staff from Tees, Esk and wear Valleys NHS Foundation Trust (TE&WV Trust) and Stockton-on-Tees Borough Council (the Council) were also involved in Mrs X’s care. Mrs X’s daughter, Ms Y, complains that:
      1. Staff continued to contact Mr X’s son about Mrs X’s care after concerns were raised about him sending abusive and threatening messages to Mrs X.
      1. Staff failed to consider all relevant factors, or obtain adequate supporting information from the family, in order to fully and properly understand the nature of Mrs X’s presentation. Ms Y said this resulted in doctors misdiagnosing Mrs X, and staff wrongly determining that Mrs X lacked the capacity to make decisions about her care and accommodation.
      2. NTH Trust inappropriately and unnecessarily implemented urgent Deprivation of Liberty Safeguards (DoLS) for Mrs X for four days. Ms Y said this caused Mrs X distress during her time on the ward.
      3. Professionals failed to properly consider Mrs X’s best interests, and failed to properly involve Ms Y in the best interests’ process.
  2. Ms Y said that, because of these issues, Mrs X was transferred to an inappropriate care home which terrified and traumatised her. Ms Y said the way services treated Mrs X made her last few months miserable and terrifying. Further, Ms Y said she suffered from stress because of the way Mrs X was treated.
  3. After she left hospital Mrs X moved into Allison House and stayed there for two days. Ms Y complains that:
      1. Staff at Allison House wrongly told her that DoLS were in place, and that Ms Y could not remove Mrs X from its care. Ms Y said no one told her that DoLS had not been properly authorised, or that she was able to discharge Mrs X. Ms Y said this meant Mrs X had to remain in Allison House for longer than necessary.
      1. Allison House took Mrs X’s nebuliser, lighters and phone charger away from her. Ms Y said this caused Mrs X avoidable distress and stress.
      2. Allison House inappropriately sought to have anti-psychotic medication prescribed for Mrs X.
  4. Mrs X returned to North Tees Hospital in May 2023.
      1. Ms Y complains that NTH Trust and the Council inappropriately and unnecessarily implemented DoLS during this admission.

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The Ombudsmen’s role and powers

  1. 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). The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended). The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
  2. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we can complete our 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)
  3. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
  4. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 

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What I have and have not investigated

  1. I have investigated issues (a) to (f) and issue (h) listed above. I have not investigated issue (g) because a team assessed Mrs X and did not prescribe or administer any medication to Mrs X. As such, it is unlikely an investigation by the Ombudsmen would be able to find evidence of a personal injustice related to this issue.

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How I considered this complaint

  1. I considered Ms Y’s written complaint to the Ombudsmen and spoke to her on the phone. I wrote to the NH&T Trust, TE&WV Trust, the Council and Allison House to explain what I intended to investigate and to ask questions and for relevant evidence. I considered all the papers I received in response. I read relevant legislation and guidance.
  2. I shared a confidential version of this draft decision with Ms Y and the organisations and invited their comments on it. I considered all the comments I received in response.

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What I found

Legislation and guidance

Mental Capacity

  1. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Mental Capacity Act 2005 (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
  2. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:
  • because they make an unwise decision;
  • based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
  • before all practicable steps to help the person to do so have been taken without success.
  1. Health and social care organisations must assess someone’s ability to make a decision when that person’s capacity is in doubt. How they assess capacity may vary depending on the complexity of the decision.
  2. An assessment of someone’s capacity is specific to the decision to be made at a particular time. When assessing somebody’s capacity, the assessor needs to find out the following:
  • Does the person have a general understanding of what decision they need to make and why they need to make it?
  • Does the person have a general understanding of the likely effects of making, or not making, this decision?
  • Is the person able to understand, retain, use, and weigh up the information relevant to this decision?
  • Can the person communicate their decision?
  1. The person assessing an individual’s capacity will usually be the person directly concerned with the individual when the decision needs to be made. More complex decisions are likely to need more formal assessments.
  2. If there is a conflict about whether a person has capacity to make a decision, and all efforts to resolve this have failed, the Court of Protection might need to decide if a person has capacity to make the decision.

Best interest decision making

  1. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
  2. If there is a conflict about what is in a person’s best interests, and all efforts to resolve the dispute have failed, the Court of Protection might need to decide what is in the person’s best interests.

