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Sussex Partnership NHS Foundation Trust (20 001 063a)

Category : Health > Mental health services

Decision : Upheld

Decision date : 29 Mar 2021

The Ombudsman's final decision:

Summary: We consider East Sussex County Council, Change Grow Live, Sussex Partnership NHS Foundation Trust and Old School Surgery missed the opportunity to meet and discuss Ms E’s worsening alcohol misuse and mental health before she died. That has caused Ms E’s family uncertainty. They will not know if a joint meeting would have changed the outcome. The organisations should apologise for that fault.

The complaint

  1. Mrs X complains about East Sussex County Council (the Council), Change Grow Live (CGL), Sussex Partnership NHS Foundation Trust (the Trust) and a GP at Old School Surgery (the Surgery).
  2. Mrs X says the organisations did not work together, share information, or take responsibility for her daughter’s (Ms E) mental health and alcohol misuse before she died under their care. Specifically:
    • A Psychiatrist at CGL did not chase responses from the GP after seeking information about Ms E’s mental health diagnosis, treatment plan and discharge letter from The Priory.
    • After The Priory discharged Ms E, her physical and mental health issues meant she could not engage with preparation work toward residential rehabilitation.
    • The Council and CGL should have fast-tracked Ms E for urgent support.
    • Despite the family highlighting concerns before Ms E died, no organisations acted to support her.
    • The Trust did not agree with the families view that Ms E’s mental health issues were significant.
    • CGL did not carry out a home visit the day before Ms E died, because it had the wrong address on its system.
  3. Mrs X says the organisations communication with the family was poor. Specifically:
    • No one told the family The Priory were going to discharge Ms E in May 2017.
    • No one offered to be a single contact for the family.
    • The Council and CGL did not tell the family Ms E had been given funding for residential rehabilitation before she died.
  4. Mrs X also complaints about how CGL handled her complaint.
  5. Mrs X says that had the organisations made different decisions, shared information, and communicated properly, the outcome may have been different for Ms E.
  6. Mrs X says it was distressing for the family to see Ms E worsen after May 2017. It was frustrating the organisations did not provide the support Ms E needed. The family were left confused by the communication about Ms E’s mental health and alcohol misuse.
  7. Mrs X would like organisations to clearly define their responsibilities for service users in the future. There should also be a process where one person acts as a lead contact who communicates with families.

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What I have investigated

  1. I have investigated paragraphs two and three. The final section of this statement contains my reason for not investigating paragraph four.

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The Ombudsmen’s role and powers

  1. 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).
  2. 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.
  3. The Ombudsmen 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. (Health Service Commissioners Act 1993, sections 3(4)- 3(7), and Local Government Act 1974, section 34(3), as amended)
  4. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies.
  5. 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

  1. I have considered information Mrs X has provided in writing and spoke to her. All parties have had the opportunity to comment on a draft of this statement. I have considered Mrs X’s comments on the draft statement before reaching my final decision.

