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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.

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