Summary: Mrs A complains about a Council and NHS Trust regarding her son’s treatment and accommodation under section 117 of the Mental Health Act which she says led to his death. We will not investigate this case as we would be unlikely to add to the work already carried out by the Trust.

The complaint

1. Mrs A has complained about Humber Teaching NHS Foundation Trust

(the Trust) and Kingston Upon Hull City Council in relation to the care and accommodation of her son Mr B, who died in 2022 in a placement (the Placement) funded by the NHS and Council under s117 of the Mental Health Act.

2. Specifically, Mrs A has complained:

• the placement was unsuitable,
• a Community Treatment Order (CTO) was not put in place to protect her son and not properly explained; and
• her son was not discovered for three days at the Placement after he died.

3. Mrs A said the impact of this is she is still very sad about what happened and exhausted by the process.
4. She is also frustrated that she seems to be dismissed by the Trust with no detail of changes made to reassure her.
5. Mrs A said she would never get over her son being left for three days and the thought that people are still being sent to the Placement.
6. As an outcome Mrs A would like help to understand the issues that she has raised. She also wants to know what changes been made and how they have been implemented. This would provide reassurance for future patients.

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The Ombudsmen’s role and powers

7. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• the fault has not caused injustice to the person who complained, or
• it is unlikely we could add to any previous investigation by the bodies.

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How I considered this complaint

8. I considered evidence provided by the Trust and Mrs A as well as relevant law, policy and guidance.

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What I found

Background

9. 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’.
10. 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.
11. Section 117 of the Mental Health Act imposes a duty on health and social services to meet the health/social care needs arising from or related to the person’s mental disorder for patients who have been detained under specific sections of the Mental Health Act (e.g. Section 3). This is known as s117 aftercare.
12. Mr B was detained under the Mental Health Act and was discharged under s117 to the Placement in 2022. This was under a discharge plan to the Placement’s supported accommodation.
13. Several weeks later, Mr B died at the Placement and the coroner’s inquest verdict on his cause of death was sudden cardiac death with cardiomyopathy. Cardiomyopathy is a general term for diseases of the heart muscle, where the walls of the heart chambers have become stretched, thickened or stiffened.
14. The last time staff at the Placement had seen Mr B was three days before he was found dead in his room.
15. Mrs A complained to the Trust who carried out a Significant Event Analyis (SEA). An SEA is a structured, team-based, retrospective review of significant incidents—positive or negative, such as near misses or patient harm—to understand what happened, why it occurred, and to identify lessons learned.
16. The SEA made several recommendations for actions which were then carried out to improve services. There was then the inquest in 2024, following which Mrs A approached the Ombudsman with her complaint.

The Placement

17. Mrs A said that the Placement was not adequate to meet her son’s needs which required more support than the Placement gave him.
18. She said that there was another facility her son could have gone to with more one-on-one support.
19. The Trust said that Mr B had not wanted to go to the facility Mrs A suggested. In addition, it said that Mr B was assessed as appropriate for the Placement. The Placement offered support for four hours in the morning and another four in the evening. Support would be given to apply for benefits and seek further accommodation after leaving the Placement.

Analysis

20. There does not appear to be fault in how the Trust selected the Placement. In addition, Mr B’s mental health did not seem to deteriorate at the Placement at the time of his death. Therefore, we would not investigate this aspect of the complaint.

Lack of a Community Treatment Order

21. A CTO is a mechanism under the Mental Health Act that allows patients with mental health issues to receive supervised treatment while living in the community rather than remaining in hospital. If a patient breaches the conditions of the CTO or becomes unwell, they can be recalled back to hospital for treatment.
22. Mrs A said that there was evidence in the records that this was considered, and the family believed the Trust would put a CTO in place. However, the Trust did not place Mr B under a CTO and this led to confusion. She said that after being discharged Mr B had suffered ill effects from taking the wrong dose of medication and this could have resulted in him being recalled to hospital. This led to uncertainty about whether a CTO would have prevented Mr B’s death.
23. The Trust said that a CTO would not have been appropriate in Mr B’s case.
24. It also pointed out that Mr B was taking his medication (albeit he took a wrong dose at one point) and had not shown signs of mental deterioration so even if he was on a CTO, he would not have been returned to hospital.
25. The Trust agreed that the communication around a proposed CTO could have been better and made changes to prevent this happening again. The SEA also said that the possibility of a CTO could have been explored more and made recommendations about this that a clearer rationale should be recorded for patients of why a CTO is or is not appropriate.

Analysis

26. Mr B did not seem to be showing signs of mental health deterioration and died of natural causes. It does not appear that a CTO would have made any difference to the outcome in this case as it was unlikely that Mr B would have been recalled to hospital.
27. In addition, if there was a fault on the part of the Trust regarding communication or the consideration of the CTO, it has taken action to prevent it happening again. Therefore, an investigation by us would not add to this.

Mr B was left for three days

28. Mrs A said that staff should have been checking on her son regularly and if so, he may have been found while unwell or his body found earlier.
29. The Trust said that this was an independent living placement and so residents were not checked upon. However, since the incident, staff would now regularly check on residents.

Analysis

30. The Placement was independent living. There was evidence staff would check on Mr B, if asked to by the Trust for example, but was given his independence otherwise.
31. It does not appear to be a fault to not check on residents. In addition, the Placement has changed its practices and so an investigation would not recommend anything further.

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Decision

32. We will not investigate this complaint as we would be unlikely to uncover fault or add to the investigation and action undertaken by the Trust.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman