Summary: We will not investigate Ms B’s complaint about her son’s mental health care and support in 2019 and 2020 prior to his death. Her complaint to us was made outside our 12-month time limit and it would have been reasonable to complain to us sooner.

The complaint

1. Ms B complains about her late son Mr C’s mental health care and support in 2019 and 2020, prior to his death. Her complaint involves Cornwall Partnership NHS Foundation Trust (the Trust), Cornwall Council (the Council) and NHS Cornwall and Isles of Scilly Integrated Care Board (the ICB). Ms B complains about various issues including:
• her son’s involvement in a clinical trial
• failure to adequately monitor his health and medication
• a delay in admitting him to hospital when he was unwell
• discharging him from hospital prematurely
• failures in his care in mental health supported accommodation
• a delay in arranging for him to be admitted to hospital after a Mental Health Act assessment
• safeguarding failures
• being excluded from her son’s care and support
• inconsistencies in explanations about how her son died
• loss of her son’s personal belongings
2. Ms B says she believes failings in her son’s care and support contributed to his death in early 2020. She says she wants full explanations about what happened to her son, what went wrong in his care and support, and an apology from the organisations involved.

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The Ombudsmen’s role and powers

3. 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).
4. We cannot investigate late complaints unless we decide there are good reasons to do so. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4)).

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How I considered this complaint

5. I have considered information from Ms B and her advocate, and from the Trust and Council. I also considered the Ombudsman’s Assessment Code, and relevant legislation and guidance.

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What I found

6. Mr C had a long-term mental health condition and lived in supported housing with a care and support package. He received care and support under section 117 of the Mental Health Act (section 117 aftercare).
7. Section 117 imposes a duty on health and social services to meet the health/social care needs arising from or related to a person’s mental disorder where the person has been detained under specific sections of the Mental Health Act (e.g. Section 3).
8. The ICB and Council were jointly responsible for commissioning and arranging Mr C’s section 117 aftercare, and the Trust provided some of Mr C’s care and support. In addition, Mr C was assessed under the Mental Health Act 1983 by staff acting on behalf of the Council and ICB. For these reasons I have included all three organisations in this complaint.
9. Mr C was admitted to hospital under the Mental Health Act in December 2019. His mental health condition was stabilised and he was discharged in mid-January 2020 to his supported housing placement. Mr C’s mental health started to deteriorate and staff at the supported housing placement raised concerns about him.
10. In late January an Approved Mental Health Professional (AMHP) and two doctors assessed Mr C under the Mental Health Act and decided they should apply for him to be detained under the Mental Health Act. As there were no available mental health beds, the AMHP and doctors decided to wait for a bed to become available in the next 24 – 48 hours, and for Mr C to stay at his supported housing placement until then. Sadly, Mr C was found dead in his room later that day.
11. Mr C’s death was reviewed by the Coroner and was deemed to have been from natural causes. No inquest was held.

Complaint

12. Ms B complained to the Trust in June 2020, and the Trust responded in late July. It said some of its response was general in nature because it had not seen a form of authority such as a Grant of Probate to enable it to share confidential information about Mr C with Ms B.
13. Ms B said she continued to raise concerns about her son’s care with the Trust and his housing placement. The Trust records show Ms B making further contact about the complaint in November 2020, between August and October 2021, and in January 2022 when she applied for a copy of her son’s medical records. In August 2023 she contacted the Trust again, and the Trust suggested she speak with an advocacy organisation about her concerns. The Trust also advised Ms B several times between July 2020 and August 2023 that she could take her complaint to the Ombudsman if she wanted to pursue it further.
14. The advocacy organisation contacted the Trust on Ms B’s behalf in October 2023. They asked whether the Trust would consider responding to Ms B’s complaint more fully, as Ms B had further questions to ask and had applied for copies of her son’s medical records. The advocacy organisation explained that Ms B had Letters of Administration (similar to a Grant of Probate but issued when someone dies without a Will) and that this should entitle her to a fuller and more complete response.
15. The Trust decided not to investigate any new or outstanding issues, as it said they were raised outside the time limit allowed for complaints. It said Ms B was able to bring the other elements of complaint within time, and it had not seen a good reason to consider the new elements of complaint some three years later. It also said it would not be able to effectively investigate the issues then, and it would not be reasonable or proportionate to do so. The Trust told Ms B and the advocacy organisation about this decision at the end of October 2023.
16. Ms B’s advocate complained to the Ombudsmen on her behalf at the end of December 2023.

My assessment

17. I have decided we will not investigate Ms B’s complaint. I consider the complaint is late and should have been brought to the Ombudsmen sooner.
18. I have considered the reasons Ms B and her advocate provided about why the complaint was made to us late, almost four years after the events. These include:
• the impact of grief following her son’s death
• Ms B’s poor mental and physical health
• difficulties contacting the Trust
• lack of support
• not realising she was entitled to a fuller response due to having Letters of Administration until much later
19. I appreciate that Mr C’s unexpected death will have had a very significant impact on Ms B and may have delayed her ability to pursue the complaint. I also appreciate that Ms B may have found out some additional information in 2022 / 2023 about her son’s care.
20. However, it is my view (from the evidence available) that Ms B was aware of many of the key concerns about her son’s care before late 2023, even if there were some issues she only understood more fully in 2023 after accessing her son’s medical records.
21. I have taken into account the reasons Ms B and her advocate gave for the delays in pursuing the complaint. But, even taking this into account, my view is it would have been reasonable for Ms B to have taken steps to pursue her key concerns further, either with the Trust or by bringing them to the Ombudsmen, sooner than she did. I note that Ms B was signposted to the Ombudsmen several times between July 2020 and late 2023 but did not approach us until December 2023.
22. It is also important to note that we provide a free service but must use public money carefully. We may decide not to start an investigation if the prospect of conducting an effective investigation is reduced.
23. In this case, it has been almost four years since the events complained about happened. The amount of time that has passed impacts on our ability to investigate a complaint fairly and effectively. For example, people’s memories and recollections fade and it can be much harder to obtain accurate accounts of events which happened years before.
24. Overall, I am not persuaded there are sufficient reasons to explain the extent of the delay in Ms B’s complaint being submitted to the Ombudsmen. The complaint is considerably outside our 12-month time limit, and I have not seen grounds to exercise our discretion to investigate it now.

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Decision

25. We will not investigate Ms B’s complaint about her son’s mental health care and support in 2019 and 2020 prior to his death. Her complaint to us was made outside our 12-month time limit and it would have been reasonable to complain to us sooner.

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Investigator's decision on behalf of the Ombudsman