Summary: Miss Y complained about a support service commissioned by the Council for people in its area recovering from alcohol and drug misuse and provided to Mr X, her late father. We have found fault, causing injustice, by the service provider in failing to: follow its proper procedure in response to a suspicion Mr X had been drinking alcohol: record this procedure in writing; and ensure all staff had received training about the procedure. The Council has agreed to remedy this injustice by apologising to Miss Y for the distress caused and providing evidence from the service provider it has completed service improvements.

The complaint

1. The Council commissioned Service A to provide an accommodation-based support service for people in its area recovering from alcohol and drug misuse. Service A sub-contracted part of this service to Service B.
2. Under its contract with Service A, Service B provided an accommodation-based alcohol recovery service to Mr X, Miss Y’s late father. Mr X died while accommodated at Service B’s centre.
3. Miss Y complains Service B failed to:
1. follow proper procedures or carry out appropriate checks when it suspected Mr X had been drinking alcohol; and
2. (i) carry out a proper investigation of events leading up to Mr X’s death; and (ii) provide an adequate account of its mistakes and their impact.
4. Miss Y says Service B’s failures, together with the loss of her father, caused her huge distress.
5. She wants Service B to acknowledge it understands what went wrong and that it has taken action to ensure the mistakes don’t happen again.

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The Ombudsman’s role and powers

6. 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, sections 24A(1)(A) and 25(7), as amended).
7. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these.
8. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
9. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

11. I considered evidence provided by Miss Y, the Council and the service providers as well as relevant law, policy and guidance.
12. Miss Y, the Council and Service B had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What should have happened

The commissioning of alcohol treatment and recovery services

13. County and unitary councils have a duty to take steps to improve the health of their populations and carry out other public heath functions. This includes the commissioning of drug and alcohol treatment and recovery services. (Health and Social Care Act 2012 and Local Authorities (Public Health Functions and Entry to Premises…) Regulations 2013 as amended).
14. The Council commissioned Service A to deliver an accommodation-based recovery support service for people in its area with drug or alcohol misuse issues. The agreement required Service A to:

• ensure operational processes complied with Safeguarding and NHS and other Serious Incident requirements.
• support, train, supervise and appraise all staff who were employed to ensure they were fully equipped to provide and/or manage the services.
• ensure all staff had the necessary training, competencies and personal qualities to enable them to relate well to, and effectively support, service users

15. The Council’s agreement with Service A also required it to include these same obligations in any contracts with sub-contractors.

What happened

16. I have set out a summary of the key events below. It is not meant to show everything that happened. It is based on my review of all the evidence provided about this complaint.

Background

17. Service B provided Mr X with an accommodation-based alcohol recovery service.
18. Mr X stayed with Service B for some months. Its support workers found Mr X dead in his room one morning. Emergency services were called and attended the incident.
19. Service B notified the CQC and Service A about Mr X’s death and carried out an investigation into the circumstances.
20. A post-mortem was completed. The report recorded that toxicology tests showed no evidence acute toxicity or alcoholic ketoacidosis played a role in Mr X’s immediate cause of death. It concluded the cause was long-term health conditions.
21. The assistant coroner certified the cause of Mr X’s death following the post-mortem without an inquest.

Service B’s investigation report

22. Service B investigated the circumstances around Mr X’s death and completed a fatality investigation report. This said:

• Mr X had been last seen by staff in the late afternoon of the day before Mr X was found dead in his room, He was not seen again by staff that evening;
• there was no record a standard nightly welfare check had been completed for Mr X that night;
• a night staff worker handed over to a day staff worker at 7.30am the next morning. The day staff worker reported that, at the handover, the night staff worker mentioned their suspicion Mr X had been drinking alcohol the previous day;
• the night staff worker had not recorded this information in the communication book; and
• staff carried out a welfare check on Mr X at around 8.30am in response to a concern raised by his family. They found Mr X dead in his room.

23. The report also:
1. set out the process staff should follow if a resident was suspected of drinking alcohol. This was to:

• complete a breathalyser test;
• undertake a key work session, if it was established a resident had been drinking, to discuss this, including what had been drunk and how much; and
• carry out regular welfare checks, as a minimum hourly throughout the night, if the discussion raised concerns about the client’s safety’;
2. said the process was not written down but staff were aware of this as expected practice; and
3. said there was no record of this process being followed in Mr X’s case.

24. Service B set out its proposed action plan to address the learning from Mr X’s death, including the response to suspected substance misuse. It said:

• it would develop a written procedure for staff to follow in response to concerns a client was drinking or taking drugs; and
• this procedure should include clarity over the levels of risk which would be managed by Service B’s staff or referred to emergency services.

Miss Y’s complaint

25. Miss Y raised her concerns with the service providers about the circumstances of Mr X’s death and the procedures followed.
26. Service B met with Miss Y to discuss her concerns. In its written response it said it:

• upheld her complaint it had not followed the correct procedures in response to the suspicion Mr X had been drinking alcohol; and
• had learned lessons and put an action plan in place to strengthen its processes.

Council’s comments

27. The Council has told us although Service B alerted Service A and the CQC, it did not signpost Miss Y to the Council.
28. This meant the Council did not have an opportunity to formally consider the complaint, and it would have welcomed the opportunity to investigate the matter under the statutory procedure at the time.

My decision – was there fault by Service B causing injustice?

Complaint (a) failure to follow proper procedures

29. Service B has accepted, and I agree, it failed to follow its proper procedure in response to the suspicion Mr X had been drinking alcohol. It failed to carry out a breathalyser check to confirm whether Mr X had drunk alcohol.
30. It also failed to carry a standard nightly welfare check on Mr X.
31. These failures were fault.
32. Service B’s failure to record its expected procedure in written form and ensure all staff, including agency staff, received appropriate training on this was also fault.

Impact of these faults

33. Because of Service B’s failure to follow the proper procedure and carry out a breathalyser test, Mr X lost the opportunity to be provided with the additional support and checks which would have been put in place had it followed this procedure and confirmed he had been drinking.
34. I note the coroner’s finding Mr X’s death was caused by long-term health conditions and there was no evidence acute toxicity or alcoholic ketoacidosis played a role in his immediate cause of death.
35. There is no way for us to say, even on balance, it is more likely than not there would have been a different outcome had Service B followed its expected procedure. It is sadly too late to put this right for Mr X now.
36. But, in my view, the uncertainty about whether there might have been a different outcome has caused Miss Y distress.

Complaint (b) failure to carry out a proper investigation

37. I haven’t found fault with Service B’s investigation of the circumstances around Mr X’s death, or that it failed to provide an adequate account of its mistakes and their impact. This is because:
1. it properly notified the CQC and Service A and:

• gathered the relevant information by reviewing the appropriate records, including notes on Mr X’s risk assessment and its communication book, and speaking to its managers, staff and support workers; and
• completed its investigation in a timely way.
2. in its report it set out:
• a timeline of events before and after Mr X’s death;
• details of the procedure staff were expected to follow;
• its finding the procedure was not followed in Mr X’s case; and
• its failings, identified from the investigation, and the action it should take to address these.
3. it had a meeting with Miss Y to discuss her complaint and go through its investigation findings with her. It acknowledged proper procedures had not been followed that evening and that it was implementing an action plan to address this.

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Action

38. When a council commissions or arranges for another organisation to provide services, we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions.
39. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with Service B’s actions and made the following recommendations to the Council, which it has accepted.
40. To remedy the injustice caused by the above faults, and within four weeks from the date of our final decision, the Council has agreed to:

• apologise to Miss Y for the distress and uncertainty caused by Service B’s failure, as the Council’s service provider, to follow its expected procedure in response to the suspicion Mr X had been drinking alcohol. This apology should be in line with our guidance on Making an effective apology

41. And within two months from the date of our final decision, the Council has agreed to:

• provide us with a report from Service B confirming the action it has taken to address the failure to follow expected procedure and strengthen its processes in response to the lessons learned from Mr X’s death.

42. The Council should provide us with evidence it has complied with the above actions.

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Decision

43. I find fault causing injustice. The Council has agreed to take the above actions to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman