Summary: Mrs C complains that two Council-commissioned alcohol treatment and recovery services failed to provide her sister’s late partner, Mr B, with appropriate ‘dual diagnosis’ (alcohol dependence and coexisting bipolar affective disorder) support and treatment. Mrs C says as a result Mr B was unable to maintain permanent abstinence from alcohol and this contributed to his death. The Ombudsman has found fault in some of the communication to Mr B and his family but is satisfied the actions already taken by the provider together with an apology and a service improvement review by the Council provide a suitable remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs C, complains that two Council-commissioned alcohol treatment and recovery services (Open Road and Essex Specialist Treatment and Recovery Service (STaRS)) failed to provide her sister’s late partner, Mr B, with appropriate ‘dual diagnosis’ (alcohol dependence and coexisting bipolar affective disorder) support and treatment between November 2017 and September 2018. Mrs C says the Council-commissioned services:

• delayed responding to Mr B’s initial request for help in November 2017;
• knew from November 2017 that Mr B had bipolar affective disorder as well as alcohol dependency but failed to implement or refer him for adequate support for his mental health without which he could not successfully or permanently stop misusing alcohol; and
• failed to communicate effectively with Mr B and his family including failing to explain the availability of dual diagnosis treatment and how Mr B could access this until approximately a month before he died.

2. Mrs C says because of the Council’s fault, Mr B did not get the ‘dual diagnosis’ support and treatment he should have had and so he was unable to maintain permanent abstinence from alcohol and this contributed to his death in September 2018.

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The Ombudsman’s role and powers

3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
4. 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)
5. We cannot question whether a 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. (Local Government Act 1974, section 34(3), as amended)
6. 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)

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How I considered this complaint

7. I read the papers provided by Mrs C and discussed the complaint with her. I have considered some information from the Council and provided a copy of this to Mrs C. I have explained my draft decision to Mrs C and the Council and considered the comments received before reaching my final decision.

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What I found

Legal and administrative background

8. Section 12 of the Health and Social Care Act 2012 inserted a new section 2B(1) into the National Health Service Act 2006. This gave upper tier and unitary local authorities a duty to take steps to improve the health of their populations and to carry out other public health functions.
9. The Local Authorities (Public Health Functions and Entry to Premises by Local Healthwatch Representatives) Regulations 2013 (SI 2013/351) (2013 Regulations), amended in 2015 and 2017, specify what local authorities must do to:

• carry out their health improvement functions; and
• exercise the Secretary of State’s public health functions.

10. 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.
11. In 2016 the National Institute for Health and Care Excellence (NICE) issued guidance (NG58) ‘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.
12. 
    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.
13. 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.
14. NICE Alcohol Guidelines suggests 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.

Council commissioning

15. The Council has confirmed it does not commission individual placements for community substance misuse services. It commissions a variety of county wide substance misuse services from several third sector and NHS providers for the residents of Essex to access. Residential detoxification funding requests must complete a panel application. This process is led by STaRS and supported by the wider treatment system providers. The Council has confirmed this was the only service specifically procured for Mr B and was approved in February 2018.
16. The Council’s contracts state in the terms and conditions that providers must comply with recommendations contained in guidance and appraisals by NICE. The Council’s commissioning further requires providers to comply and deliver services in line with:

• The National alcohol strategy
• Public Health England commissioner’s alcohol support pack
• Current clinical guidelines and best practice
• Essex Joint Strategic Needs Assessment (JSNA)
• Input from service users and family

17. In line with NICE guidance the Council did not create a specialist Dual Diagnosis service but says its providers are required to work with other services to ensure that clients with Dual Diagnosis are supported by the most appropriate agency and ensure joint working is standard. Providers are required to offer equitable access and support to those with Dual Diagnosis issues in collaboration with mental health and other relevant services.
18. Contracts for commissioned services specify the outcomes to be achieved and these outcomes are regularly monitored and reviewed. In complying with guidance, the Council says its providers:

• involve patients in developing and reviewing care plans
• involve family and carers if requested by the patient and encourage this support
• consider concerns raised by friends and family
• offer family bereavement support
• work in a collaborative way. If other agencies are required, they are engaged with by the care coordinator and alcohol worker
• appropriately tailor treatment interventions to levels of severity and complexity of need
• undertake regular reviews for all clients and update treatment in response to changing needs
• ensure that all staff receive supervision and support.

19. The Council’s alcohol services provider at that time (Synergy) and care-coordination provider (Open Road) provided the service to Mr B during the relevant period. The Council holds the services to account based on current best practice and clinical governance standards using:

• Quarterly Service quality performance meetings
• Analysis of National Drug Treatment Monitoring System (NDTMS) data to inform improvements

Key events

20. The Council says Mr B engaged with its commissioned services at various times from November 2014. Mr B completed a period of detoxification in hospital in October 2017 after an admission for a chest infection and had been abstinent for several weeks following discharge. The Ombudsman has investigated events from November 2017.
21. Mrs C says Mr B telephoned Open Road in November 2017 seeking help but did not receive a call back. Mrs C says Mr B had found making the call difficult and the failure to respond affected his mental health. A follow up call was made on Mr B’s behalf and he was accepted to the service. Mrs C says they received an apology at the time about this initial contact. Whilst accepting the impact on Mr B I consider the apology and service provision already provided were enough to remedy his injustice.
22. An assessment of Mr B in December 2017 noted a history of serious physical health problems and that he was diagnosed as bipolar in 2007. The assessment noted there were no mental health admissions and Mr B was currently under his GP for his mental health with no current problems. There were no recorded concerns about Mr B’s mental state following past detox treatment. This assessment recommended an inpatient detox due to his past physical health issues and because the risk of relapse at home was higher due to the access to alcohol. Mrs C says the family also provided personal statements about Mr B‘s mental health and their view this would need to be addressed as part of any treatment.
23. The inpatient detox was for 12 days at the end of February 2018 and was considered successful. A treatment plan was put in place which included Mr B completing a rehabilitation programme in the community following his detox and attending ‘breaking the cycle’ groups and follow up appointments with his keyworker. The community rehabilitation was for the period March to May. There was a short delay in putting in place the community rehabilitation but this was subsequently put in place and transport costs paid. I do not consider any delay here caused a significant injustice requiring a remedy.
24. The records provided for the period until the end of June 2018 indicate Mr B was following the treatment plan and doing well. Mrs C then contacted the service seeking help as Mr B was struggling and says she was wrongly told to contact the crisis team when this could only be done by a medical professional.
25. Mr B subsequently reported struggling and a lapse at the end of July 2018 himself following a return from a holiday. During this telephone call Mr B agreed to attend the ‘breaking the cycle’ group and Alcoholics Anonymous and was given information about a dual diagnosis worker with a suggested referral by his GP or Open Road.
26. It was noted that Mr B appeared intoxicated at group appointments during August and he was advised to contact his GP. A request was also made for STaRS consultant psychiatrist to review Mr B during August.
27. Open Road is co-located with STaRS and its consultant physiatrist met with Mr B in relation to his mental health and communicated with his GP. Both the consultant and GP considered Mr B’s medication needed to be stabilised before making a formal referral to mental health services. It is noted in the records that the consultant contacted the GP to discuss a referral to mental health services and they agreed to do this following Mr B’s admission to detoxification and rehabilitation. It was reported that Mr B was not responding well to the new medication in early September and this was adjusted on the advice of the consultant psychiatrist. The Ombudsman cannot investigate the clinical decisions made here.
28. Mr B attended an appointment on 12 September 2018 which had been arranged to complete a further detox and rehabilitation application. However, he was advised to go to hospital after physical health concerns were noted. Mr B was admitted to hospital the same day and sadly died in hospital on 18 September.
29. Mrs C had complained to Open Road in August. Open Road responded at the end of August and accepted some lessons had been learnt. These included that it would have been helpful to have provided a more comprehensive explanation about the different roles and responsibilities of the services involved at the initial assessment and that Mr B would need to approach his GP to discuss his mental health in the context of his treatment. The service confirmed it had shared this learning point across all teams to ensure the additional safeguard was in place in future. The service also apologised for saying it would make an urgent referral to a dual diagnosis worker. It should not have done so as Mr B’s mental health was being care coordinated by his GP and any referral into the Dual Diagnosis team would have needed to be made by his GP. Open Road made clear its workers were non-medical and could not do so. The service confirmed it had reminded all workers of the correct referral process. The service also confirmed the personal statements from family members about Mr B’s mental health had been considered but this was done within the context of his mental health being reported as stable and effectively managed by his GP.
30. Mrs C contacted Open Road again and sought further investigation. Mrs C met with Open Road and other providers involved in Mr B’s treatment in December. Overall, the organisations acknowledged some shortcomings but did not find there had been any significant failings. Fundamentally, the providers concluded they had made appropriate attempts to support Mr B.
31. The Council received a request in December 2018 from Mrs C for an investigation following her complaint to Open Road and a request for the records it held. The Council completed its own investigation which included meeting with representatives of all its providers that were involved in the recent care of Mr B and looking at all the available records.
32. The Council was satisfied that it met its obligation in commissioning appropriate alcohol misuse services and that it’s commissioned providers Open Road and STaRS supported and referred Mr B for treatment appropriately.

My consideration

33. Based on the evidence provided, I am satisfied the Council commissioned an alcohol service in line with the relevant Models of Care. The evidence provided also shows Mr B was under the care of his GP for his mental health with no current problems identified at the time of his initial assessment. This assessment noted both his bipolar diagnosis and history of serious physical health problems. There is good evidence of regular assessment of Mr B to support him with issues of alcohol misuse and I have seen nothing to suggest the Council’s commissioned providers failed to comply with the relevant guidance and best practice.
34. However, it has already been accepted that the communication about the different roles and responsibilities of the services involved could have been better and it would have been good practice for Mr B to have been told he would need to approach his GP to discuss his mental health in the context of his treatment at the outset. It has also been accepted that Open Road wrongly said it would make an urgent referral to a dual diagnosis worker when this needed to be done by Mr B’s GP. The service apologised for these shortcomings and put in place service improvements to avoid a repetition. On balance, I consider the shortcomings identified above constitute fault.
35. I have noted the records show a history of serious physical health problems and that Mr B engaged with services and was considered to be doing well until July 2018. I also note Mr B was advised to contact his GP about his mental health once he began struggle but it appears did not do so. It is impossible to know whether contact with his GP about his mental health during the earlier period when he was doing well would have avoided Mr B’s subsequent relapse in August and hospital admission in September. In the circumstances, I consider Mrs C and Mr B’s family have suffered an injustice in terms of the uncertainty around whether Mr B’s death was avoidable.

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Agreed action

36. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of Open Road, I have made the recommendations to the Council. The Council should:
1. write to Mrs C to apologise for the lack of clarity in the information provided about how Mr B’s mental health needs would be addressed within the context of his alcohol detox and support treatment and the uncertainty this has caused within one month of my final decision;
2. review the information provided to patients and their families by its commissioned drug and alcohol treatment services about the differing roles and responsibilities in the context of a patient clinically diagnosed as having a serious mental health illness to ensure this is provided at the outset and is clear and comprehensive; and
3. review the information and training provided to relevant workers in its commissioned services to ensure the correct referral process is understood and advised to patients and their families within three months of my final decision.

Final decision

37. I have completed my investigation as I have found evidence of fault but consider the actions already taken together with the agreed actions above are enough to provide a suitable remedy.

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Investigator's decision on behalf of the Ombudsman