Deprivation of Liberty Safeguards (DoLS)

  1. The Deprivation of Liberty Safeguards 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. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without the authorisation, the deprivation of liberty is unlawful. It is the responsibility of the care home or hospital to apply for authorisation. The DoLS Code of Practice 2008 provides statutory guidance on how they should be applied in practice.
  2. The Supreme Court defined deprivation of liberty as when: “The person is under continuous supervision and control and is not free to leave, and the person lacks capacity to consent to these arrangements”.
  3. Once there is or is likely to be a deprivation of liberty, it must be authorised under the DoLS scheme in the Mental Capacity Act 2005.
  4. The ‘managing authority’ of the care home or hospital (the person registered or required to be registered by statute) must request authorisation from the ‘supervisory body’ (the council). There must be a request and an authorisation before a person is lawfully deprived of their liberty.
  5. The application for authorisation should be made within 28 days.
  6. There are two types of authorisation: standard authorisations and urgent authorisations. Standard authorisations are made by the council.
  7. On application, the supervisory body must carry out assessments of the six relevant criteria: age, mental health, mental capacity, best interests, eligibility and ‘no refusals’ requirements. A minimum of two assessors, usually including a social worker or care worker, sometimes a psychiatrist or other medical person, must complete the six assessments. They should do so within 21 days, or, where an urgent authorisation has been given, before the urgent authorisation expires.
  8. Urgent authorisations are made by the managing authority of the care home in urgent cases only, for seven days, pending application for a standard authorisation. In some cases, the supervisory body can extend an urgent authorisation up to 14 days in total.

