Summary: Mr Y was a vulnerable man who died during a hospital admission. We found fault on the part of two NHS Trusts concerning their failure to work together to identify Mr Y’s family. This meant Mr Y’s funeral proceeded without their knowledge. We also found fault by one Trust regarding the handling of a safeguarding referral for Mr Y. This fault caused Mr Y’s brother, Mr X, significant distress. The NHS Trusts will apologise to Mr X and pay a financial remedy in recognition of the impact this fault had on him. These organisations, along with the Council, will review their policies and procedures to prevent similar problems occurring in future.

The complaint

1. The complainant, who I will call Mr X, is complaining about the care provided to his brother, Mr Y, by Pennine Care NHS Foundation Trust (PCFT) and Oldham Metropolitan Borough Council (the Council) in 2017. In addition, he is complaining about the actions of PCFT, the Council and Pennine Acute Hospitals NHS Trust (PAHT – now part of Northern Care Alliance NHS Foundation Trust) following Mr Y’s death.
2. Mr X’s complaint is as follows.

• The Council and PCFT placed Mr Y in unsuitable accommodation and without appropriate support to meet his care needs.
• PAHT failed to take appropriate safeguarding action when Mr Y was admitted to hospital with bruising consistent with being grabbed or mishandled.
• PCFT, PAHT and the Council failed to work together to identify and contact the family following Mr Y’s death in November 2017. This meant Mr Y’s funeral was arranged and went ahead without the family’s knowledge.

3. Mr X says the family was denied the opportunity to attend Mr Y’s funeral. He says this was extremely distressing for the family. Mr X says the situation has been made worse by the failure of the organisations involved to properly explain what went wrong.
4. Mr X would like the Ombudsmen to investigate his complaint and make appropriate recommendations to address any fault identified during the investigation.

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What I have investigated

5. I have investigated Mr X’s complaint as set out above. However, I have not investigated the actions of a private genealogy company that was also involved in these events. I have explained the reasons for this in paragraph 111 of this draft decision statement.

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The Ombudsmen’s role and powers

General powers and jurisdiction

6. 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).
7. 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.
8. 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)

Registrar’s Service

9. Mr X is complaining about the role of the Registrar’s Service in the events following Mr Y’s death.
10. The Superintendent Registrar is employed by the local authority and has legal custody of all birth, marriage and death registers for the local area. For the purposes of an investigation by the Ombudsmen, the Registrar’s Service is considered to be acting on behalf of the local authority (in this case the Council) in pursuit of its statutory functions.

Coroner’s Office

11. Mr X is also complaining about the actions of the Coroner’s Office following the death of Mr Y in November 2017. Specifically, Mr X complained that the Coroner’s Office failed to ask the Police Coroner’s Office to complete a database search that might have identified Mr Y’s next of kin.
12. In her response to Mr X’s complaint, the Coroner explained that one of her officers sent an email to the Police Coroner’s Office, but did not request a database search. As a result, no database search was completed. The Coroner apologised to Mr X for this oversight.
13. The extent of the Local Government and Social Care Ombudsman’s (LGSCO) jurisdiction is set out in Sections 24 to 26 of the Local Government Act 1974. In essence, these sections of the Act hold that the LGSCO may investigate alleged or apparent maladministration in connection with the exercise of a local authority’s administrative functions.
14. A coroner is an independent judicial office holder and is not employed by a local authority. However, they are appointed by a local authority (or, as in this case, a group of local authorities), funded by those local authorities and investigate deaths in those local authorities’ areas. In addition, Section 24 of the Coroners and Justice Act 2009 provides that a local authority for a coroner area has an obligation to secure provision of staff and accommodation for that area. We therefore consider it can be reasonably inferred that a local authority’s functions include provision of coroner services.
15. For this reason, we consider that if a complaint concerns the administrative actions of a coroner, we can investigate it. This could include the actions of those officers delegated by a coroner to undertake administrative tasks, even if those individual officers are not employees of the local authority. This is because we consider those officers are still undertaking actions on behalf of the local authority through its requirement to provide the coroner’s service.  
16. Where an officer is carrying out a task delegated to them by a Coroner but that task is related to the Coroner’s role as a judicial post holder however, we do not have the jurisdiction to investigate the complaint, such tasks could include identifying the next of kin of a deceased person.
17. Mr X’s complaint about the Coroner’s Office concerns an email sent by one of the Coroner’s officers to the Police Coroner’s Office on 22 November 2017. Although this was essentially an administrative task the officer sent this email at the Coroner’s direction further to her duty to identify Mr Y’s next of kin.
18. As this action was judicial, rather than administrative in nature, the Coroner’s officers were not exercising the Council’s administrative functions. Therefore, in this case, the LGSCO has no jurisdiction to investigate Mr X’s complaint about the Coroner’s Office.
19. Nevertheless, I have referred to the involvement of the Coroner’s Office in establishing the sequence of events following Mr Y’s death.

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How I considered this complaint

20. In making my final decision, I considered information provided by Mr X and discussed the complaint with him. I also considered information and records provided by the Council, Mental Health Trust, Hospital Trust and Coroner’s Office. I took account of relevant legislation and guidance. Furthermore, I considered comments from all parties on two draft decision statements.

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What I found

Relevant guidance and legislation

Adult safeguarding

21. The Care Act 2014 sets out the powers and duties of local authorities with regards to safeguarding vulnerable adults. The Care and Support Statutory Guidance (the statutory guidance) that accompanies the Act provides detailed guidance on how it should be implemented.
22. Sections 14.62 to 14.67 of the statutory guidance emphasise the importance of effective multi-agency working in safeguarding vulnerable adults. The statutory guidance says local authorities and partner agencies (such as NHS Trusts) must cooperate for the purposes of safeguarding.
23. At the time of the events Mr X is complaining about, PAHT had its own safeguarding policy in place entitled Policy for Protection of Adults at Risk of Abuse and Neglect (the safeguarding policy).
24. Section 3.9.4 of the safeguarding policy explains what a PAHT officer needs to do to make a safeguarding referral. This section says the officer should “[c]omplete the Trust’s referral form…print a copy of the completed form and forward by fax to adult social care”. Furthermore, the safeguarding policy directs staff to “[c]omplete a clinical incident via the Safeguard Incident Reporting System.”
25. Section 3.11 of the safeguarding policy sets out the importance of good record keeping. This section says that staff should “ensure that records are contemporaneous records of all observations, actions and concerns which are timed, dated and signed as soon as possible.”

Registration of deaths

26. The Births and Deaths Registration Act 1953 is the law that governs the registration of deaths in England and Wales.
27. Section 17 of the Act concerns situations where “a person dies elsewhere than in a house”. This includes deaths in hospital. Section 17(2) states that “[t]he following persons shall be qualified to give information concerning the death, that is to say –
1. any relative of the deceased who has knowledge of any particulars required to be registered concerning the death;
2. any person present at the death;
3. any person finding or taking charge of the body;
4. any person causing the disposal of the body.”