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What I found

Background

  1. CGL provided support for Ms E’s alcohol misuse since 2016.
  2. CGL updated Ms E’s recovery plan in March 2017. She wished to abstain from alcohol and attend residential rehabilitation. She would achieve that by attending appointments and groupwork in preparation.
  3. Later that month, Ms E’s previous Surgery referred her to the Trust’s community mental health team (CMHT). Ms E’s family were concerned her mental health was worsening. The CMHT referred Ms E for short-term support from the crisis resolution and home treatment team (CRHT). The CRHT supported Ms E until late April.
  4. After the CRHT discharged Ms E, her mental and alcohol misuse worsened again, and she started having suicidal thoughts. Ms E’s family raised those concerns to the CRHT and CMHT. In early May, the CRHT reviewed Ms E again and arranged for Ms E to attend The Priory for detoxification (detox). That included stopping her alcohol intake with support for the withdrawal symptoms. Ms E stayed at The Priory for two weeks. During her stay, the CMHT and CGL assessed her.
  5. When The Priory discharged Ms E:
    • She agreed to have weekly appointments with a mental health nurse, part of the CMHT. But Ms E needed to work with CGL to treat her alcohol misuse.
    • CGL’s psychiatrist amended Ms E’s medication and encouraged her to attend groupwork. While Ms E’s anxiety impacted her ability to engage, the longer she abstained from alcohol, her anxiety would improve. CGL agreed to request certain information from the CMHT about Ms E.
    • The Council’s Substance Misuse Service (the SMS) agreed to support Ms E with CGL to work toward residential rehabilitation.
  6. Ms E did not attend any appointments with the CMHT after May. The CMHT followed up missed appointments, but Ms E did not respond.
  7. In June, the SMS applied for Ms E to attend residential rehabilitation at The Naomi Project. After a telephone and face to face assessment, the Naomi Project decided Ms E needed to show she was motivated to change. It did not offer her a place.
  8. By July, Ms E had started drinking again. Despite this, the SMS planned to apply for residential rehabilitation at ANA Treatment Centre (ANA). The SMS referred Ms E for extra support to attend appointments because she had not attended appointments with CGL. The SMS also confirmed in writing to Ms E and the family how each organisation was responsible in her care and support.
  9. In mid-July, Ms E’s family shared concerns with the SMS and Surgery about Ms E’s mental health. The Surgery assessed Ms E. She was drinking but Ms E said she would be attending CGL groupwork again.
  10. In late-July, ANA assessed Ms E for residential rehabilitation. It raised concerns about Ms E’s mental health medication, but it provisionally agreed to support her. However, Ms E would need to remain open to the CMHT, and detox before starting. CGL agreed to seek funding for Ms E’s placement. The SMS discussed Ms E’s mental health medication with the CMHT.
  11. Ms E attend two groupwork sessions with CGL in August. However, she stopped attending after 19 August. Ms E remained drinking.
  12. By September, the family said Ms E’s physical, mental health and drinking were worsening. They were worried she was going to die because she had withdrawn from all support. On 5 September, Ms E told the SMS she was fine. However, the family felt Ms E was telling people what they wanted to hear.
  13. On 14 September, CGL’s panel did not agree funding for Ms E to attend residential rehabilitation at ANA. The SMS confirmed this to Ms E’s father.
  14. The same day, the SMS and CGL tried to engage Ms E over the phone but were unsuccessful. They asked CRHT and the Surgery to review Ms E. CGL agreed to visit Ms E the next day. However, it attended the wrong address as its system was not up to date. The SMS later attended the correct address, but she did not answer. The SMS asked the police to carry out a welfare check on Ms E. The police attended Ms E’s house later that day and found Ms E had died at home.
  15. Mrs X complained to the organisations between September 2017 and December 2019.

Care and support for Ms E’s alcohol misuse and mental health

  1. Since 1 April 2013, local authorities have been responsible for improving public health through provision of drug and alcohol treatment services. This is funded by a Government public health grant. Local authorities can commission NHS trusts, private organisations and/or not-for-profit sector organisations to provide the care. Care and treatment can include care from psychiatrists and other clinicians as well as support workers, and can happen in the community or in residential placements. Local authorities remain responsible for the quality of care people receive. This means that complaints about alcohol and drug treatment services commissioned by a local authority are within the Ombudsman’s jurisdiction.
  2. In this case, the Council commissioned CGL (previously called STAR) to provide its drug and alcohol treatment service on its behalf. This explains why my recommendations are to the Council, rather than CGL, later in the decision statement.

CGL not chasing the Practice and The Priory

  1. In response to Mrs X’s complaint, CGL apologised that it did not chase the GP or the CMHT after its psychiatrist sought information about Ms E. CGL recognised that was frustrating for the family.
  2. I consider CGL acted with fault, but there was no injustice to Ms E. That was because the SMS got the records the psychiatrist needed instead. However, I understand how CGL’s fault would have caused Mrs X and the family frustration.
  3. CGL should have had a process in place to chase organisations who do not respond to information requests. I asked CGL how it would avoid similar fault in future. CGL told me that in late 2020 it introduced a centralised administration team. That team supports clinical staff, and is responsible for requesting and chasing records, such as discharge and mental health information. CGL noted there has been significant improvements in responsiveness to information requests.
  4. Overall, I consider CGL has taken appropriate action to remedy the frustration the family suffered. Also, its actions should avoid similar fault happening again.

Residential rehabilitation

  1. The East Sussex Commissioning Strategy of Substance Misuse (2012-2015) is the local vision for treatment services, which CGL worked toward.
  2. Residential rehabilitation provides structured psychosocial interventions and independent living skills in a safe, drug and alcohol-free environment. The programmes last three to six months, sometimes longer. Before CGL agrees to fund a residential rehabilitation placement, the service user must carry out certain steps first, including group preparation work.
  3. While CGL did not formalise a pathway until October 2017 (one month after Ms E died), its ‘Referral Pathway for Residential Rehabilitation’ would have been applicable in Ms E’s case. That pathway followed the steps below:
    1. Service user appeared motivated and attended group preparation work.
    2. Care Coordinator and Team Leader agree to proceed to assessment.
    3. Service user booked onto next rehab preparation group
    4. Service user to complete ‘Get ready for rehab’ workbook and personal statement.
    5. Complete rehab application form.
    6. Complete rehab preparation group.
    7. Email application to rehab inbox.
    8. Panel meeting held and decision made.
  4. In response to my enquiries, CGL said:
    • The SMS managed rehabilitation referrals.
    • The purpose of the group preparation work was to reduce the chance of an unplanned exit, and to maximise the benefit of rehabilitation.
  5. In response to my enquiries, the Council said:
    • Ms E needed to attend group preparation work to access residential rehabilitation.
    • It followed the relevant pathway.
    • In July 2017 it referred Ms E for support to attend appointments for alcohol misuse and her mental health. The Primary Care Pilot supports people who have disengaged from support services.
  6. First, I consider the pathway in paragraph 38 suitably expects service users to show the drive to complete preparation work before residential rehabilitation. Those placements are funded with public money. I am satisfied it is fair that a panel must expect someone to show they have properly prepared for residential rehabilitation.
  7. I will now consider if the SMS and CGL supported Ms E to attend residential rehabilitation in line with the relevant pathway.
  8. There is clear evidence in CGL and the SMS’s records that they provided a significant level of support to Ms E to engage in preparation work. When Ms E chose not to attend appointments, I cannot say that was because of any fault on CGL or the SMS’s part. Ms E had to show willing before residential rehabilitation. The lack of preparation work was clearly a barrier in getting the funding for it.
  9. The SMS tried to improve Ms E’s engagement with CGL by referring her for support attending those appointments. It recognised she had disengaged and tried to get her back to the CGL appointments. That was a good example of how the SMS supported Ms E.
  10. Overall, I consider the SMS and CGL appropriately followed the relevant pathway to support Ms E to access residential rehabilitation.
  11. I will explain next why the organisations were right to treat Ms E’s alcohol misuse before her mental health issues.

Lack of support for Ms E despite the families concerns

  1. In 2016 the National Institute for Health and Care Excellence (NICE) issued guidance Coexisting severe mental illness and substance misuse: community health and social care services for commissioners of recovery services. This provides guidance on how to identify and provide support to people with coexisting severe mental illness and substance misuse.
  2. Severe mental illness includes a clinical diagnosis of: schizophrenia, schizotypal and delusional disorders, or bipolar affective disorder, or severe depressive episodes with or without psychotic episodes.
  3. NICE guidance says existing specialist services should be adapted to meet both a person's coexisting severe mental illness and substance misuse needs and their wider health and social care needs rather than the creation of a specialist 'dual diagnosis' service. Whilst guidance recognises the need for joined up working, it also acknowledges that alcohol treatment must take precedence in some situations.
  4. In 2011 NICE issued guidance Alcohol-use disorders: diagnosis, assessment and management of harmful drinking (high risk drinking) and alcohol dependence (CG115) for health professionals and the public. They suggest that service users who have been dependent on alcohol will need to be abstinent, or have very significantly reduced their drinking, to benefit from psychological interventions for any coexisting mental health disorder.
  5. In response to my enquiries, the Council said:
    • It shared the families concerns with the right organisations.
    • It followed the NICE guidance. It worked collaboratively with the organisations between May and September 2017. However, a multiagency meeting would have been helpful to understand each organisations approach to treat Ms E. That could have included a more robust care plan and risk assessment.
  6. In response to my enquiries, CGL said:
    • It followed the NICE guidance. However, it could have responded better to Ms E’s changing circumstances when her mental and physical health worsened when she relapsed between July and September 2017.
    • During that period, it should have reviewed her risk management and support plans. The support plan was not robust.
    • Also, it should have considered assessing Ms E’s drinking and suitability for detox because it was a requirement for ANA’s residential rehabilitation.
  7. In response to my enquiries, the Trust said:
    • It followed the NICE guidance. It encouraged Ms E to engage with CGL to address the alcohol misuse before it could robustly assess her mental health.
    • It worked collaboratively with Ms E and CGL to manage her alcohol misuse, which it hoped would stabilise her mental distress.
    • Between June and September 2017, Ms E did not attend appointments. It could have considered visiting Ms E at home when she did not attend.
  8. I have considered if the organisations supported Ms E in line with the relevant NICE guidelines.
  9. I am satisfied that each organisation followed the NICE guidelines when supporting Ms E. I consider the organisations were correct to prioritise support for Ms E’s alcohol misuse before assessing her mental health. That was in line with the NICE guidelines.
  10. However, the NICE guidelines highlight that working together is necessary for patients with alcohol misuse and mental illness.
  11. I have seen the organisations were in contact with each other about Ms E. However, I consider the SMS, CGL and CMHT missed the opportunity to provide a better multiagency approach to manage Ms E. That was fault. When Ms E started to disengage in July 2017, I consider her well-being most likely would have benefited from meeting the SMS, CGL and CMHT to discuss her care and support. By then, Ms E had started drinking again too.
  12. Each organisation had a significant role to play at that stage. The SMS and CGL were trying to engage Ms E in group preparation work before residential rehabilitation. Also, the CMHT had not seen or spoken to Ms E for two months.
  13. I have reviewed each organisation’s support plans and risk assessments.
  14. I consider CGL could have used a multi-agency meeting to update Ms E’s recovery plan. It had not reviewed that plan since March 2017. The plan contains little detail about Ms E’s work towards residential rehabilitation. It did not reflect Ms E’s deterioration in July 2017. That was fault, which CGL has accepted.
  15. CGL also did not update its risk assessment after April 2017. That was fault. I agree that when Ms E’s condition deteriorated, it should have updated her risk assessment. That was a missed opportunity. Again, that was fault, which CGL has accepted.
  16. The CMHT did not speak or see Ms E since May 2017. It says it chased Ms E up after she missed appointments. However, I consider the CMHT should have taken further action to engage Ms E, or try to arrange a home visit (as it suggested). That was a missed opportunity. While I recognise CGL and the SMS were trying to support Ms E’s alcohol misuse, the CMHT still had a role supporting her mental health which was worsening.
  17. I consider that was fault. I cannot say what the outcome of any joint meeting would have been, or if the outcome would have been different for Ms E. However, it was still a missed opportunity, which will leave the family with a sense of uncertainty.
  18. Each organisation (to different degrees) has accepted better working together would have benefited Ms E.
  19. CGL told me that it has developed new guidance with the Trust for people in its area: ‘Dual Diagnosis: Joint working agreement, for people affected by mental ill‑health and substance use’. The agreement aims to do three things:
    • Improve the experience of people who need access to both mental health services and substance misuse services.
    • To meet their needs, through a combined approach.
    • To treat the person as a whole, rather than a sub-set of their difficulties.
  20. The agreement includes plans to assess people jointly, create combined treatment plans and share information. They will also hold forums every three months to discuss people like Ms E.
  21. I consider this agreement is a good way which would avoid similar fault happening to others. Overall, while I am satisfied the organisations have learnt from the fault, they still need to take further action to remedy to injustice to the family.

Missed opportunity to fast-track Ms E

  1. In response to my enquiries, CGL told me there was no choice to fast-track Ms E for residential rehabilitation. In November 2017 (after Ms E died), it introduced a fast-track process for detox. However, Ms E was working towards residential rehabilitation. Therefore, CGL did not assess Ms E for detox.
  2. Ms E’s aim was to work toward residential rehabilitation. Preparation work was clearly fundamental to access residential rehabilitation. As there was no fast-track for that, I cannot say the SMS or CGL missed an opportunity to fast‑track Ms E.

The Trust’s view of Ms E’s mental health

  1. I have considered the CMHT’s medical records. The medical records show the CMHT was clearly aware of Ms E’s mental health conditions, and I am persuaded it did take those seriously.
  2. The NICE guidance (paragraph 47) state that someone should be abstinent from alcohol for three to four weeks to assess if there is a significant improvement in their depression.
  3. From the records I have seen, Ms E could not remain abstinent for three to four weeks. Ms E’s drinking made it difficult for the CMHT to assess her mental health after May 2017. However, I understand the lack of contact between the CMHT and Ms E (compared to the SMS and CGL) led the family to believe the CMHT were not taking Ms E’s mental health seriously. Rather, the CMHT was focussed on Ms E accessing support for her alcohol misuse. I have already decided the organisations were not at fault for focussing on supporting Ms E’s alcohol misuse before her mental health.