Brief summary of events

  1. Mrs X lived alone. She had made private arrangements for support workers to visit her twice a week. Mrs X had declined offers of support from the Council.
  2. In the middle of April 2023 Mrs X went into hospital. Doctors did not find anything that needed treatment in hospital. Staff tried to assess Mrs X with a view to offering support when she returned home. They recorded that Mrs X would not engage with their assessment. Staff noted that they considered Mrs X had the capacity to make this choice and discharged her home.
  3. The next day Mrs X called Ms Y in a distressed state. She was unable to move to go to the toilet or to get food or drink. Paramedics took Mrs X back to hospital. The paramedics also raised concerns with the Council that Mrs X appeared not to be coping at home and needed more support.
  4. On the following day medics considered Mrs X to be medically stable enough to return home. Staff saw Mrs X, to offer support at home. They noted that Mrs X would not engage in their assessment. The team recorded that they felt Mrs X had the capacity to make this decision but thought it should be considered more thoroughly through a formal capacity assessment. They said that, if this found Mrs X had the capacity to make her own decisions about her living arrangements and support, the hospital should discharge her home. It also said that, if the assessment found Mrs X did not have capacity, the hospital would need to implement DoLS to allow for a period of assessment.
  5. On the next day:
  • Staff from the Frailty Team and an Occupational Therapist (OT) saw Mrs X. They spoke to her about how she would manage at home and recorded that Mrs X could not follow the conversation or make an informed decision. They referred Mrs X to the Psychiatric Liaison team and spoke to staff from adult social care to get more information.
  • A doctor reviewed Mrs X separately. They also noted concerns that Mrs X was unable to have a full conversation, or properly understand the relevant risks, about returning home. They did not consider Mrs X had the capacity to decide her discharge arrangements because of an inability to retain information or to understand the relevant risks. The doctor concluded that Mrs X did not need to be in hospital for any medical reason but needed a psychiatric assessment.
  • Mrs X’s son visited Mrs X on the ward. Staff spoke to Mrs X and her son about Mrs X’s living situation at home. An altercation occurred and Mrs X said things which led hospital staff to seek advice from safeguarding colleagues. This, in turn, led to a safeguarding referral to the Council.
  • Staff completed paperwork to implement urgent DoLS for seven days and to request standard authorisation. This was due to professionals’ views about Mrs X’s capacity and ability to manage at home without support. The application said Mrs X did not have the capacity to make safe decisions and needed supervision in hospital to protect her from self-neglect and deterioration if she left.
  • A practitioner from the Psychiatric Liaison Team reviewed Mrs X. They requested further assessments the next day. They also suggested that a capacity assessment and DoLS should be considered.
  1. On the following day:
  • A doctor from the Psychiatric Liaison Team reviewed Mrs X. After they had spoken to Mrs X the doctor called Mrs X’s son to ask for additional information. The doctor found that Mrs X’s presentation might be in keeping with paranoid personality traits, and that she may also have a delirium.
  • The doctor from the Psychiatric Liaison Team called Ms Y in the afternoon, returning her call. They advised Ms Y to speak to the ward for further information.
  1. Two days later:
  • The hospital referred Mrs X to the Council, asking it to arrange a placement for her in a nursing home.
  • The Council noted that Mrs X had previously said she would not want to go into a care home, but others felt she needed such a placement. The Council asked for a best interests decision about where Mrs X should be discharged to.
  • A Council safeguarding officer emailed other professionals and noted that Ms Y wanted to be kept updated about Mrs X’s discharge plans.
  1. On the next day:
  • A member of staff from the Frailty Team considered Mrs X’s capacity to decide whether she should return home. They concluded she did not have the capacity to make this decision.
  • An OT from the Psychiatric Liaison Team and a social worker from the Council saw Mrs X together. They discussed how Mrs X might manage at home and both professionals talked to her about why they felt she needed to go into a nursing home. They concluded that Mrs X lacked insight into her care needs and did not have the capacity to make the relevant decision. This, in turn, led to a recommendation for a best interests decision on Mrs X’s behalf, about where she should go when she left hospital. The OT gave their view that they considered a place in a nursing home would be the most suitable option at present and asked for this to be arranged, in Mrs X’s best interests.
  • Following the OT and social worker’s conversation with Mrs X, the social worker called Ms Y. The social worker said professionals had made a decision in Mrs X’s best interests to place her in a nursing home for a period of assessment. They noted Ms Y disagreed with this decision.
  • The social worker completed a best interests form following the telephone conversation with Ms Y. The form noted Ms Y’s views. It recorded that Mrs X and Ms Y wanted Mrs X to return home. It said this would mean Mrs X’s needs would not be met and she would be at risk of harm. The form recorded that a nursing home would be able to meet Mrs X’s needs and would reduce the risk of harm to her. It said, because of this, while it was a more restrictive option than Mrs X returning home, it was in her best interests.
  1. On the following day (a Saturday):
  • Mrs X left hospital and went to Allison House for a period of assessment.
  • In the evening, Mrs X asked staff for her inhalers. Staff gave her two inhalers. Mrs X asked for them an all. While a member of staff was away Mrs X moved to another area and called an ambulance. Paramedics arrived and did not have any concerns about Mrs X’s health and supported her to return to bed.
  • Mrs X also called the police and said Allison House was depriving her of her nebuliser.
  1. On the Sunday Allison House raised concerns with a mental health team that it was struggling to manage Mrs X’s needs.
  2. On Monday:
  • Mrs X called the Care Quality Commission (the CQC) to raise concerns about her care and treatment at Allison House.
  • Allison House contacted Mrs X’s social worker to note it was struggling to manage Mrs X’s needs and that she wanted to return home.
  • Allison House completed paperwork to implement urgent DoLS. The form stated that the DoLS were required from the date of Mrs X’s arrival.
  • Allison House called Mrs X’s social worker and asked them to arrange alternative accommodation for Mrs X.
  • A social worker called Ms Y and encouraged her to wait for a review for a planned discharge. They told Ms Y there was nothing to prevent her from taking Mrs X home. Ms Y said she would collect Mrs X and take her home that day, and would provide support to her there. The social worker asked Allison House to keep Mrs X’s place open for two days as a contingency plan, and said they would arrange a review of Mrs X’s needs in the community.
  • Ms Y took Mrs X home in the afternoon.
  1. Social care staff visited Mrs X and Ms Y several days later to assess Mrs X’s needs. The social worker found Mrs X had needs which would be eligible for support. However, they noted Mrs X wanted to make her own care arrangements and did not want the Council to arrange any support for her. The social worker concluded that Mrs X had the capacity to decide where she should live and what care she should receive.
  2. In the middle of May one of Mrs X’s private support workers called the Council and raised concerns that Mrs X did not have enough support. A social worker called Mrs X and, owing to symptoms Mrs X described, advised her to call an ambulance to go to hospital. Mrs X arrived at the Emergency Department later that afternoon. The hospital recorded that the reason for Mrs X’s admission was a reduced ability to move around on her own due to chronic pain and was not managing at home.
  3. Two days later medics decided Mrs X was medically stable enough to leave hospital and referred her to the Council. The Council began considering support for Mrs X in her own home. However, in the days after this staff felt that Mrs X had become more confused and was no longer medically stable enough to leave hospital.
  4. Four days after the Mrs X’s admission a doctor assessed her capacity to decide whether to remain in hospital and whether to undergo further investigations and treatment. The doctor concluded that Mrs X did not have capacity to make these choices. Following this, NTH Trust implemented urgent DoLS for seven days and applied for standard authorisation. The nature of the restrictions was “supervision in an acute hospital” and noted that Mrs X was not free to discharge herself on the basis that she would be at risk of harm.
  5. On the same day doctors noted Mrs X had a possible infection and prescribed antibiotics. Staff from the Psychiatric Liaison service also assessed Mrs X. They noted that DoLS had been put in place.
  6. Several days later a psychiatrist assessed Mrs X’s mental health and capacity as part of the application for the standard authorisation for DoLS. The assessments supported the application. Toward the end of the month the Council completed further assessments and approved the standard authorisation for four weeks.
  7. At the end of May 2023 various professionals and Ms Y attended a multi‑disciplinary meeting. They considered various options for Mrs X’s care when she left hospital. It was agreed that Mrs X should return home to be supported there by support arranged by the Council.
  8. The Council began arranging this. The first care provider they approached did not have capacity to provide the necessary support. The second provider did. It agreed to start supporting Mrs X at home from 12 June.
  9. On 9 June Mrs X had a seizure on the ward and a scan found she had a large intracerebral haemorrhage. She died later that day.