What happened

28. Mr Y had complex health and social care needs. In 2017, he was receiving mental health care from PCFT and had an allocated care coordinator who visited him regularly. In addition, Mr Y received fortnightly depot injections of antipsychotic medication.
29. Mr Y was living in a private rented accommodation property. He used Direct Payments to employ the landlord of the property as a personal assistant. The landlord supported Mr Y to meet his assessed social care needs.
30. On 7 November, Mr Y attended an appointment with his care coordinator and a consultant psychiatrist. Mr Y reported feeling unwell. He was coughing heavily and reported pains in his right side. The care coordinator established that Mr Y was due to see his GP later that week and advised him to mention these symptoms at his appointment.
31. Mr Y attended the appointment with his GP on 10 November. The GP arranged for him to be admitted to hospital that day. The clinical team diagnosed suspected lung cancer.
32. During his admission, PAHT staff noticed that Mr Y had bruising on his upper limbs consistent with grabbing or mishandling. A nurse completed a safeguarding referral form. It is unclear whether this was shared with the Council.
33. Mr Y died in hospital on 18 November. At that point, it was not possible to determine the cause of his death.
34. On 20 November, a PAHT bereavement officer contacted Mr Y’s recorded next of kin. This was his landlord. Mr Y’s landlord was unwilling to make arrangements for his funeral and provided no details for any relatives. The following day, PAHT forwarded a death report to the Coroner’s Office.
35. On 22 November, one of the Coroner’s officers spoke to Mr Y’s landlord. The landlord said he understood Mr Y had a sister in Scotland but was unable to provide further details. A Coroner’s officer provided this information to the Police Coroner’s Office on 22 November.
36. In her response to Mr X’s complaint, the Coroner said her officers contacted PAHT on 22 November to request further information about Mr Y’s next of kin. The Coroner said her office subsequently received a response from PAHT on 24 November to advise that Mr Y had an older sister in Scotland and a daughter with whom he had no contact. I found no evidence of these contacts in the records of the PAHT.
37. On 24 November, the PAHT bereavement office contacted a local newspaper to arrange for an appeal for help to be placed in the newspaper.
38. The Coroner authorised a post-mortem examination on 27 November as the cause of Mr Y’s death was then unknown. The PAHT bereavement office arranged for Mr Y’s clinical notes to be sent to the hospital mortuary.
39. The local newspaper published the appeal on 30 November.
40. At the request of the Police Coroner’s Office, Mr Y’s care coordinator visited the hospital mortuary on 1 December to identify his body.
41. The Coroner completed her investigation on 5 December. Her officers forwarded a release note to the hospital mortuary. This confirmed that Mr Y’s body could be released.
42. On 13 December, the Coroner received the final post-mortem report. This confirmed Mr Y’s cause of death as metastatic lung cancer. The Coroner discontinued her investigation as she was satisfied Mr Y’s death was due to natural causes.
43. The PAHT procedure at that time required officers to allow a period of 21 days following the publication of the newspaper appeal. PAHT received no response to the appeal and the waiting period expired on 21 December. As it was close to the festive period, PAHT staff took no further action to arrange Mr Y’s funeral at that stage.
44. On 23 January 2018, a member of the PAHT bereavement team approached a funeral director to make arrangements for Mr Y’s funeral and cremation. These were scheduled to take place on 14 February.
45. In late January, the landlord contacted the PCFT mental health team as he was concerned that no arrangements were in place for a funeral. Mr Y’s care coordinator was absent from work at this time. A support worker in the team reviewed the case records for further information about Mr Y’s next of kin. When this was unsuccessful, she referred the case to a private genealogy company for assistance.
46. On 2 February, the Coroner’s Office provided the funeral director with mortuary release and cremation papers.
47. On 5 February, the Coroner’s Office notified the Registrar’s Office that the Coroner had completed her investigation and identified the cause of Mr Y’s death. The Coroner’s Office provided the contact details for Mr Y’s landlord (as his recorded next of kin). The notification also stated that Mr Y had a sister in Scotland but that no contact details were available.
48. The Registrar’s Office subsequently contacted Mr Y’s landlord, who in turn provided contact details for Mr Y’s care coordinator.
49. An officer from the private genealogy company spoke to Mr X and his sisters on, or around, 5 February. No record of these calls exist. However, Mr X told me he informed the private genealogy company that Mr Y also had a daughter.
50. Mr Y’s funeral and cremation proceeded as planned on 14 February. A member of the PAHT bereavement team was present. Mr Y’s family were not aware of the funeral and so could not attend.
51. An officer from the private genealogy company contacted the PCFT support worker on 16 February. The genealogy company officer provided some further information about Mr Y’s family. She also explained that she had spoken to Mr X and his sisters and that they “are not sure whether they want any involvement or to be informed of the funeral arrangements.”
52. Mr X strongly disputes this account. He said both he and his siblings had made clear to the private genealogy company that they would need to discuss and plan Mr Y’s funeral as a family.
53. The Registrar’s Office subsequently contacted the PCFT team that had been caring for Mr Y. The PCFT team provided the Registrar’s Office with contact details for Mr Y’s sister. It is unclear when this happened as the Registrar’s Office did not retain copies of its contemporaneous notes.
54. In its response to Mr X’s complaint, the Registrar’s Office said it contacted Mr Y’s sister to advise that his death needed to be registered. It said a staff member told Mr Y’s sister that the death would need to be registered in England at the nearest Register Office in Carlisle. The Registrar’s Office said Mr Y’s sister “declined to register and did not offer any other relatives’ details”.
55. Again, Mr X strongly disputes this account. Mr X said he spoke to both of his sisters having received the complaint response and that neither had spoken to an officer from the Registrar’s Office. There is no contemporaneous record of this call.
56. On 22 February, the Registrar’s Office asked the PCFT support worker to attend a local Register Office to register Mr Y’s death. She subsequently did so on 27 February.
57. In March, the genealogy company attempted to contact Mr Y’s daughter without success.
58. In the meantime, Mr X appointed a funeral director to make arrangements for Mr Y’s funeral. On 23 April, the funeral director contacted the PAHT bereavement team, who advised that Mr Y’s funeral had already taken place. The funeral director informed Mr X that day.
59. On 24 April, a PAHT officer visited the crematorium and established that Mr Y’s ashes had already been scattered.

