The Ombudsman's final decision:
Summary: The Ombudsmen are satisfied a Trust, Council and CCG provided largely appropriate care to an elderly woman with complex care and housing needs. However, the Ombudsmen find fault with the initial support provided by the Council’s housing team. This caused the woman’s son avoidable frustration and distress. The Ombudsmen also find the Council contributed to the woman’s delayed discharge from hospital as it failed to clearly establish her housing needs.
- The complainant, who I will call Mr B, is complaining about the care and support provided to his mother, Mrs C, by London Borough of Havering (the Council), North East London NHS Foundation Trust (the Trust) and Havering Clinical Commissioning Group (the CCG). Specifically, Mr B complains that:
- The Council failed to support Mrs C when she was at risk of homelessness between April 2018 and October 2019.
- In July 2018, the Council placed Mrs C in a care home that was not suitable for her needs. Mr B says the placement should have been for two weeks, but that Mrs C remained in the care home for eight months.
- The Council failed to arrange for Mrs C’s physical and mental health needs to be assessed when her health began to deteriorate in April 2018 and she was at risk.
- The Council and Trust delayed in discharging Mrs C from hospital following her detention under the Mental Health Act 1983, even though her section had ended. Mr B says the Trust failed to keep him updated about Mrs C’s diagnosis and the reasons for her detention.
- The Council, Trust and CCG failed to ensure Mrs C had proper accommodation, care and support following her discharge from hospital in October 2019.
- Mr B says these failings caused Mrs C great distress and resulted in her mental health deteriorating. He says Mrs C was twice deprived of her liberty for long periods without suitable accommodation being arranged. Mr B says he also found these events very distressing and was put to considerable time and trouble pursuing appropriate care for Mrs C. He says this caused his own health to deteriorate.
- Mr B would like the organisations he is complaining about to acknowledge what went wrong and apologise. He would also like assurances that the Council will arrange suitable long-term accommodation for Mrs C. Furthermore, he would like to receive financial recompense in recognition of the impact these events had on him and Mrs C.
The Ombudsmen’s role and powers
- We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
- If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
- In making this final decision, I considered information provided by Mr B. I also considered comments and documentation from the Council, Trust and CCG including the care records and housing records. In addition, I considered comments on my draft decision statement from Mr B and the organisations he is complaining about.
What I found
Relevant legislation and guidance
- Part 7 of the Housing Act 1996 and the Homelessness Code of Guidance for Local Authorities (the Code of Guidance) set out councils’ powers and duties to people who are homeless or threatened with homelessness.
- Someone is threatened with homelessness if, when asking for assistance from a council:
- he or she is likely to become homeless within 56 days; or
- he or she has been served with a valid section 21 eviction notice which will expire within 56 days
- If a council is satisfied an applicant is threatened with homelessness and eligible for assistance, it must help the applicant ensure that accommodation does not stop being available for their occupation. This is known as the ‘prevention duty’. (Housing Act 1996, section 195)
- A council must complete an assessment if it is satisfied an applicant is homeless or threatened with homelessness. It should work with the applicant to identify practical and reasonable steps for the council and the applicant to take to help the applicant keep, or secure, suitable accommodation. These steps must be provided to the applicant in writing as a Personalised Housing Plan (PHP). (Housing Act 1996, section 189A and Homelessness Code of Guidance paragraphs 11.6 and 11.18)
- If the applicant becomes homeless and is eligible for assistance, a council must take reasonable steps to secure accommodation for that person. This is known as the ‘relief duty’ (Housing Act 1996, section 189B)
Adult social care
- Sections 9 and 10 of the Care Act 2014 place a duty on local authorities to carry out an assessment for any adult with an appearance of need for care and support.
- The local authority must provide an assessment to all people regardless of their finances or whether the local authority thinks that individual has eligible needs.
- The assessment must consider the adult’s needs and how these impact on that person’s wellbeing, as well as the results that person wants to achieve. It must also involve the individual and, where appropriate, their carer or any other person they might want involved.
- Where a local authority has determined that a person has eligible needs, it must meet these needs.
Mental Capacity Act 2005
- The Mental Capacity Act 2005 provides a statutory framework for people who 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 themselves.
