Poole Borough Council's risk assessments for a walking group organised by its Community Outreach and Support Team were flawed.
Poole Borough Council's risk assessments for a walking group organised by its Community Outreach and Support Team were flawed, finds Local Government Ombudsman, Jane Martin. In her report, issued today (23 December 2010) she says:
“In light of the coroner’s conclusions there can be no suggestion that any fault identified in this report caused [the client]’s death… However, I consider the Council’s maladministration caused the family’s distress to be greater than it would have been.”
She finds that the Council “failed to identify at all some obvious risks which were included on the Council's own list of factors to be considered” and criticises the Council’s communications with the client’s mother. She welcomes the Council’s positive response to her recommendations for remedying the injustice.
‘Mr Clark’ (not his real name for legal reasons), a 43-year-old man with learning difficulties, died in July 2008 on a walk organised and supervised by the Council. Mr Clark’s family complained that the Council failed to properly assess the risk of – and provide them with information about – the walk, and also that Mr Clark was not properly looked after during the walk. The family believes Mr Clark’s death may have been precipitated by the strenuous nature of the walk and consider that the way they were told of his death and the way the Council responded to their enquiries was insensitive.
A post mortem found Mr Clark had an undiagnosed heart condition and that he had suffered a myocardial infarction some 24 hours before he died. The coroner decided Mr Clark had died of natural causes and declined to hold an inquest.
The Council’s own investigations recommended some improvements to procedures and that an apology be made to the family for the difficulties they experienced in obtaining information and the manner in which Mr Clark’s death was communicated to them.
The Ombudsman considered there was maladministration in the Council’s risk assessments and supervision arrangements for the walking group. The Ombudsman was concerned about the appropriateness of the route of the walk. The Ombudsman also considered that communication with Mrs Clark was poor, including the way she was informed about Mr Clark’s death.
The coroner’s decision means that no fault on the part of the Council can be seen to have caused Mr Clark’s death. However, the Ombudsman considers the maladministration identified in this complaint did increase the family’s distress beyond that they would have inevitably experienced.
The Ombudsman finds maladministration causing injustice, and the Council has agreed to her recommended remedy. It has already implemented procedural improvements to address the difficulties highlighted in this investigation, and has also agreed to pay Mr Clark’s family £1,500 in recognition of their additional distress and £500 for their time and trouble in bringing the complaint.
Report ref no 09 000 266
Article date: 23 December 2010