Analysis

Care and support

60. Mr X complained that the Council and PCFT placed Mr Y in unsuitable accommodation in the months leading up to his death. Mr X says Mr Y did not have appropriate care in place to meet his complex needs.
61. Mr Y had complex health needs, with diagnoses including Paranoid Schizophrenia and Chronic Obstructive Pulmonary Disorder (COPD – a lung condition causing breathing difficulties). He also had a history of substance misuse.
62. Mr Y was under the care of a PCFT Community Mental Health Team (CMHT). He had an allocated care coordinator who visited him regularly. In addition, Mr Y received fortnightly depot injections of antipsychotic medication and was reviewed by a consultant psychiatrist.
63. Mr Y lived in private rented accommodation. Mr Y used his housing benefit to pay his rent and used Direct Payments to employ his landlord as a personal assistant.
64. Mr Y’s care plan set out his assessed social care needs. This was in keeping with the requirements of the statutory guidance. The care plan recorded that Mr Y needed prompting to take medication and attend his depot injection appointments. Mr Y also needed help with shopping, keeping his accommodation clean and tidy and maintaining his personal hygiene. In addition, Mr Y needed support to access the community. Mr Y’s landlord supported him to meet these needs.
65. In January 2017, Mr Y’s landlord reported that he appeared mentally well and was not misusing substances. However, he said Mr Y was not eating well and continued to smoke heavily. The care coordinator discussed this with Mr Y in March 2017, noting that he “appears quite emaciated”. Mr Y insisted that he ate when hungry. The care coordinator advised him to access the community to help him generate increased appetite and suggested he eat more fattening foods. He also advised Mr Y to stop smoking as Mr Y had a cough. Mr Y was unwilling to do so.
66. On 7 November, Mr Y attended an appointment with his consultant psychiatrist. His care coordinator was also present. Mr Y reported feeling unwell. He was coughing heavily and reported pains in his right side and left hip. The care coordinator established that Mr Y was due to see his GP later that week and advised him to mention these symptoms at his appointment. The care coordinator again advised Mr Y to stop smoking.
67. Mr Y subsequently attended the GP appointment, accompanied by his landlord on 10 November. The GP arranged for Mr Y to be admitted to hospital that day.
68. There are no records available relating to the day-to-day support provided to Mr Y by his landlord. I am unable to comment on the quality of this support, therefore. However, I note Mr Y had been living in the same accommodation, with the same support in place, since 2009. During this period, Mr Y was under the care of both PCFT and his GP. There is no evidence in the records I have seen to suggest any of the professionals involved in Mr Y’s care were concerned about the support provided to Mr Y by his landlord.
69. Nevertheless, on Mr Y’s admission to hospital, a PAHT nurse completed a safeguarding referral that described him as “malnourished and emaciated”. This is understandably concerning for Mr X.
70. There is evidence in the case records to show Mr Y had a poor appetite. Mr Y’s consultant, landlord and PCFT care coordinator all noted that he appeared underweight in the months preceding his admission. The case records show Mr Y’s care coordinator acted on the concerns of Mr Y’s landlord and offered appropriate health advice. However, the records suggest Mr Y preferred to stay at home to avoid social situations in which he may be tempted to misuse substances. This was ultimately a matter of choice for Mr Y, who had capacity to make decisions about his care.
71. There are no entries in the case records, prior to the consultant review of 7 November 2017, to suggest Mr Y was feeling significantly unwell. When he reported feeling pain in his right side and left hip at that appointment, the care coordinator appropriately advised Mr Y to discuss these symptoms at his forthcoming GP appointment.
72. The available care records suggest PCFT was also providing Mr Y with appropriate care and treatment to meet his mental health needs. This included regular depot injections, visits from his care coordinator and reviews by his consultant psychiatrist. This was in keeping with good clinical practice.
73. Taking all available evidence into account, I am satisfied the care provided to Mr Y by the Council and PCFT was appropriate. I found no fault in this regard.
74. I have commented in further detail on the handling of the safeguarding referral below.