CGL’s attempted home visit

  1. In response to Mrs X’s complaint, it accepted it had the wrong address for Ms E on its system. Therefore, on 14 September 2017 it did not see Ms E at home that day. CGL said it cannot say if the outcome would have been different for Ms E had it reviewed her on that day.
  2. I have considered CGL’s records from 14 September.
  3. I agree that CGL should have carried out the home visit on 14 September. That was fault.
  4. I agree that I cannot say the outcome would have been different for Ms E, had CGL reviewed her that day. Unfortunately, again this leaves the family with uncertainty.
  5. I am satisfied CGL has recognised that fault and apologised to the family. However, I consider it should take further action to avoid similar fault happening to others.

Organisations communication with the family

The discharge from The Priory

  1. In response to Mrs X’s complaint:
    • The Council and Trust jointly acknowledged it was not ideal when someone is discharged late at night without telling the family. The Trust told The Priory about how important conversations about discharge are with families.
    • The Surgery said it was aware Ms E had moved to The Priory on 3 May 2017 and was expected to stay for four weeks. However, the Surgery received Ms E’s discharge summary two weeks later.
    • CGL was only aware of Ms E’s admission at The Priory when a Psychiatrist at CGL completed a medical assessment while she was on day release. It acknowledged there was little joint working when The Priory discharged Ms E.
  2. In response to my enquiries:
    • The Council said the CMHT was responsible for telling the family The Priory would be discharging Ms E in mid-May 2017.
    • The CMHT did not receive a copy of the discharge summary from The Priory. While there is no evidence the CMHT told other organisations, The Priory would be discharging Ms E, it was working closely with the other organisations.
    • At the time, CGL was not aware of the admission and discharge from The Priory. Therefore, it could not contribute to aftercare planning on discharge.
  3. Mrs X says the CMHT did not tell the family The Priory was discharging Ms E so late at night. Also, CGL ordered that discharge.
  4. Based on the responses to my enquiries, there was clearly confusion among the organisations in Ms E’s care about the discharge.
  5. The Priory were responsible for communicating Ms E’s discharge to the organisations involved in her care, and any relevant family members. I cannot make any decisions about The Priory because they are not subject to my investigation. I also cannot hold the CMHT responsible for The Priory’s actions. It would have been best practice for The Priory to send a copy of the discharge summary to the organisations involved in Ms E’s care and support.
  6. From the records I have seen, the only organisation who received a copy of The Priory’s discharge summary was the Surgery. By the time The Priory sent the discharge letter, it would have already discharged Ms E. I consider there was little the Surgery could do to facilitate the discharge.
  7. Also, I have not seen any evidence that CGL ordered the discharge. On the contrary, CGL had little involvement in the decision to admit and discharge Ms E to The Priory.
  8. Overall, I consider The Priory was responsible to organising the safe discharge of Ms E. As it is not subject to my investigation, I cannot find fault with its actions.

No single contact for the family

  1. In response to my enquiries:
    • The Council said the SMS explained the roles of the professionals involved to Ms E verbally and in writing in July 2017.
    • CGL said each organisation had a point of contact for the family. However, it accepted the organisations did not clearly explain the roles and responsibilities to the family.
    • The Trust said it worked collaboratively with CGL to encourage Ms E to attend appointments.
    • The Surgery said Ms E’s lack of consent impacted its ability to discuss the families concerns.
  2. I have considered the SMS, CGL and CMHT’s records.
  3. First, I will detail what each organisation was responsible for in Ms E’s care:
    • CGL provided clinical treatment and support for her alcohol misuse.
    • The SMS supported her to access residential rehabilitation.
    • The CMHT supported her mental health.
    • The Surgery supported her physical health.
  4. In Ms E’s case, it was always going to be difficult to have one point of contact considering the number of people involved in her care. I do not agree it would have been more helpful to have a single point of contact with the family. This was because one person would not have been able to robustly address the families concerns about four different organisations. Rather, I consider the organisations should have clearly explained their role and responsibilities to the family. The organisations should have clearly explained how they interact with each other. Also, they should have each provided a point of contact for when the family had certain concerns. I have considered below if each organisation did that.
  5. In July 2017, the SMS sent a letter to Ms E, copying in Mrs X. That letter confirmed the point of contacts and contact numbers for itself and CGL. It said: “[The CGL worker] is primary contact regarding all matters other than work specific to rehab”. Also, the SMS supported Ms E “specific to any discussions/ work around rehab”.
  6. I consider that letter clearly explained what the SMS and CGL’s roles were, and who the family should contact. After that letter, Mrs X and her other daughter were in communication with the SMS and CGL about their respective support.
  7. I am also persuaded the family understood how the Surgery were supporting Ms E. Mrs X raised concerns for Ms E’s physical health in August 2019.
  8. However, I have not seen the CMHT clearly explained how it supported Ms E after May 2017.
  9. Considering the above, I understand why the family felt there was a lack of joint working between the organisations. While I do not consider there should have been a single contact for the family, as I have already found, the organisations missed the opportunity to meet and discuss Ms E with the family. That would most likely have assured them about the different professional’s roles and responsibilities.