- This Act is accompanied by statutory guidance entitled the Mental Capacity Act Code of Practice (the Code of Practice).
- The Act makes clear that a person must be presumed to have capacity to make a decision unless it is established that he or she lacks capacity. If there are doubts about a person’s capacity to make a specific decision, that person’s capacity should be assessed. This assessment should be specific to the decision to be made at a particular time.
- If a person is found to lack capacity to make a specific decision, a decision may be made on behalf of that person in his or her best interests.
Deprivation of Liberty Safeguards
- The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 and came into force on 1 April 2009. The 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.
- On receipt of a DoLS application, a local authority must assess the application to decide whether to authorise a deprivation of liberty. This involves two assessments (one by an appropriately qualified doctor and one by a best interests assessor).
Mental Health Act 1983
- Under the Mental Health Act 1983, when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’.
- Usually three professionals need to agree that the person needs to be detained in hospital. These are either an Approved Mental Health Professional (AMHP) or the nearest relative, plus a doctor who has been specially approved in Mental Health Act detentions and another doctor. The AMHP is responsible for deciding whether to go ahead with the application to detain the person and for telling the person and their nearest relative about this. Admission should be in the best interests of the person and they should not be detained if there is a less restrictive alternative.
- The purpose of detention under section 2 of the Mental Health Act 1983 is for assessment of a patient’s mental health and to provide any treatment they might need. Patients can be detained under section 2 for a maximum of 28 days.
- Section 3 of the Mental Health Act is for the purpose of providing treatment. Detention under section 3 empowers doctors to detain a patient for a maximum of six months. The detention under section 3 can be renewed for another six months.
- Section 117 of the Mental Health Act 1983 (the MHA) imposes a duty on health and social services to provide free aftercare services to patients who have been detained under Section 3. There is no restriction on the type of services that can be provided. However, the services must be to meet needs arising from the patient’s mental health condition and to try to prevent another hospital admission. This is known as Section 117 aftercare.
- Mrs C has complex physical health needs and a diagnosis of schizophrenia. In 2018, she was living with Mr B in private rented accommodation.
- In April 2018, Mr B and Mrs C approached the Council for assistance. They were at risk of becoming homeless as their landlord had issued them with an eviction notice.
- In May 2018. The Council accepted the homelessness prevention duty and agreed a Personalised Housing Plan (PHP) with Mr B.
- In July 2018, Mr B and Mrs C attended a further meeting with the housing team. Mr B explained that he had been unable to secure suitable accommodation for Mrs C and that they were expected to leave their rented property the following day. The Council ended the prevention duty and accepted the relief duty.
- Later that month, the Council arranged a temporary respite placement for Mrs C in a care home.
- In August 2018, the Council completed a social care assessment for Mrs C. This found Mrs C would be at risk of harm without the level of support she was receiving in the care home.
- In early September, the care home gave Mrs C notice. The care home felt it could not safely meet her needs due to her mental health needs. She remained in the care home while the Council looked for alternative accommodation.
- The Council arranged for an extra care housing (ECH) placement for Mrs C in March 2019. This is a housing scheme with care and support services on site 24 hours per day. However, she declined the placement.
- The Council convened an emergency meeting at its offices to discuss Mrs C’s care and accommodation. Mrs C and Mr B were present. During the meeting, Mrs C absconded from the offices. The police later found Mrs C in the local town centre and transported her to a mental health hospital.
- The Trust detained Mrs C under Section 2 of the Mental Health Act 1983 for assessment. When the Section 2 detention lapsed in April 2019, Mrs C initially remained in hospital on a voluntary basis.
- However, as Mrs C was keen to leave the hospital, a clinician completed a capacity assessment in May 2019. This found Mrs C was unable to understand the risks to her physical and mental health if she left hospital without proper discharge planning. The assessment concluded Mrs C lacked capacity to make informed decisions about her care.
- The Council issued a DoLS authorisation and the professionals supporting Mrs C decided it would be in her best interests to remain in hospital while efforts were ongoing to identify suitable accommodation.
- Mrs C’s social worker applied for another ECH placement in June 2019. The Extra Care Housing Panel declined the application as it felt there would not be sufficient support for Mrs C.
- Later that month, an assessment found Mrs C’s mental health had improved. Mrs C reported that she wanted to return to Estonia. The professionals caring for Mrs C initially agreed to support her to do so.
- However, in early July 2019, Mrs C was refusing to take her medication. She demanded to leave the hospital with the intent of going straight to the airport and seemed unable to understand the risks associated with this decision. The Trust detained Mrs C under Section 3 for further treatment.
- During a ward round later that month, Mrs C told clinicians she had decided to remain in the UK if the Council could arrange suitable accommodation for her.
- A social worker made another referral for Mrs C for ECH. However, the panel again declined the application.
- The Council arranged a further social care needs assessment and updated risk assessment for Mrs C and submitted these in support of another ECH application.
- In October 2019, the panel agreed Mrs C could move to an ECH placement. She was discharged there later that month on a temporary basis with a care package.
- Following a review in November 2019, Mrs C became a permanent resident in the ECH scheme.
Housing and care support – April 2018 to March 2019
- Mr B complained that the Council failed to support Mrs C when she was threatened with homelessness between April 2018 and October 2019.
- The case records show Mr B and Mrs C’s landlord issued them with an eviction notice in April 2018 as she was intending to sell her property. They approached the Council for support.
- At a meeting in early May 2018, the Council accepted the homelessness prevention duty and issued Mr B with a PHP. This set out that he would continue to search for suitable private rented accommodation. The Council agreed to provide Mr and Mrs C with a first month’s rent and deposit.
- At the Council’s request, Mr B and Mrs C’s landlord reissued the eviction notice. This gave them until July 2018 to vacate the property.
- On 31 May, the Council completed an OT assessment for Mrs C. This found she may benefit from some additional equipment to assist her to transfer from her bed. The OT also recommended an additional assessment to explore ways Mrs C could get out of the property to socialise.
- Mr B identified a potentially suitable apartment in a neighbouring retirement housing scheme. He applied for an apartment for Mrs C. In the meantime, Mr B contacted the Council’s housing team on 8 June to request a letter in support of his application. Mr B sent two further emails to the housing team on 12 and 13 June. I could not locate a response in the records I reviewed.
- On 16 July, the letting agent for the retirement apartment advised Mr B that the apartment had been let to somebody else.
- Mr B and Mrs C attended a further appointment with the housing team later that day. The Council again accepted the homelessness prevention duty as Mr B and Mrs C had to leave their property the following day. A housing officer issued a revised PHP. This set out that Mr B would continue to search for sheltered accommodation for Mrs C. The housing officer provided Mr B with a list of estate agents to contact and agreed to refer Mrs C to a local housing charity. The housing officer also agreed to call Mr B in August to check his progress.
- Mr B wrote to the Council on 18 July to explain that he had placed Mrs C in a hotel temporarily and was himself staying with friends. Mr B explained that they were now homeless and requested additional help.
- This led to a further meeting with the housing team on 20 July. As Mr B and Mrs C were now homeless, the housing team ended the prevention duty and accepted the relief duty. A social worker from the Council’s adult social care team also attended the meeting. She confirmed that she had secured an interim respite placement for Mrs C in a care home. Mrs C moved to the care home later that day.
- The placement was for an initial two-week period. However, the Council extended this to 17 August to allow for a reassessment of Mrs C’s needs with an interpreter present to support her. The assessment found Mrs C had a history of wandering and that Mr B had needed assistance from the police to locate her. The assessment found Mrs C struggled to understand the risks associated with her wandering and that she would be unsafe in the community as Mr B was working full-time and would not be present all the time.
- Mrs C absconded from the care home on 19 August. Staff were able to safely return her. However, the care home served notice on 3 September as it felt it could not provide the level of care Mrs C required for her schizophrenia diagnosis. The care home suggested a sister facility in a neighbouring borough that may be suitable. However, the Council found the care home in question had received a ‘requires improvement’ rating from the Care Quality Commission and the neighbouring council had stopped placing service users there. The Council concluded the care home would not be suitable for Mrs C.