Safeguarding

75. Mr X said that Mr Y was admitted to hospital with bruising to his upper limbs, with the appearance of grab marks. Mr X complained that PAHT failed to investigate this appropriately and did not make a safeguarding referral to the Council.
76. The clinical records show a PAHT nurse completed a safeguarding referral form for Mr Y on 15 November. She recorded that Mr Y had bruising on his arms consistent with grabbing and that he appeared “malnourished and emaciated”. The nurse noted that a ward clerk had faxed the referral to the Council that day.
77. The nurse also spoke to Mr Y’s care coordinator. The care coordinator recalled he had spoken to Mr Y’s landlord about the bruising. The care coordinator recalled the landlord telling him that Mr Y “slipped and bumped down the stairs. He had been helped up by pulling him up using his arms. I could understand how the bruises could be caused in such a fall.”
78. The Council told me it had no record of having received the safeguarding referral. Indeed, I found no contemporaneous evidence to confirm the fax was sent as described by the nurse. As a result, I am unable to say, even on balance of probabilities, whether the referral was sent.
79. I found no evidence to suggest PAHT staff chased the referral when they did not receive a response from the safeguarding team. This was a significant omission given the serious concerns outlined in the referral. Had PAHT staff chased the referral it is likely, in my view, that this confusion would have been avoided. The failure to do so represents fault by PAHT.
80. It is not now possible to determine what the outcome of contemporaneous safeguarding enquiries would have been. However, I am satisfied the failure to make enquiries did not have an impact on Mr Y. This is because the risk of any possible abuse or neglect was removed as Mr Y remained in hospital until his death.
81. Nevertheless, I recognise the failure to handle the safeguarding referral properly caused Mr X significant distress and uncertainty.
82. The Council’s records show PAHT forwarded a copy of the referral to the safeguarding team on 26 June 2018 following Mr X’s complaint. The Council in turn sent the referral to Mr Y’s care coordinator for consideration the following day.
83. PCFT confirmed the care coordinator discussed the referral with his team manager. PCFT told me they decided to take no further action. PCFT advised me there were two main reasons for this. Firstly, Mr Y was by that point deceased. Secondly, the care coordinator had discussed the safeguarding concerns with the PAHT nurse in November 2017 when Mr Y was still alive. At that stage, he felt Mr Y’s injuries were consistent with an accidental fall. PCFT told me the care coordinator was confident Mr Y would have told him if he was suffering abuse. The care coordinator also said Mr Y had never previously suffered injuries that were suggestive of abuse.
84. The decision on whether to take further action on the safeguarding referral at that stage was ultimately one for the professionals involved. However, it is of significant concern that PCFT staff made no contemporaneous record of these important considerations. Furthermore, there is no evidence that PCFT staff advised Mr X of the outcome of its consideration. This was fault. This contributed to Mr X’s distress and concern that the safeguarding concerns had not been taken seriously.
85. The Council said it will now work with PCFT to review the case to identify any learning points and take action to prevent similar problems occurring in future.
86. I am satisfied the action agreed by the Council and PCFT will ensure proper consideration is given to the safeguarding concerns raised in Mr Y’s case.