Analysis

Complaint (a) – that staff continued to contact Mr X’s son about Mrs X’s care

  1. Staff first spoke to Mrs X’s son while he was on the ward, visiting Mrs X. This was reasonable. The circumstances of the visit resulted in a safeguarding referral. This did not relate to abusive or threatening messages.
  2. On the next day a doctor from the Psychiatric Liaison team spoke to Mrs X’s son to ask for information. They wanted more information to add to what they had gathered from the records and from their direct contact with Mrs X. The day after that a member of the Discharge Team called Mrs X’s son and left a message for him. He told Ms Y that when he called back they advised that Mrs X would be discharged to a care home. There is no evidence of any further contact with Mrs X’s son before she left hospital.
  3. At the point when the doctor called Mrs X’s son the safeguarding concern had not been investigated. There had been no advice from the safeguarding team to limit contact with any member of Mrs X’s family. The evidence does not suggest any professional placed a disproportionate amount of weight on the information that was obtained from Mrs X’s son.
  4. Overall, I have not found any evidence of fault here.

Complaint (b) – that staff failed to consider all relevant factors to fully and properly understand the nature of Mrs X’s presentation and wrongly determined that Mrs X lacked the capacity to make decisions about her care and accommodation

  1. The evidence from the two Trusts’ records and the Council’s records shows that staff did not rush to conclusions about Mrs X. There is evidence to show that staff sought advice and second opinions from colleagues. There is also evidence to show that various professionals had appropriately detailed discussions directly with Mrs X before reaching conclusions about likely diagnoses, and about Mrs X’s capacity.
  2. I have seen that, at Mrs X’s prior attendance at hospital, staff concluded that she had the capacity to decide to go home. I have also seen that when Mrs X was at home, between the hospital admissions in April and May, the Council also found she had the capacity to decide to reject its offers of help. However, this does not mean that the professionals’ judgements about Mrs X’s capacity were wrong. Capacity can fluctuate and guidance is clear that it needs to be considered on a time- and decision‑specific basis. It is also not the Ombudsmen’s role to make or re-make judgements about whether a person had capacity at any given point.
  3. Overall, there is evidence to show that professionals considered a proportionate and adequate amount of information before making decisions about Mrs X’s presentation and capacity. I have not found fault here.

Complaint (c) – that NTH Trust inappropriately and unnecessarily implemented urgent DoLS for Mrs X for four days in April 2023

  1. The Ombudsmen’s role here is to consider whether professionals followed the appropriate process. In this instance there is evidence to show that professionals thought about the necessary factors when considering whether Mrs X had the capacity to decide whether to stay in hospital. There is also evidence that NTH Trust completed appropriate paperwork in order to implement urgent DoLS and to request standard authorisation, in case Mrs X remained in hospital after seven days. As such, I have not found fault here.

Complaint (d) – that professionals failed to properly consider Mrs X’s best interests, and failed to properly involve Ms Y in the best interests’ process, in April 2023

  1. During the complaints process the Council acknowledged that:
  • There should have been more discussion about Mrs X’s discharge plans in April, and
  • Ms Y should have been invited to a face-to-face meeting with professionals to discuss Mrs X’s best interests, and it should have delayed Mrs X’s discharge until this could be arranged.
  1. The Council said that, if these things had happened, they would have allowed more comprehensive discussions of the available options. It said it would also have allowed Ms Y a chance to discuss her views and wishes, and to explain what support she was willing to provide.
  2. The Council said a return home with a combination of formal and informal care “could have been a viable option had time been taken to consider this”. The Council acknowledged that “if more person-centred discharge planning had taken place” the long-standing nature of Mrs X’s mental health needs, and the fact that the hospital environment was exacerbating it, would have been more evident.
  3. I agree with the Council’s conclusions. There is evidence to show that various professionals talked directly to Mrs X about her needs and home circumstances. I can also see that staff spoke to Ms Y and recorded her disagreement with the plan to discharge Mrs X to Allison House. However, on balance, the evidence suggests that the professionals had already decided to discharge Mrs X to Allison House before they spoke to Ms Y. This is not in line with guidance on the best interests process. Given professionals did not consider Mrs X had the capacity to understand the decision in question, there should have been a family member present during the discussions to represent Mrs X.
  4. Overall, there was fault here, by the Council. Mrs X was an inpatient of an NTH Trust hospital, and staff from TE&WV Trust took part in discussions. However, the evidence suggests it was the Council which made the final decision about Mrs X’s discharge plans.
  5. The impact was that there was a missed opportunity to have a full and proper discussion about Mrs X’s wishes and the options available to her. Further, given the outcome of the discharge discussions in May, and what we know about Mrs X’s wishes when she was deemed to have capacity, it is more likely than not that a properly completed best interests process would have resulted in different decision.
  6. The evidence available to me shows that Mrs X found her time in Allison House to be stressful and upsetting. Ms Y has explained that Mrs X was a very independently minded and spirited person and found controlled environments and situations difficult. She also enjoyed smoking and was unable to do this freely when in Allison House, instead needing to rely on staff taking her outside. Mrs X’s calls to the police, and ambulance and the CQC demonstrate her unhappiness at Allison House. On balance, the distress and upset Mrs X experienced while in Allison House was avoidable. Ms Y was witness to these events and Mrs X’s distress. This, in turn, caused her stress and upset which is an injustice to her.
  7. While the Council was open in acknowledging the fault already, I do not consider it did enough to address the injustice Ms Y experienced. I have, therefore, made recommendations below.

Complaint (e) – that staff at Allison House wrongly told Ms Y that she could not remove Mrs X from its care