- On 28 September, the care home made a DoLS application to the Council. While Mrs C was awaiting an assessment, she absconded from the care home again on 11 October and was returned by the police.
- A psychiatrist assessed Mrs C on 16 October. He found Mrs C could not retain and weigh information about her care and her stay at the care home. The psychiatrist found that Mrs C lacked capacity to make decisions about her care. The psychiatrist concluded that a DoLS authorisation would be appropriate to keep Mrs C safe.
- The Council then passed Mrs C’s case to a best interests assessor.
- The Council identified an alternative care home placement for Mrs C and arranged for her to move there on 20 October, accompanied by Mr B and a carer. However, Mrs C refused to enter the new care home and had to be taken back to the original care home.
- Mrs C absconded from the care home again on 2 November. She initially became physically aggressive towards the care home staff who attempted to escort her back. However, they eventually persuaded her to return.
- On 8 November, the Council completed a best interests assessment. This concluded that it was necessary for the care home to deprive Mrs C of her liberty to prevent her leaving the home and placing herself at risk. The Council issued a DoLS authorisation on 27 November, to last two months. The Council later extended this for a further two months.
- The Council continued to search for a suitable placement for Mrs C that would be able to meet her care needs.
- The Council reviewed the DoLS authorisation in February 2019. A further assessment by a psychiatrist found Mrs C was now compliant with her medication and that her mental health improved. The psychiatrist felt Mrs C had regained capacity to make decisions about her care and where she wished to live. As a result, the Council rescinded the DoLS authorisation.
- On 12 March, staff at the care home reported their concern that Mrs C may be experiencing a relapse in her mental health. Staff reported that Mrs C was refusing to take her medication and would not eat or drink. The Council advised the care home to contact the Trust for support.
- On 16 March, staff from the care home took Mrs C to hospital as they were concerned about her deteriorating mental health. Mr B was also present. The Trust assessed Mrs C and concluded she did not meet the criteria for detention under the Mental Health Act at that time. Nevertheless, Mrs C refused to return to the care home. Mr B arranged for Mrs C to stay in a hotel for two nights.
- The Council arranged a temporary placement for Mrs C in an extra care housing apartment. When Mr B and two carers accompanied Mrs C to the apartment, she refused to enter. Mrs C instead returned to her old address. Mr B was eventually able to persuade Mrs C to return to the hotel.
- Mr B and Mrs C attended an emergency meeting with the Council on 20 March. During the meeting, Mrs C absconded from the Council offices. The police located Mrs C in the local town centre and transported her to a mental health hospital, where she was detained under Section 2 of the Mental Health Act. This allows a person to be detained for up to 28 days for assessment if that person is considered to have a mental disorder that places them, or another person at risk of harm.
- The case records show the Council accepted the homelessness prevention duty to Mrs C in May 2018. It agreed a Personalised Housing Plan with Mr B setting out the steps he would take to secure private rented accommodation for himself and Mrs C to prevent them becoming homeless. This was in keeping with the Homelessness Code of Guidance.
- However, I do have concerns about the level of support provided to Mr B during this period. The correspondence provided by Mr B shows he approached the Council’s housing team three times in June 2018 to request support with an application for a retirement property for Mrs C. The housing team failed to respond to Mr B’s emails. This is fault.
- I am unable to say whether the Council’s intervention at this stage would have resulted in Mrs C being offered the property in question. Nevertheless, I accept this lack of support caused Mr B unnecessary frustration and distress at what must have been an already difficult time. The Council has agreed to take action to remedy the injustice this caused to Mr B. This is set out in the ‘agreed actions’ section of this decision statement.
- When Mr B and Mrs C became homeless in July 2018, the Council accepted the homelessness relief duty. This required the Council to help Mr B and Mrs C to secure appropriate accommodation. In the meantime, the Council had a duty to provide interim accommodation for Mrs C.
- The adult social care team placed Mrs C in the care home temporarily. This placement served two main purposes. It allowed for Mrs C to have a safe place to live while efforts were continuing to secure suitable long-term accommodation for her. The placement also allowed professionals to assess Mrs C’s ongoing care needs to determine whether she would need additional support when returning to live in the community. In my view, this placement was appropriate and in keeping with the Council’s duties under the Care Act 2014.
- The case records show Mrs C was prone to wandering and frequently left, or attempted to leave, the care home during her time there. This meant staff from the care home, the police and Mr B had to locate her and return her to the care home. The evidence I have seen suggests Mrs C was unable to appreciate the risks associated with this behaviour. As a result, she required constant supervision.
- Despite this, Mrs C remained adamant that she wished to return to living in the community with Mr B. However, this was not a viable option as Mr B did not have permanent accommodation of his own. Furthermore, he was working full-time and so would have been unable to provide the level of support Mrs C required.
- The Council was placed in a challenging position with regards to finding appropriate accommodation for Mrs C. The Council had a duty to consider Mrs C’s wish to live independently in the community. However, this had to be balanced against her welfare and the level of support she needed to keep her safe.
- The situation was further complicated by the fact that Mrs C’s capacity to make decisions about her care and accommodation fluctuated throughout this period. This meant that, at times, the Council had to deprive Mrs C of her liberty in her best interests.
- I recognise Mrs C remained in the care home for significantly longer than had been intended (around eight months). Nevertheless, I do not consider this to be the result of undue delay by the Council.
- In my view, the case records show the Council was making every effort to secure appropriate accommodation for her during this period. Indeed, the Council identified an alternative care home placement in October 2018 and an ECH apartment in March 2019, both of which Mrs C refused. I found no fault by the Council with regards to the support it provided to Mr B and Mrs C between July 2018 and March 2019.
Housing and care support – March 2019 to October 2019
- Mrs C entered hospital in March 2019 and was detained under Section 2 of the Mental Health Act for assessment.
- Mrs C told clinical staff that she wished to be discharged so she could return to Estonia.
- In early April 2019, a psychiatrist assessed Mrs C. Mr B was also present. This found Mrs C was not suffering from an acute mental illness and did not require treatment under the Mental Health Act. The psychiatrist noted that Mrs C had capacity to make decisions about her care and would remain in hospital while efforts to secure suitable accommodation for her were ongoing. Mrs C told the psychiatrist she would like to live in sheltered accommodation with fewer restrictions on her liberty.
- The Trust arranged further assessments with a physiotherapist and OT to assess Mrs C’s suitability for sheltered accommodation. However, Mrs C refused to engage with the assessments.
- On 18 April, Mrs C again told Trust staff that she intended to return to Estonia. Mr B expressed concern about this, explaining that Mrs C did not have accommodation to go to there and had no family to support her.
- By 23 April, Mrs C was insisting on discharge, telling staff she would find her own accommodation. This led the Trust to apply for a DoLS authorisation as staff were concerned Mrs C did not understand the risks associated with her leaving hospital without support.
- A subsequent mental capacity assessment by a psychiatrist found Mrs C lacked capacity to make informed decisions about her care. This was followed by a best interests assessment. This concluded Mrs C should remain in hospital until suitable accommodation had been secured. The Council issued a DoLS authorisation for an initial two-month period.
- On 5 June, the Trust convened a multidisciplinary team meeting to discuss Mrs C’s care. This included representatives from the Trust and Council. Mr B and Mrs C were also present. The meeting agreed Mrs C would benefit from an ECH placement with a package of additional care visits.
- The adult social care team submitted an ECH application, with supporting information, to the housing team on 17 June. However, the ECH panel declined the application later that month as it felt ECH would not offer Mrs C the level of support she required.
- A social worker applied instead for a short-term residential placement for Mrs C so she would not need to remain in hospital unnecessarily.
- However, on 27 June, a further capacity assessment found Mrs C had regained capacity to make decisions about her care. Mrs C told staff she wanted to return to Estonia.
- On 4 July, Mrs C demanded to leave the ward immediately. She said she would go directly to the airport to catch a flight to Estonia. Staff were concerned that Mrs C could not understand that she had no money and did not have her passport. The Trust contacted Mr B. He was reluctant to provide Mrs C’s passport as he felt she would be unsafe in Estonia as she had no accommodation to return to.
- The Trust held a meeting to discuss Mrs C’s care later that day. Staff asked Mrs C if she would remain on the ward while further arrangements were made for her discharge. However, she refused. Staff were also concerned that Mrs C had begun to refuse her antipsychotic medication and was exhibiting paranoid behaviours. As a result, the Trust detained Mrs C under Section 5(2) of the Mental Health Act. This is a section of the Act that allows for the detention of patients who are already in hospital. This allows the patient to be detained for up to 72 hours for assessment.
- On 6 July, an AMHP acting on behalf of the Council completed a Mental Health Act Assessment for Mrs C. this recommended she should be detained under Section 3 for further treatment. However, the application process required the AMHP to contact the nearest relative. As the AMHP was unable to contact Mr B, the application did not initially proceed.
- Another AMHP attended the ward on 8 July to complete a further assessment. She successfully contacted Mr B and noted that he had no objection to Mrs C being detained under Section 3. The Trust confirmed the section that day.
- The clinical records show that Mrs C’s mental health began to improve over the following weeks and that she was compliant with her medication.
- During a ward round on 22 July, Mrs C told staff she would remain in the UK if the Council could arrange suitable accommodation. She said she did not wish to go into another care home and would prefer a place in a sheltered housing or ECH scheme.
- Mrs C’s social worker applied for an ECH placement for her on 26 July, with supporting information from the Trust. However, the ECH again panel declined the application on the basis that an ECH placement would not offer enough support.
- Following a professionals meeting on 10 September, Mrs C’s social worker submitted an updated risk assessment and OT assessment in support of a further ECH application later that month.
- The ECH panel approved the application and Mrs C moved into an ECH property on 29 October.
- The case records show it was very challenging for the professionals supporting Mrs C to make discharge arrangements for her. This is because she changed her mind frequently about whether she wished to return to Estonia or remain in the UK. This situation was exacerbated as Mrs C’s capacity to make decisions about her care and ability to understand the risks associated with these decisions fluctuated throughout this period.
- In my view, the evidence shows Council and Trust staff were working towards Mrs C’s safe discharge. The case records show the professionals supporting Mrs C regularly sought her views and attempted to identify suitable accommodation in accordance with her wishes.
- Nevertheless, I did identify some evidence of unnecessary delay in the discharge process.
- The evidence I have seen suggests that, by June 2019, the professionals supporting Mrs C recognised it would be essential to secure suitable accommodation for her before she could be safely discharged.
- Mrs C’s social worker submitted two unsuccessful ECH applications on her behalf (in June and July 2019). The housing team had a duty to clearly explain the panel’s reasons for declining these applications. I found no evidence in the case records to suggest it did so.
- This should have prompted the social worker to request more information from the housing team to better understand its decisions. She did not do so until September 2019.
- At this point, the housing team explained that the panel had declined Mrs C's applications primarily on the basis of the risk assessment the social worker had submitted with the applications. When this was discussed at the professionals meeting on 10 September, it quickly became apparent that the listed risk factors were no longer relevant. The social worker completed an updated risk assessment and her subsequent application was successful.
- The Council had a duty to clarify Mrs C’s housing needs and provide accurate and up-to-date information in support of housing applications made on her behalf. In my view, it failed to discharge this duty happen between 24 June (when the panel declined the first application) and 10 September (when the social worker sought further input from the housing team). This is fault.
- I recognise that Mrs C is unlikely to have been discharged before August 2019 even if a successful housing application had been submitted on her behalf in June or July 2019. This is because the deterioration in Mrs C’s mental health in July 2019 means it is likely her discharge may have been delayed in any case.
- However, this fault by the Council contributed to Mrs C’s delayed discharge and meant she remained in hospital longer than necessary. This was particularly so between August and October 2019.
- The Council has agreed to take action to remedy the injustice this caused to Mrs C. This is set out in the ‘agreed actions’ section of this decision statement.
Physical and mental health support
- Mr B complained that the Council failed to arrange for Mrs C’s physical and mental health needs to be assessed when her health began to deteriorate in April 2018 and she was at risk.
- The case records show Mr B first approached the Council’s adult social care team in April 2018. He explained that he and Mrs C were due to become homeless. Mr B also raised concerns about Mrs C’s mobility.
