A joint investigation by the Health Service Ombudsman and the Local Government Ombudsman has revealed how a vulnerable adult in Merseyside, referred to as Mr B, was let down by the joint service provided by the NHS trust and council responsible for his care.

In a report published on 5 July 2011, the two Ombudsmen describe how the joint Community Mental Health service of the 5 Boroughs Partnership NHS Trust and St Helens Metropolitan Borough Council failed to monitor Mr B and respond to signs that he was at risk, resulting in the serious deterioration of his living conditions and the neglect of his personal health.

Mr B had schizophrenia and had lived in his own home for more than ten years with a support package, jointly managed by the Trust and the Council through a Community Mental Health Team (CMHT). This included regular visits from a support worker and a community psychiatric nurse from the CMHT together with practical help from Council cleaners.

Mr B’s health and living conditions deteriorated and he was unable to care for himself. He developed a serious physical illness. His cousin, Ms A, alerted the Trust and the Council when she became concerned about his personal health and hygiene and the state of his flat. Unhappy with their response, she then complained to the Health Service Ombudsman and the Local Government Ombudsman.

Ms A described how Mr B had come to their aunt’s home, was extremely dirty and unkempt, had lost a great deal of weight and was feeling unwell. Ms A went to Mr B’s flat and was horrified by what she saw. By Ms A’s account, there were cockroaches and flies, food that was over a year out of date, uneaten takeaway food, stains on every surface, and faeces and urine stains on the carpets and furniture. She said she spent several days cleaning the flat. 

When Mr B returned home, his physical health quickly deteriorated and he was admitted to hospital as an emergency. He was found to be severely malnourished, dehydrated, lethargic and confused. He was diagnosed with myeloma, a bone cancer, and was eventually moved to a nursing home where he later died.

The Ombudsmen found that the joint CMHT had failed Mr B. Their report highlights how Mr B’s care plan was not properly implemented. Evidence given during the investigation revealed how there was poor communication and gaps in records as well as a failure to review Mr B’s care, to assess in depth his mental state, capacity or risk, and to act on concerns raised about his welfare. The Council’s cleaners raised concerns but little action by appropriate professionals followed.

In recognition of the distress and emotional upset Mr B’s family experienced, the Ombudsmen recommended that the Trust and the Council apologise to Ms A and pay her £2,000 compensation and a further £1,500 to cover her legal costs. The Ombudsmen also asked the two bodies to produce an action plan setting out what they will do to prevent other vulnerable people being let down in the same way in the future. The Trust and the Council have agreed to all these recommendations.

Health Service Ombudsman, Ann Abraham, said:

 "This is an extremely sad case about a vulnerable person who was not supported in the way he should have been. The Trust and the Council failed to deliver the standard of care Mr B was entitled to and he was left to live in unacceptable conditions. Although we cannot conclude definitely that there would have been a different outcome for Mr B, in terms of the diagnosis and treatment of his myeloma, we did find that the failure to implement his care plans and to manage risk appropriately played some part in his rapid deterioration."

Local Government Ombudsman, Anne Seex, said:

"By complaining to the Ombudsmen Ms A has provided a valuable service to her wider community. Our investigation resulted in assurances from the 5 Boroughs Partnership NHS Trust and St Helens Borough Council that lessons have been learnt and others are now less likely to suffer as Mr B did. A key lesson is the importance of observations from workers like cleaners who had the most regular contact with Mr B.

"We hope that our joint investigation has given Ms A the explanations she wanted about how her cousin came to be living in the conditions that she found at his flat.

"The Ombudsmen’s power to investigate complaints jointly is particularly important when health and local government join together to provide a combined ‘seamless’ service - joint services mean joint accountability if things go wrong."

Report reference: 08 020 142

Article date: 04 July 2011