  1. During the complaints process the Council acknowledged that there had not been any valid DoLS in place during Mrs X’s time in Allison House because the relevant paperwork was not completed at the correct time. It also noted that, even if they had been in place, they would not have prevented Ms Y from taking Mrs X home. The DoLS in Allison House would have related to her being in a locked environment, and needing to ask staff for access to the outside and to some of her possessions.
  2. The Council said that it told Ms Y she could take Mrs X home as soon as it knew she wanted to. Allison House said that it had a duty of care to ensure Mrs X was not discharged from its care without appropriate care being arranged in coordination with the social worker and family.
  3. Based on the information available to me I cannot say, even on balance, what Ms Y or Mrs X were told by Allison House at any given time. However, it is apparent that Mx Y was under the impression that she was not allowed to take Mrs X home.
  4. Allison House’s view that it had a duty to ensure there was adequate care in place when Mrs X left is reasonable. Mrs X went into Allison House on a Saturday. On the Sunday staff at Allison House noted that Ms Y had visited and said she wanted Mrs X to go home, with a full care package, as soon as possible. The member of staff noted that they had emailed Mrs X’s social worker to advise them of this. There is evidence that a member of staff then called the social worker the next day, Monday, to reiterate this.
  5. Overall, there was clearly a misunderstanding about the nature of Mrs X’s placement in Allison House. It seems that Mrs X and Ms Y both felt that Mrs X had effectively been detained there. This was not the case. As above, it is not possible for me to say how this misunderstanding happened or if it could have been avoided. Once Allison House knew Ms Y wanted to take Mrs X home it sought to help her with this, by telling the Council. This was reasonable, as it considered that Mrs X had needs that would need to be met in an alternative way. It was hampered by the fact that this happened at a weekend, but that was out of its control.
  6. The Council has already noted an intention to speak to Allison House about the issues with the DoLS paperwork. I am satisfied that was a reasonable step to take, and I do not consider there is any further outstanding fault that needs to be addressed here.

Complaint (f) – that Allison House took Mrs X’s nebuliser, lighters and phone charger away from her

Nebuliser

  1. Allison House has a medications policy. This states that all medicines must be stored in a locked cupboard. There is evidence in Allison House’s records that it spoke to Mrs X about the safe storage of her medication on the day she arrived. It records that she was “happy for the nurse to lock them away safely”. The solution for use in Mrs X’s nebuliser is a prescribed medication. Based on this evidence, there was no fault in Allison House’s actions here.

Lighters

  1. When Mrs X went into Allison House it completed a care plan in relation to her choice to smoke. It noted that Mrs X would need to smoke in the garden and staff would support her to do so. It also noted that Mrs X’s lighter was in the nursing office. Allison House told us that Mrs X gave staff her lighter on admission. It said this was in line with its policies and procedures, in relation to reducing the risk of fire within the home.
  2. It is reasonable for a home such as Allison House to operate a policy which prohibits smoking inside. It is also appropriate to consider fire safety risks and to take steps to mitigate any. In this context, the decision to keep Mrs X’s lighter in the office was reasonable and I have not found fault.

Phone chargers

  • Ms Y said Allison House took Mrs X’s phone chargers away from her. She said she looked for them and was told that they were locked in the office drawer. Ms Y said she replaced them but, on the day she took Mrs X home, was told they were locked up again and staff had to retrieve them.
  • Allison House said it did not take Mrs X’s phone charger away from her. It said Mrs X’s phone was continually charged as she was in constant contact with Ms Y. In addition, Allison House said the PA called 999 and the CQC during her stay.
  1. There are two conflicting accounts of events here. I have seen evidence that Mrs X called an ambulance and the police in the evening of the day she arrived at Allison House. There is also paperwork which suggests that Mrs X called the CQC on the day she left Allison House. I have no way of establishing the level of battery on Mrs X phone at any other time.
  2. Overall, given the conflicting accounts and limited independent evidence available to me, I cannot make a finding on this issue.

Complaint (h) – that NTH Trust and the Council inappropriately and unnecessarily implemented DoLS during Mrs X’s hospital admission in May 2023

  1. As with the earlier decision, in April, there is evidence to show that professionals acted in line with the Mental Capacity Act. They thought about the necessary factors when considering whether Mrs X had the capacity to decide whether to stay in hospital and whether to agree to investigations and treatment. There is also evidence that NTH Trust completed appropriate paperwork in order to implement urgent DoLS and to request standard authorisation. As such, I have not found fault here.

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Agreed actions

  1. Within one month of the final decision the Council should write to Ms Y to acknowledge the impact that its failings in the best interests process had on her. It should apologise for this. In addition, the Council should explain how it used its learning from this case to ensure it would take a more considered approach in future (as it said it would do in its complaint response in October 2023).
  2. Within two months of the final decision the Council should pay £250 to Ms Y to act as a tangible acknowledgment of the avoidable distress she experienced because of the fault.

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Decision

  1. I have completed this investigation on the basis that the recommendations will provide a proportionate remedy for the outstanding injustice I found.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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