- The Council officer who spoke to Mr B advised him to approach the housing team to resolve his housing situation. She also offered to arrange an OT assessment for Mrs C to determine whether she needed additional support.
- In the meantime, the clinical records show Mrs C attended hospital twice in May 2018. On the first occasion, Mrs C was complaining of weakness, dizziness and leg pain. Mrs C said she was finding it difficult to walk. A clinical assessment revealed no abnormalities and Mrs C was discharged home with a walking frame.
- Later that month, Mrs C attended hospital again with Mr B. Mrs C reported worsening depressive episodes. The clinician who reviewed Mrs C recommended an urgent mental health assessment. Mr B and Mrs C agreed to approach their GP to arrange this.
- The OT assessment took place on 31 May. The OT found that Mrs C required some support to manage at home and suggested a package of care visits. Mrs C refused this. However, she agreed to have bed raisers fitted to help her transfer from bed.
- The OT contacted Mr B again in June to check that the bed raisers had been fitted. Mr B confirmed this. The OT also offered a home visit. She noted that Mr B ”declined and reported everything was fine and no concerns addressed.”
- I acknowledge that Mr B was concerned about Mrs C’s mental health. The clinical records show Mrs C was taking an appropriate antipsychotic medication to treat the symptoms of her schizophrenia. There is no indication in the case records that Mrs C was suffering from mental health crisis at that time. Nevertheless, it was open to Mr B and Mrs C to approach their GP for further support with Mrs C’s mental health needs.
- Similarly, the clinical records for Mrs C’s hospital attendance in early May found no significant underlying physical problems. In the circumstances, it was appropriate for the Council to arrange an appropriate OT assessment to explore Mrs C’s declining mobility and whether she required additional assistance. The OT assessment identified that Mrs C did have care and support needs. However, Mrs C declined a package of care at that time.
- I am satisfied the Council provided Mrs C with appropriate for support for her care needs during the period April to July 2018 and find no fault in this matter.
Delayed hospital discharge
- Mr B complained that the Council and Trust delayed in discharging Mrs C from hospital after she had been detained under the Mental Health Act 1983, even though her section had ended. Mr B says the Trust did not provide him with information about Mrs C’s diagnosis or the reason for her detention.
- I have already commented in detail on the delay in discharging Mrs C from hospital. In my view, this was attributable mainly to the need to secure long-term accommodation for Mrs C and to her fluctuating mental health.
- Mrs C was escorted to hospital by the police on 20 March 2019 under Section 136 of the Mental Health Act. This section of the Act allows the police to remove someone with a mental disorder to a place of safety if they believe that person to be a risk to themselves or others. Trust staff spoke to Mr B, who was unable to attend hospital that evening.
- Trust staff spoke to Mr B again the following morning. The notes of this conversation record that Mr B told a Trust officer that “he believes that his mother currently requires hospital admission…He does not believe that she has been compliant with her medication. He also reported that his mother has been refusing to engage with mental health services.”
- Later that day, the Trust completed a Mental Health Act Assessment for Mrs C. An interpreter was present to support Mrs C. The assessment noted that Mrs C’s mental health had deteriorated and that she was refusing to comply with her medication. The assessment noted Mrs C intention to leave the hospital and return to Estonia. The assessment concluded Mrs C was at risk and should be detained under Section 2 for further assessment.
- Trust staff advised Mr B of the outcome of the assessment and again noted his agreement that Mrs C required hospital admission.
- On 9 April, a Trust psychiatrist met with Mr B and Mrs C. An interpreter was also present. The psychiatrist explained that Mrs C did not appear to be exhibiting any psychotic symptoms and that there was no need for her to remain under section. However, Mrs C agreed to remain on the ward until suitable accommodation could be arranged.
- The clinical records show staff were in regular contact with Mr B during the following weeks. Mr B attended a further ward round on 29 April and a discharge planning meeting on 5 June.
- By late June, Mrs C’s mental health appeared to have improved considerably and clinicians were satisfied she had capacity to make decisions about her care. Mrs C continued to tell staff that she wished to return to Estonia. As a result, the professionals caring for Mrs C began to explore how they could support her to achieve this.
- The clinical records show Trust staff discussed this with Mr B. However, he was reluctant to provide Mrs C’s passport as he was concerned she had no home in Estonia and would be at risk.
- The clinical team were becoming increasingly concerned that Mrs C was unable to weigh up the risks associated with her returning to Estonia without accommodation or support. The team concluded Mrs C would be at risk of harm if discharged without support. As a result, the treating clinicians made the decision to detain Mrs C under Section 5(2) so a full Mental Health Act Assessment could take place.
- On 8 July, an AMHP contacted Mr B to discuss the assessment. The AMHP noted that Mr B was relieved that Mrs C would remain in hospital and agreed with the recommendation that she should be detained under Section 3 for further treatment.
- I appreciate this was a difficult time for both Mrs C and Mr B and that the situation was made more confusing as Mrs C’s mental health fluctuated throughout this period. I also note there were some occasions when Mr B was not invited to attend meetings and assessments.
- However, the clinical records show that Trust staff regularly discussed Mrs C’s care with Mr B and attempted to involve him in decisions about her care and accommodation as fully as possible. I found no fault by the Trust in this regard.
Support in the community
- Mr B complained that the Council, Trust and CCG failed to ensure Mrs C had appropriate accommodation, care and support following her discharge from hospital in October 2019.
- Mrs C had been detained under Section 3 of the Mental Health Act. As a result, she was entitled to free aftercare services under Section 117 of the same Act on discharge from hospital. The Council and CCG had a shared statutory duty to provide, or arrange for the provision of, these services. The CCG commissions the Trust to provide these services on its behalf.
- On 28 October, the Trust convened a meeting to discuss Mrs C’s Section 117 aftercare needs. The meeting established that Mrs C would be discharged to extra care housing the following day, with follow-up visits from her allocated care coordinator. Mrs C also agreed to continue with her depot injections in the community. In addition, the social worker arranged a care package consisting of three 30-minute care visits per day. Furthermore, the Council agreed a further three hours of support per week to assist Mrs C with her shopping and help her to access the community.
- On 15 November, the social worker and care coordinator completed a joint review. They visited Mrs C at the extra care housing property. An interpreter was also present to support Mrs C. The social worker noted that Mrs C had settled well and was happy with the support she was receiving.
- There is evidence to show the professionals caring for Mrs C put appropriate support in place for her on her discharge back into the community. I found no fault by the Council, Trust and CCG in this matter.
- Within one month of my final decision statement, the Council will:
- Apologise to Mr B for the distress and frustration caused to him by its failure to respond to his requests for assistance in June 2018 when he and Mrs C were threatened with homelessness.
- Pay Mr B £100 in recognition of the impact of this fault on him in terms of distress and frustration.
- Apologise to Mr B and Mrs C for its failure to clearly establish Mrs C’s housing needs between July and September 2019. This contributed significantly to Mrs C’s delayed discharge from hospital
- Pay Mrs C £400 in recognition of the impact of this fault on her in terms of her delayed discharge from hospital.
- Within three months of my final decision statement, the Council will also write to the Ombudsmen to:
- Explain what action it will take to ensure there is a clear process in place for handling correspondence from service users threatened with homelessness.
- Explain what action it will take to ensure there is a robust procedure in place for sharing information between the adult social care and housing teams regarding service users with complex needs. This is to enable key information to be shared promptly between these teams, as well as with external agencies.
- The case records show that Mrs C has complex needs. I am satisfied that, on the whole, the Council, Trust and CCG made appropriate efforts to support her to live in the community, albeit this took a significant amount of time.
- However, I found fault with the initial support provided by the Council’s housing team when Mrs C was first threatened with homelessness.
- I also found fault with the Council’s failure to ensure there was a clear understanding of Mrs C’s housing needs. This meant information provided in support of housing applications was inaccurate and out-of-date and Mrs C remained in hospital longer than necessary.
- I am satisfied the actions the Council has now agreed to complete represent a reasonable and proportionate remedy for the injustice caused to Mr B and Mrs C by this fault.
- I have now completed my investigation on this basis.
Investigator's decision on behalf of the Ombudsman