Download Six Lives Press Release - Local Government Ombudsman

PRESS RELEASE - CONFIDENTIAL
Strictly embargoed 00.01 Tuesday 24 March
Ombudsmen’s report calls for urgent review of health and social
care for people with learning disabilities
An independent report, based on six investigations, published today by the Health
Service Ombudsman and the Local Government Ombudsman reveals:





Significant and distressing failures in service across health and social care;
One person died as a consequence of public service failure. It is likely the death
of another individual could have been avoided, had the care and treatment
provided not fallen so far below the relevant standards.
People with learning disabilities experienced prolonged suffering and poor care,
and some of these failures were for disability related reasons;
Some public bodies failed to live up to human rights principles, especially those
of dignity and equality;
Many organisations responded inadequately to the complaints made against
them which left family members feeling drained and demoralised.
The Ombudsmen recommend that NHS bodies and councils urgently confront
whether they have the correct systems and culture in place to protect individuals
with learning disabilities from discrimination, in line with existing laws and
guidance.
Health Service Ombudsman, Ann Abraham, together with the Local Government
Ombudsman, Jerry White, uncover these failings and offer a series of
recommendations in Six Lives: the provision of public services to people with
learning disabilities. The report responds to complaints brought by the charity
Mencap on behalf of the families of six people with learning disabilities who died
whilst in NHS or local authority care between 2003 and 2005. The cases of
Mark Cannon, 30; Warren Cox, 30; Edward Hughes, 61; Emma Kemp, 26; Martin
Ryan, 43 and Tom Wakefield, 20 and were brought to public attention in Mencap’s
2007 report Death by Indifference.
Speaking about the Six Lives report, Ann Abraham, Health Service Ombudsman for
England said:
“The recurrence of complaints across different agencies leads us to believe that
the quality of care in the NHS and social services for people with learning
disabilities is at best patchy and at worst an indictment of our society.
“Six Lives has highlighted distressing failures in the quality of health and social
care services for people with learning disabilities. No investigation can reverse the
mistakes and failures but if NHS and social care leaders take positive steps to
deliver improvements in services, this may bring some small consolation to the
families and carers of those who died.”
Local Government Ombudsman, Jerry White, said:
“Six Lives shows that on many occasions basic policy and guidance were not
observed, the needs of people with learning disabilities were not accommodated
and services were unco-ordinated. The complex factors which led to these failures
to protect vulnerable individuals demonstrate the need for stronger leadership
throughout the health and care professions – this report is not solely a concern for
specialists in learning disabilities.”
The Ombudsmen make three key recommendations:
First, that all NHS and social care organisations in England should review
urgently:

the effectiveness of the systems they have in place to enable them to
understand and plan to meet the full range of needs of people with learning
disabilities in their areas;
and

the capacity and capability of the services they provide and/or commission
for their local populations to meet the additional and often complex needs
of people with learning disabilities;
and should report accordingly to those responsible for the governance of those
organisations within 12 months of the publication of the Ombudsmen’s report.
Secondly, that those responsible for the regulation of health and social care
services (specifically the Care Quality Commission, Monitor and the Equality
and Human Rights Commission) should satisfy themselves, individually and jointly,
that the approach taken in their regulatory frameworks and performance
monitoring regimes provides effective assurance that health and social care
organisations are meeting their statutory and regulatory requirements in relation
to the provision of services to people with learning disabilities; and that they
should report accordingly to their respective Boards within 12 months of the
publication of the Ombudsmen’s report.
Thirdly, that the Department of Health should promote and support the
implementation of these recommendations, monitor progress against them and
publish a progress report within 18 months of the publication of the Ombudsmen’s
report.
The investigations found maladministration, service failure and unremedied
injustice in a number, but not all, of the 20 bodies investigated (three Councils,
16 NHS bodies and the Healthcare Commission).
The Ombudsmen found that many organisations compounded their failures by poor
handling of the complaints made against them and by a reluctance to offer
apologies. Most of the bodies concerned have since apologised for their
mishandling of the families’ initial complaints and have provided information on
improvements they have made. Financial compensation has also been offered.
From 1 April 2009, a single comprehensive complaints process spanning both health
and adult social care will come into effect. The new process will focus on resolving
complaints locally with a more personal and co-ordinated approach. The
Healthcare Commission will be removed as a second tier complaint handler for
complaints about the NHS and the Ombudsmen will provide the second and final
tier of the new system across both health and adult social care.
Six Lives: the provision of public services to people with learning disabilities
can be downloaded at www.ombudsman.org.uk. For further information or
interview requests please contact 0300 061 4996.
An overview of upheld complaints accompanies this release.
Details of the remedies secured in the four cases where the Ombudsmen
upheld complaints are included in the individual investigation reports.
Notes to editors
Six Lives contains six individual case reports (three of which span health and social
care) together with an overview report which draws out common themes and
learning from these cases.
In February 2009 the Parliamentary and Health Service Ombudsman published
Ombudsman’s Principles. The Ombudsman’s Principles bring together the
Principles of Good Administration, Principles of Good Complaint Handling and
Principles for Remedy. They were published to help public bodies in the
Ombudsman’s jurisdiction by promoting a shared understanding of what is meant
by good administration, good complaint handling and a fair approach to providing
remedies.
The Parliamentary Ombudsman, the Health Service Ombudsman and the Local
Government Ombudsman are appointed by the Crown and are completely
independent of the Government, the NHS and local government. Ann Abraham
holds both posts as UK Parliamentary Ombudsman and also Health Service
Ombudsman for England. Her role is to provide a service to the public by
undertaking independent investigations into complaints that government
departments, a range of other public bodies in the UK, and the NHS in England,
have not acted properly or fairly or have provided a poor service.
There are three Local Government Ombudsmen in England and they each deal
with complaints from different parts of the country. Local Government
Ombudsmen investigate complaints of injustice arising from maladministration by
local authorities and certain other bodies. Jerry White is the Local Government
Ombudsman who published this joint report with Ann Abraham.
There is no charge for using the Ombudsmen’s services.
Kirsten Connick 0300 061 4996 [email protected]
Overview of upheld complaints in Six lives: the provision of public services to
people with learning disabilities
Body complained about
Buckinghamshire
Hospitals NHS Trust
Decisions on upheld complaint





Gloucestershire County
Council




Cheltenham and
Tewkesbury Primary
Care Trust (now
Gloucestershire
Primary Care Trust)




Gloucestershire
Partnership NHS
Foundation Trust
(now 2gether NHS
Foundation Trust for
Gloucestershire)




Body complained
Inadequate care and treatment including
inadequate attempts to assess, plan and deliver
care by nursing staff and inadequate discharge
arrangements which were unsafe.
These failures were for disability related reasons.
In some areas the Trust failed to live up to
human rights principles of dignity and equality.
Failure to inform patient’s family of significant
events in care.
Poor complaint handling.
Arrangements for transition from residential
school to adult care fell significantly below a
reasonable standard.
Some of this maladministration was for disability
related reasons.
The Council failed to live up to human rights
principles of dignity and equality.
Poor complaint handling.
Shortcomings in fulfilling of responsibilities with
regard to planning for the health needs of people
with profound and multiple learning disabilities.
This service failure was for disability related
reasons.
The PCT failed to live up to human rights
principles of dignity and equality.
Poor complaint handling.
Service failure in care and treatment including
nursing care and arrangements for discharge to
an adult care home.
Some of this service failure was for disability
related reasons.
The Trust failed to live up to human rights
principles of dignity and equality.
Poor complaint handling.
Decisions on upheld complaint
about
Gloucestershire
Hospitals NHS
Foundation Trust



Kingston Hospital NHS
Trust





London Borough of
Havering





Barking, Havering and
Redbridge Hospitals
NHS Trust





Failures in care and treatment including the
co-ordination and supervision of care, poor
record keeping, inadequate observations, failure
to properly report and record highly significant
incidents, failures in nursing care, poor care
planning, failures in communications with the
patient’s family about prognosis and imminent
death.
Many of the failures in care and treatment were
for disability related reasons.
The Trust failed to live up to human rights
principles of dignity and equality.
Had service failure not occurred it is likely the
patient’s death could have been avoided.
Service failure in care and treatment including
failure in stroke care, clinical leadership,
communication and multidisciplinary working
and a failure to feed the patient.
In many respects the service failure occurred for
disability related reasons.
The Trust failed to live up to human rights
principles of dignity, equality and autonomy.
Poor complaint handing.
Contributed to public service failure which
resulted in an avoidable death.
Failure to provide and/or secure an acceptable
standard of care and consequently the care
home resident’s safety was put at risk.
Less favourable treatment for reasons related to
disability.
The Council failed to live up to human rights
principles of dignity, equality and autonomy.
Poor complaint handling.
Contributed to public service failure which
resulted in an avoidable death.
Service failure in care and treatment including
failures in pain management, post-operative
monitoring, discharge arrangements and nursing
care.
Some of these service failures were for disability
related reasons.
The Trust failed to live up to human rights
principles of dignity, equality and autonomy.
Poor complaint handling.
Royal Berkshire NHS
Foundation Trust
Healthcare Commission

Poor complaint handling.

Poor complaint handling.