Events after Mr Y’s death

87. Mr X complained that the organisations involved in Mr Y’s case failed to work together to identify and contact the family following his death in November 2017. He said this meant Mr Y’s funeral was arranged and went ahead without the family’s knowledge.
88. When Mr Y was admitted to hospital, his landlord was recorded as his nominated next of kin, though it was also noted they were not related. The available records do not reveal whether Mr Y provided this information, or whether it was taken from elsewhere in his clinical records.
89. Following Mr Y’s death on 18 November, a nurse contacted the landlord. She noted the landlord was unwilling to attend the hospital as he lived too far away. The nurse noted Mr Y “has no other family or friends to contact”.
90. The clinical records show PAHT staff were aware that Mr Y had a PCFT care coordinator. Indeed, a nurse had contacted the care coordinator on 15 November 2017 to discuss her safeguarding concerns. It is clear from the clinical records that Mr Y had been under the care of PCFT for several years.
91. Despite this, PAHT staff did not staff contact the care coordinator following Mr Y’s death to seek further information about his family. This was fault by PAHT.
92. In my view, this fault is shared by PCFT. I found no evidence to suggest Mr Y’s care coordinator contacted PAHT when he learned of Mr Y’s death on 20 November 2017. Similarly, the PCFT officer who made further enquiries between December 2017 and February 2018 does not appear to have contacted PAHT as part of those enquiries.
93. The shared failure of PAHT and PCFT to work together meant opportunities were missed to identify, and contact, Mr Y’s family at an earlier stage. Instead, both organisations made enquiries in isolation. This ultimately led to Mr Y’s funeral proceeding without the knowledge of his family.
94. The evidence I have seen suggests that both Mr Y’s landlord and his PCFT care coordinator were aware from conversations with Mr Y that he had family in Scotland.
95. I recognise the situation was complicated by the absence of Mr Y’s care coordinator from work between December 2017 and June 2018. Nevertheless, I consider it likely, on balance of probabilities, that arrangements for Mr Y’s funeral in February 2018 would not have proceeded if contact had been established between PAHT and PCFT following Mr Y’s death in November 2017.
96. In his complaint to the Ombudsmen, Mr X also raised concerns about the circumstances surrounding the registration of Mr Y’s death. In its complaint responses, the Registrar’s Office said an officer had contacted Mr Y’s sister (in February 2018) to ask her to register his death but that she refused to do so. Mr X disputes this and said neither of his sisters had spoken to an officer from the Registrar’s Office. In addition, Mr X raised concerns about the qualifications of the PCFT support worker to register Mr Y’s death.
97. In its response to my enquiries, the Council explained that the Registrar’s Office does not retain a log of staff actions or calls. Rather, the Registrar’s officers note any staff actions on a printed copy of the notification of next of kin form. The Council went on to explain that, once a death has been registered, the Registrar’s officers destroy the printed copies of the forms. This is in keeping with the Council’s Corporate Records Management Policy and Retention Schedule, which require only that certain key documents relating to the registration of a death are retained.
98. However, this means the contemporaneous handwritten notes detailing any contact between the Registrar’s Office and Mr Y’s family have now been destroyed. As a result, I am unable to establish whether or when a Registrar’s officer spoke to Mr Y’s sister or what was discussed.
99. Section 17 of the Births and Deaths Registration Act 1953 makes clear that only certain persons can be considered qualified to register the death of a person who dies “elsewhere than in a house”. This section of the Act applied in Mr Y’s case as he died in hospital rather than at home.
100. Section 17(2) of the Act explains that qualified persons can include “any person finding or taking charge of the body”. I understand that, when the PCFT support worker attended the Register Office to register Mr Y’s death, her legal qualification was recorded as “in charge of the body”.
101. The evidence I have seen shows the PCFT support worker was at no point in charge of Mr Y’s body. Indeed, following Mr Y’s death, it is clear PAHT officers were in charge of his body and made arrangements for his funeral and cremation. Furthermore, the PCFT support worker did not meet any of the other qualification criteria set out in Section 17(2) of the Act.
102. I consider, therefore, that the Registrar’s Office failed to ensure Mr Y’s death was registered in accordance with the Births and Deaths Registration Act 1953. This was fault by the Council.
103. In the Council’s complaint responses, it explained that an application can be made to the GRO for the register to be corrected. This option is still open to Mr X should he wish to wish to pursue it.
104. In addition, in the Council’s response to my enquiries, it explained that it would waive the correction application fee that would ordinarily apply. I consider the Council’s offer to waive the fee to be appropriate in the circumstances of this case.

