A report by the Local Government Ombudsman (LGO) and Parliamentary and Health Services Ombudsman (PHSO) has found two Somerset authorities should have done more to safeguard a vulnerable man’s health.

The 38-year-old, who had complex physical health needs as well as some mental health problems, was well-known to both Somerset County Council and Somerset Partnership NHS Trust, and received regular visits throughout the day from a variety of nurses, social workers and carers.

The man’s mother, who brought the complaint to the ombudsmen, often took on the responsibility of caring for her son and had regular contact with the authorities in an attempt to improve the services he received. His fluctuating and deteriorating health needs meant that on some days he was able to administer his own medication, while on others – when he was in severe pain and had “maximised his opiate use”, he needed significant help.

The investigation found there was a general lack of co-ordination of his care, and nobody took responsibility for monitoring and administering the many drugs the man needed. The man died of an overdose in July 2009.

It also uncovered that the county council and trust failed to implement their joint policy on the administration of medicines. Staff were unaware of the policy’s existence, and the document only came to light following the ombudsmen’s investigation.

Dr Jane Martin, Local Government Ombudsman, said:

“Although I cannot say that these failures caused the man’s death, I can say they may have contributed to it. The picture I have seen is one of a gradual decline in the man’s health with no effective intervention to prevent it.

“While you cannot put a price on the loss of a loved one, I have recommended a financial payment to the man’s family in recognition of the stress and strain this situation must have placed them under."

Parliamentary and Health Service Ombudsman Julie Mellor said:

“This tragic case highlights the importance of joined up care. It is crucial that the NHS and local authorities communicate with each other to ensure patients’ needs are met.

“One missed opportunity by staff can lead to tragic consequences. Staff need to feel empowered to intervene and alert others when they have concerns about a patient.

“The trust failed this young man and it needs to ensure that its staff are appropriately trained in caring for vulnerable people, so that other patients receive the high quality care they deserve.”

To remedy the situation, the county council and the trust should acknowledge the failures identified in the report and apologise to the complainant. The two authorities should jointly make a payment of £2,000 to the man’s mother in recognition of the distress and time and trouble taken to pursue the complaint, and if necessary, fund bereavement counselling up to the value of £500.

The trust should review the way in which it ensures knowledge of joint policies and provides training for frontline staff, and review its district nursing teams’ compliance with multi-agency safeguarding procedures. The ombudsmen welcome the start the trust has made on this review.

The county council should refund the son’s estate any charges which were made for the care package, and review its policy about liaison with appropriate internal and external agencies where housing need has been identified.

Article date: 18 February 2014