A retired South Yorkshire miner was prevented from going home to die beside the brother he had lived with his whole life, because of a string of errors by the five organisations tasked with looking after him, an investigation has found.

The man, 77, who was unable to walk and who suffered from diabetes and Alzheimer’s, was deprived of his liberty without proper account of the law being taken, according to a joint investigation by the Parliamentary and Health Service Ombudsman (PHSO) and the Local Government Ombudsman (LGO).

The investigation probed the roles of a GP practice, a hospital trust, a primary care trust (PCT) and two local authorities.

The dying man told carers that he did not want to die in a hospital or a care home, but his wishes, and those of his brother, were not dealt with appropriately, amounting to service failure, the report said.

His brother, who was his primary carer, pleaded with NHS staff to respect the man’s wishes to die at home. A meeting to discuss the case was delayed by a month, in which time the man died in hospital, ten miles from his home.

Parliamentary and Health Service Ombudsman Julie Mellor said:

“This tragic case could have been prevented if the proper procedures were followed and a more joined up approach taken to care. A series of delays meant that a dying man’s wishes were ignored and caused unnecessary distress to his brother.

“The trust should have reacted urgently to this distressed man’s letter to the care home pleading for them to let his sick brother go home to die, within hours or days at the most. But instead they postponed a meeting for a month, in which time his brother died, away from home.”

Carers feared the dying man lacked the capacity to decide for himself where he wanted to die. But they failed to carry out a mental capacity assessment, which they were supposed to do under the Mental Capacity Act 2005. This amounted to service failure, both ombudsmen found.

The surviving brother was caused unnecessary distress. Had proper procedures been followed, he would not have been “left wondering what else [he] could have done” to get his brother home, the report said.

The surviving brother said: “Part of my life has now been taken away, this hits me so much more at night when my brain is going at 90mph and I’m left wondering what else I could have done to get my brother home. I complied with all agencies involved, and never stopped the fight to try and get my brother home.”

Local Government Ombudsman Dr Jane Martin said:

“I welcome the steps the local authorities involved have taken to improve their services since these events occurred and hope this case serves as a reminder to other authorities of the paramount importance of listening to patients and involving them and their families in the care planning process.”

The PHSO and LGO have called on the five organisations involved to apologise to the surviving brother for causing him distress, and to each pay him £200, a total of £1,000.

Article date: 03 March 2014