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Agreed actions

105. Within one month of my final decision statement, the Council, Northern Care Alliance NHS Foundation Trust and Pennine Care NHS Foundation Trust will write a joint letter to Mr X to:

• Apologise for the distress caused to Mr X by the failure of PAHT and PCFT to work together to identify Mr Y’s family following his death in November 2017.
• Northern Care Alliance NHS Foundation Trust and Pennine Care NHS Foundation Trust will each pay Mr X £500 in recognition of the distress caused to him by this fault.
• Apologise for the distress caused to Mr X by the failure of PAHT staff to appropriately follow up the safeguarding referral for Mr Y in November 2017.
• Northern Care Alliance NHS Foundation Trust will pay Mr X £100 in recognition of the distress caused to him by this fault.
• Apologise for Pennine Care NHS Foundation Trust’s failure to properly document its consideration of the safeguarding referral in June 2018 and the distress caused to Mr X by its failure to share the outcome of this consideration with him.
• Pennine Care NHS Foundation Trust will pay Mr X a further £100 in recognition of the distress and frustration this caused him.

106. Within three months of my final decision statement:

• Northern Care Alliance NHS Foundation Trust and Pennine Care NHS Foundation Trust will review all relevant policies and procedures to ensure there is a robust process in place to be observed following the death of a patient. This should include a system for contacting relevant partner agencies to gather information in the event that details for the patient’s next of kin or family are not known.
• Northern Care Alliance NHS Foundation Trust and the Council will review their adult safeguarding policies and procedures to ensure there is a clear process in place for raising, receiving and acting upon safeguarding alerts. This should include provision for following-up safeguarding referrals promptly to ensure appropriate action is taken.
• The Council and Pennine Care NHS Foundation Trust will review Mr Y’s case to identify any learning points. They will write to Mr X with the outcome of the review. This should include explaining any learning identified by the review and any further actions taken.
• The Council will review its Corporate Records Management Policy and Retention Schedule to ensure it allows for the retention, where appropriate, of significant correspondence relating to the registration of a death.

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Final decision

107. I found fault by PAHT with regards to the handling, in November 2017, of the initial safeguarding referral for Mr Y. I also found fault by PCFT in terms of the handling of the safeguarding referral in June 2018.
108. I found fault with PAHT and PCFT with regards to their shared failure to work together to identify, and contact, Mr Y’s family to allow them to make arrangements for his funeral.
109. Furthermore, I found fault by the Council regarding the registration of Mr Y’s death.
110. I am satisfied the actions the Council, Northern Care Group NHS Foundation Trust and Pennine Care NHS Foundation Trust have agreed to undertake represent a reasonable and proportionate remedy for the injustice suffered by Mr X.

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Parts of the complaint that I did not investigate

111. Mr X also complained about the actions of the private genealogy company in this case. My enquiries established that PCFT staff prompted the involvement of this company in Mr Y’s case. However, PCFT did not commission the company to provide NHS services on its behalf. Rather, the company was involved in an informal or voluntary capacity as a private company. As a result, the Ombudsmen have no jurisdiction to consider a complaint about this company.

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Investigator's decision on behalf of the Ombudsman