Decision Date: 09 January 2025
Summary
The LGSCO investigated a ‘late’ complaint despite it touching on information submitted to a coroner – an overdose follow up support service failed to update its risk assessments and share key information about Ms X’s son, Mr X, shortly before he died.
What happened
Mr X was living in supported accommodation and had a key worker at an external support service. The support service was run jointly by an NHS Trust and a private company and was commissioned by Northumberland County Council.
Mr X was admitted to hospital twice [presumably a general hospital] in one month for accidental overdoses.
Despite being made aware, the external support service did not update Mr X’s risk assessment. [The report does not make it clear whether this was a substance misuse team, or the Community Mental Health Trust.]
At the end of that month Ms X called the service herself. Ms X expressed her concern about changes in Mr X’s behaviour. Ms X asked the service to increase the support for Mr X. The service responded by offering options for support for Ms X which she declined. Ms X said it was her son (not her) that needed the help.
Following Ms X’s phone call, the service did not contact Mr X or his supported accommodation provider. It also did not update Mr X’s risk assessment, despite its policy for triggering risk assessments after ‘major changes to presentation or personal circumstances, or following an incident’.
Two weeks after Ms X’s phone call, the service attempted to contact Mr X but received no response. The following day the service called Ms X. Ms X told the service her son had died due to an overdose the day before.
The NHS Trust carried out an internal review of the support provided to Mr X. It concluded that the standard of care towards Mr X including his risk assessments was classed as “good”.
The NHS Trust submitted this information to the coroner as part of the coroner’s investigations. The coroner concluded several months later that Mr X had died by “misadventure” and decided not to issue a Report to Prevent Future Deaths.
At the Coroner’s hearing, Ms X raised concerns about the standard of care Mr X received and outlined flaws in the NHS Trust’s internal review.
Representatives from the NHS Trust met with Ms X but Ms X did not feel the meeting addressed her concerns. The NHS Trust later accepted that its officers were not fully briefed before this meeting.
Ms X made a formal complaint to the NHS Trust about her disappointment with the recent meeting. She also complained that:
· The Trust sent the wrong date of birth and of death to the coroner.
· The Trust’s internal review had failed to invite her to contribute and failed to include that she had communicated concerns and clearly felt her son’s risk was not properly assessed.
The Trust sent a response several months later.
The Trust upheld that the service should have updated Mr X’s risk assessments after his admission to hospital and it should have shared updated risk assessments with other services such as his supported housing provider in the weeks before he died, citing communication process issues.
The Trust upheld that the service should have contacted Mr X sooner after Ms X’s phone call.
The Trust apologised for its errors in its submissions to the coroner and for failing to invite Ms X to contribute to the internal review and said it had changed its procedures. It reported a merely ‘satisfactory’ self-rating to the coroner’s office.
What was found
The Ombudsman did not make any findings or comment on whether any of the faults identified could have contributed to Mr X’s death because only the coroner can make the decision on causes of death.
The external commissioned service accepted its failures in relation to its risk assessment, information it sent to the coroner and its internal review.
In the weeks before Mr X died, it failed to update Mr X’s risk assessments in response to new information and failed to ensure the updated risk assessment and information were shared as part of multi-agency working. The Trust failed to abide by its own internal risk assessment policy here and this was fault. This fault was seen as causing uncertainty for Ms X about whether her son could have accessed more or different support during this time.
The information the service sent to the coroner contained inaccuracies. It failed to record as part of its internal review that it had not adhered to its own standards for assessing risk. These faults caused Ms X avoidable distress and frustration.
The service should have consulted Ms X as part of its internal review into the care and support received by Mr X before he died. This failure to obtain important information was fault and caused Ms X frustration at an already distressing time.
The Ombudsman recommended an apology, a financial remedy and service improvements. The Council agreed to pay Ms X £800 within one month of the final decision. The Council agreed to demonstrate within three months of the date of the final decisions several service improvements.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This depressing report about a follow-up service for discharges from hospital is light on detail regarding what sort of hospital Mr X was taken to and whether or not he was admitted.
We have not heard of a follow up service ‘run by an NHS Trust and a private company commissioned by a local authority’ and doubt that that was the scenario with which the Ombudsman was actually faced.
We think that overdose patients from A&E are referred to substance misuse service or mental health service which will be commissioned by the Trust or by the Local Authority through its public health functions, so that the person is then under the CMHT or receiving prevention and reduction services or services through the Council’s Care Act arrangements.
We think that what is lacking from this report is proper probing about HOW such negligent disregard for the situation actually came about and what the reaction of the Coroner was to the new information that the support service had done such a poor job. Even if the response is ‘We were overstretched’ or ‘We have no money to train our staff on our own processes and we don’t expect them to read them as part of the job…’ it would be important for accountability that this was being regularly drawn out by the Ombudsman’s service, we think.
We are also alarmed that the Supported Living Provider was not equally criticised or complained about because unless the man had effectively left that property, in his final weeks of life, the staff there would have been bound to have known about the hospital admissions.
If he was living in supported living, he must have had a s117 aftercare plan, following on from a previous Mental Health Act detention for treatment, or a Care Act plan of some sort, assuming he had never been sectioned under s3 of the Mental Health Act. We cannot understand therefore why what was happening would not have triggered an urgent review of one or other of those forms of accountability for someone’s care and support, within at least the County Council’s sphere of responsibility.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Northumberland County Council (24 007 546) report.
If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
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