The funding for residential rehabilitation

  1. Mrs X says the SMS and CGL did not tell the family Ms E had been given funding for residential rehabilitation before Ms E died.
  2. In response to Mrs X’s complaint, CGL initially said it did not submit a funding request because she had not completed the preparation work for ANA. However, in a later response, it told Mrs X it was not aware the SMS had made a funding request.
  3. In response to my enquiries, the Council said the SMS told Ms E’s father funding had been declined.
  4. I have considered the Council and CGL care records.
  5. I consider the SMS told Ms E’s father the panel declined funding for residential rehabilitation. However, there is no record that the SMS told Mrs X.
  6. Mrs X and Ms E’s father were not in contact with each other about Ms E. They were raising separate concerns to the SMS.
  7. I consider when the SMS said he would update the family on the outcome of the funding panel, it should have communicated that to both Ms E’s father and Mrs X. However, I am not persuaded that lack of communication was fault.
  8. I can see the SMS was very busy on 14 September. They were communicating (or trying to) with CGL, the CRHT, the Surgery, Ms E and her father. Everyone had significant concerns for Ms E’s welfare, which the SMS was trying to address. I understand why communicating the outcome of the funding panel was not a priority on 14 September. The SMS communicated the outcome to Ms E’s father after her father requested a home visit for his daughter. I consider on 14 September, the SMS appropriately prioritised Ms E’s welfare.
  9. However, I have not seen any evidence the Council told Mrs X funding had been declined after 14 September. That was fault, which caused Mrs X uncertainty. Until now, Mrs X has not known if the panel accepted or rejected SMS’s funding request.
  10. Also, CGL has not provided a formal record of the panel’s decision. I consider that poor record keeping was fault, which caused Mrs X uncertainty. However, in October 2019, CGL apologised to Mrs X for that fault and agreed to take minutes for panel decisions about residential rehabilitation. It would place a copy of those minutes in the service user’s records. I am satisfied CGL’s actions have remedied Mrs X’s uncertainty.

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Agreed action

  1. Within four weeks, the Council should apologise to Mrs X for the uncertainty caused by not communicating the outcome of the funding panel.
  2. Within four weeks, the Council and Trust should apologise for the uncertainty caused by not holding a multi-agency meeting in July 2017 to review Ms E.
  3. Within eight weeks, the Council should ensure CGL reviews its existing service users’ address and contact details to ensure they are correct. The Council should also ensure CGL develops a process to periodically keep them updated.

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Final decision

  1. I have completed my investigation. There was fault by the organisations causing injustice to Mrs X.

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Parts of the complaint that I did not investigate

  1. I have not investigated how CGL handled Mrs X’s complaint.
  2. We can only uphold complaints and make recommendations where we find evidence that maladministration or service failure (which we call fault) has caused an injustice. If the actions caused an injustice which has already been put right by the organisation then we would not normally look at the complaint because there is little we could achieve by doing so.
  3. CGL recognised it handled Mrs X’s complaint with fault, and fully upheld her complaint. It accepted staff did not follow policies when agreeing to respond to Mrs X, and apologised for the additional distress it caused her. It agreed to put improvements in place to avoid similar fault happening to others. I am satisfied CGL has shown good learning from its fault. Therefore, I have decided not to investigate Mrs X’s complaint about how CGL handled her complaint.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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