National Ombudsmen
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Vulnerable man left without bathing facilities for six months due to series of care failings
A vulnerable young man was wrongly charged more than £8,000 for accommodation, left without bathing facilities for six months and put at risk of financial exploitation, because those tasked with looking after him failed to monitor his care properly.
A joint investigation by the
Parliamentary and Health Service Ombudsman (PHSO) and the Local Government
Ombudsman (LGO) unearthed a catalogue of errors in the aftercare arrangements
for the 31-year-old man, who has schizophrenia and Asperger syndrome. The
investigation found that the monitoring of the man’s care after he was
released from a psychiatric unit was so far below what it should have been that
it amounted to service failure.
The investigation found that:
Carers expected the man to manage his household money by using two tins, into
which money was paid into or taken out of and the information recorded in
ledgers. But the investigation found that some of that data from the ledgers
was missing, meaning the system was open to abuse.
- Because carers failed to help him budget effectively, he was able to open two personal bank accounts, incurring an overdraft on one.
- One of his flats where he lived for more than two years had no bathing facilities for six months.
- There were also tensions between him and the landlord who was also his carer, which as the care company commissioned to look after him later acknowledged, was unacceptable.
- The man was forced to spend weekends with his parents to get respite from the poor standard of accommodation and the unacceptable situation with his carers.
Parliamentary and Health Service
Ombudsman Julie Mellor said:
"This vulnerable man was left suffering and was out of pocket by
thousands of pounds because no one took responsibility for coordinating his
care properly.
"The NHS has a duty to care for people with a mental health problem which
doesn’t stop when that person leaves a psychiatric unit or when a service
is outsourced. This case demonstrates the shocking consequences when that duty
of care is ignored.
"Opportunities to put things right were repeatedly denied because he had
woefully insufficient aftercare plan reviews. He only had three in five years,
when the Mental Health Act Code of Practice states that he should have had
ten."
The man was discharged from a psychiatric unit under the Mental Health Act in
2004. The law states that health authorities and local social services
departments should provide aftercare services for a person discharged from
detention under the Mental Health Act for as long as that person needs them.
It also states that the aftercare plan should be reviewed every six months. But
the investigation only found three section 117 reviews for the entire five-year
period from 2004 to 2009.
Local Government Ombudsman Dr Jane Martin said:
"The complaint offered both the Trust and the council the opportunity
to review the care given to the man and to address the concerns that were
raised.
"Neither authority took that opportunity and did not give the complaints
the attention they deserved.
"Addressing a complaint locally is often the most effective way of
resolving the issues and of ensuring that the lessons learnt help drive service
improvements. In this case, the handling of the complaints by the Trust and the
council simply compounded the frustration that the man
experienced."
Plymouth Council and NHS Plymouth Primary Care Trust (now Northern, Eastern and
Western Devon Clinical Commissioning Group), which were both responsible for
his care, have been asked to pay him £12,000, split equally between
them.
The ombudsmen have also called on both the Council and the Clinical
Commissioning Group (CCG) to write to the man to acknowledge the service
failure and maladministration and to apologise for the injustice he suffered as
a result.
They have also been tasked with drawing up action plans to ensure that they
have learnt from the failings and to outline what steps they will take to stop
it from happening again.