National Ombudsmen
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Serious failings in the care provided to a man with Down’s syndrome uncovered by Ombudsmen’s investigation

An investigation by two Ombudsmen has highlighted significant  failings in the care provided to a man in Newcastle  who had Down’s syndrome. A new report, published recently (23 November 2011),  describes how Mr J’s basic human rights were ignored after he was detained  unnecessarily in hospital for months and was then moved into inappropriate locked  accommodation until his death.

The Health Service Ombudsman and Local Government Ombudsman conducted  a joint investigation into complaints made by Mr J’s brother about the care and  treatment provided by Northumberland, Tyne and  Wear NHS Foundation Trust, Newcastle City Council and the Coquet Trust.

Mr J had been an active, outgoing and sociable man, living  independently in rented accommodation with his wife. He had day-to-day support from  the Council, and his family, who he was close to, supported his wish to be as independent  as possible. When health professionals became concerned about a significant  deterioration in his skills and health, Mr J was admitted to hospital for a  short assessment. He was diagnosed with dementia and epilepsy, but in spite of  being declared ready for discharge, he was kept in hospital for a further five  months. Rather than returning home, which was now considered to be unsuitable  accommodation, Mr J and his wife were moved to a self-contained flat at a care  home for older people. The flat was kept locked to restrict Mr J’s access to  the outside, for safety reasons. Although this was supposed to be temporary  accommodation, Mr J and his wife were still living there ten months later when Mr  J became ill with a chest infection. He was admitted to hospital, where he  sadly died. He was 53.

The Ombudsmen found significant failings by both the NHS Trust  and the Council. Mr J’s basic human rights, to liberty and to family life, had  not been given appropriate consideration when decisions were being made about  his care needs. The importance of Mr J’s family in his life was not appreciated and as a  result they were not fully involved in plans for his care. Opportunities to  ensure that Mr J’s wishes and best interests were fully taken into account were  therefore missed. There was a lack of any properly co-ordinated and documented  health and care plan for Mr J, and no-one from either the NHS Trust or the  Council took a leadership role and had responsibility for co-ordinating his  care and representing his interests. Action was not taken quickly enough to  find permanent suitable accommodation for Mr J and his wife, and contact with  his family had been restricted.

Following the Ombudsmen’s investigation, the NHS Trust and  the Council agreed to provide Mr J’s family with a full acknowledgement of the  serious mistakes they made, together with an apology. They also agreed to pay £2,000  in recognition of the distress caused, which the family have said they will  donate to charity. The Ombudsmen have also asked the NHS Trust and the Council to  prepare, and report progress on, an action plan setting out what they have done  (or will do) to ensure that these mistakes are not repeated in future.

Health Service Ombudsman, Ann Abraham, said:

‘Mr J’s rights, best interests, and family relationships were not taken  into account when the Trust and the Council made plans for his care. This was  highly likely to have had some impact on the quality of his life, and hence his  well-being, in the last 18 months or so of his life. Mr J’s family were also  wrongly denied the opportunity to be involved and will never know if they could  have made a difference to his quality of life in those last months, which must  be a cause of significant and ongoing distress for them. It is shocking that  the events described in this report happened in the 21st century. I hope the  lessons from Mr J’s story will be understood by public bodies and thereby help  to drive improvements in public services.’

Local Government Ombudsman, Anne Seex, said:

‘The failures in Mr J’s case show how public authorities can neglect a  vulnerable person’s wishes and basic human rights to liberty and family life.  The Ombudsmen’s joint investigation brought serious service failures to light.  As a result, the authorities concerned will make changes so that other families  are not treated this way.’

For more information or to request an interview, please  contact the Health Service Ombudsman’s Press Office on 0300 061 4996/3924 or  email

Notes to Editors: 

  1. The  Health Service Ombudsman’s role is to consider complaints that the NHS in England  has not acted properly or fairly, or has provided a poor service. Ann Abraham  currently holds the post of Health Service Ombudsman and is also Parliamentary  Ombudsman. She is appointed by the Crown and is completely independent of  government and the NHS. 
  2. Anne  Seex is one of the Local Government Ombudsmen in England. She is appointed by the  Crown and is completely independent of local government and other bodies in her  jurisdiction. The Local Government Ombudsmen have the power to investigate  complaints of injustice arising from maladministration or service failure by  local authorities and certain other bodies; complaints about injustice in  connection with privately arranged and funded adult social care; and complaints  from pupils or their parents about schools in 14 local authority areas. 
  3. The  Coquet Trust is a non statutory organisation which had been contracted by the  Council to provide support to Mr J. 
  4. The  Parliamentary and Health Service Ombudsman and the Local Government Ombudsmen  can share information, carry out joint investigations and issue joint reports  on cases which are relevant to more than one of them. 
  5. The  full report will be available to download from the Ombudsman’s websites: or