Summary: Mr X complained about support for drug dependence for his late relative Mr Y. The Council which commissioned Change Grow Live, was at fault because there was no review of Mr Y’s long-term prescription of diazepam, no audit of the file and a failure to deal with a request for records within legal timescales in the Access to Health Records Act 1990. There was also a failure to advise Mr X of his right to complain to us. This caused avoidable distress. The Council will apologise and ensure Change Grow Live takes action to minimise the chance of recurrence set out in the statement.

The complaint

1. Mr X complained about Change, Grow, Live (CGL), a drug and alcohol support service which Cambridgeshire County Council (the Council) commissioned to provide drug treatment and support to his late relative Mr Y. He said:
1. CGL continued to prescribe diazepam above the recommended dosage despite a negative urine test result in January 2019;
2. Mr Y did not get his prescriptions for diazepam and methadone for eight days from 8 July 2019;
3. there was a failure to update Mr Y’s records to record his consent and this meant it took six months to get copies of records;
4. CGL sent an incident report to the Care Quality Commission (CQC) which contained incorrect information; and
5. CGL took too long to complete the complaints process.
2. Mr X said the above fault left Mr Y at high risk of taking an overdose and left him stressed and anxious. It also worsened the family’s grief.

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The Ombudsman’s role and powers

3. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
4. Mr X’s complaint to us is late as it is about events in 2019 and he did not complain to us until November 2021. But I have investigated it because there was delay by CGL in providing records to the family and in completing all stages of the complaints’ procedure. There was also unavoidable delay because of lockdown restrictions. There is evidence Mr X and other members of his family chased CGL for updates and did not let matters rest. Relevant records are still available. All these are good reasons for me to investigate.
5. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
6. The Health and Social Care Act 2012 amended the NHS Act 2006, placing a duty on local authorities to improve the health of people in their area. Since this change in the law, councils have been responsible for improving public health through provision of drug and alcohol treatment services. As the Council commissions CGL to provide drug and alcohol services under its powers in public health law, we can investigate CGL and any fault we find in its services is fault by the Council.
7. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
8. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I considered Mr X’s complaint to us, CGL’s responses to his complaint and documents in this statement. We spoke to Mr X about his complaint.
10. Mr X, CGL and the Council had an opportunity to comment on my draft decision. I considered their comments before making this final decision.

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What I found

Relevant law, policy and guidance

11. Councils and bodies acting on their behalf must make arrangements to deal with complaints about health and social care to ensure complainants receive:
• a timely and appropriate response (within six months of the complaint, or if this is not possible, an explanation for the delay) and are told the outcome of their complaint; and
• where the complaint relates to the functions of a council, details of the right to complain to the Local Government and Social Care Ombudsman.

(The Local Authority Social Services and NHS Complaints (England) Regulations 2009)

12. CGL’s complaints policy and procedure has up to three stages, an investigation and up to two reviews by different directors when a complainant remains dissatisfied. The first response is due within 28 days. The policy does not give timescales for the review stages. It does not say anything about the complainant’s right to contact the Ombudsman if they are unhappy with CGL’s final response.
13. Where a patient has died, their personal representative or any person who may have a claim arising from their death, may make an application for their health records. The holder needs to supply a copy of the record within 40 days, unless the record contains a note from the patient that they did not consent to access the records. (The Access to Health Records Act 1990, Section 3(1), (2) and (5) and Section 4(3).)
14. CGL’s data protection policy and procedures says it follows the Access to Health Records Act. It says CGL can share information with people who may have a claim arising from the estate and with the executor or personal representative where they provide proof.
15. CGL’s incident reporting procedure says any event or circumstance which resulted in or could have resulted in harm to a service user, including a medicines management incident, should be reported on Datix (incident reporting software) within three working days and an investigation completed within thirty working days. Learning and an action plan should be shared with relevant staff as appropriate.
16. CGL’s Opioid Medication Assisted Treatment (MAT) in Community Settings Policy describes four stages or pathways.
• MAT 1: (28 days) assessment and induction onto MAT.
• MAT 2: Person continues with MAT and also uses illicit opioids ‘on top’ (the goal of this stage is for the person to reduce and eliminate illicit use).
• MAT 3: Person continues with MAT and no illicit use, builds recovery skills and well-being. This is measured by drug screening.
• MAT 4: Person chooses to detoxify (come off MAT).
17. The Opioid MAT policy sets out actions to take where a patient disengages and/or misses a prescription.
• Staff should actively follow people up if they miss prescriptions.
• If a person misses their opioid prescription for three consecutive days, it will be suspended. The person should see their recovery worker for a review.
• Patients who have not collected their medication for four to 14 days need to be assessed in relation to substance misuse for the previous four to five days, reason for cessation and motivation for treatment. The prescriber will decide whether a face-to-face review is needed.
18. The Opioid MAT policy goes on to say where a patient repeatedly misses appointments, their care should be discussed to formulate a plan to ensure the risk of disengaging from MAT is minimised. A review may result in changes to prescription dispensing to promote safety.
19. CGL’s Management of Benzodiazepines Procedure includes the following guidelines on assessment and treatment of benzodiazepine dependence syndrome (a condition in which someone has developed one or more of either tolerance, withdrawal symptoms, drug seeking behaviour, continued use despite harmful effects)
• Benzodiazepines are generally not appropriate for long-term treatment, but they are for short-term relief in severe anxiety and insomnia and in some neurological conditions. NHS guidelines recommend use for no more than two to four weeks for anxiety disorder
• For patients who have been using benzodiazepines on a regular prescription and who have been using them consistently over six months, follow national clinical guidelines to reduce the dose by between one tenth and one quarter each week or fortnight. For patients on doses of 30 mg or more, reduce by 5 mg weekly or fortnightly. If severe withdrawal symptoms occur then increase slightly until improvement, but only for two to four weeks with a robust plan to restart reduction. The aim should be to prescribe a reducing regime for a limited period of time. Maintenance treatment with benzodiazepines will not be offered. There is no evidence to support routine substitute prescribing. (clinical prescribing to replace harmful or illicit drug use.)
• The clinician should encourage the patient to work with their key workers to develop a specific benzodiazepine relapse prevention plan.
• If the patient receives a long-term methadone prescription for opioid dependency as well, benzodiazepine withdrawal should be considered first. The methadone dose should remain stable throughout the benzodiazepine reduction period.
• Patients should be informed that the rate of dose reduction will be increased if drug screens indicate any other illicit use of Class A drugs (including heroin).
• The clinician should aim for the lowest dose to prevent withdrawal symptoms. The rate of withdrawal is often determined by the patient’s ability to tolerate symptoms. Patients should be made aware withdrawal symptoms are usual during the reduction process and encouraged to seek increased psychosocial support. (help to address a person’s psychological and social needs.)
• CGL services should strive to do three to six monthly benzodiazepine audits to check everyone is on a reduction regime and if someone is on a static dose this should be documented on the electronic record and should not be more than 14 to 28 days. A robust review plan should be in place to restart reduction after the stabilisation period.

What happened

20. Mr Y had a history of heroin addiction and benzodiazepine misuse. He attended CGL’s service for treatment and support since CGL took over the contract from a different organisation in 2018. Mr Y attended regular sessions with a recovery worker and also had input from one of CGL’s doctors and a non-medical prescriber (NMP) for medication reviews. (NMP’s are healthcare professionals who prescribe medication and who are not doctors. They are usually nurses with additional training.) CGL prescribed two long-term medications for Mr Y: methadone (which reduces withdrawal symptoms from heroin) and diazepam (a benzodiazepine which has a sedative effect and reduces anxiety and panic attacks).
21. I asked CGL for copies of Mr Y’s care plans from January to July 2019. CGL provided a copy of a full risk assessment/care plan dated 27 May 2019. This said:
• he had problems getting to the pharmacy daily so weekly pick-ups from the service had been agreed to coincide with sessions with the recovery worker;
• he reported abstinence but screening came back positive for heroin; when challenged he said he used heroin now and then;
• he told other CGL staff he used drugs with friends; and
• the recovery worker discussed the case with the doctor, explored tolerance with Mr Y and gave him advice around preventing overdose. They reviewed consent to share information.
22. The plan set out a number of agreed actions for Mr Y and CGL including:
• Mr Y to attend appointments;
• A discussion about the arrangements for collecting prescriptions;
• Mr Y to attend mental health support if he wished to; and
• recovery worker to liaise with the GP over any physical health concerns.
23. CGL’s staff kept case records of the support and treatment to Mr Y. I have summarised these for the period January to July 2019.
24. In January, staff from CGL had an internal discussion by email about changing Mr Y’s prescription regime because he was not attending appointments. or he was cancelling them and was using heroin on top of his prescribed medication. One of CGL’s doctors said ‘if on top usage continues to be of concern, his diazepam could be reduced and pick-ups increased’. Staff did not come to a collective decision about this, but the plan was for the recovery worker to ask Mr Y whether he wanted to remain in treatment before deciding whether to change his collection regime from weekly to more frequent collection. The following week Mr Y attended an appointment with the recovery worker. He said he had used heroin recently.
25. The recovery worker emailed CGL’s doctor saying CGL had decided to hold Mr Y’s prescriptions at the office because of poor engagement and high concerns about his physical and mental health. (The aim of holding the prescriptions at CGL’s offices was to encourage Mr Y to attend sessions with the recovery worker when he collected his prescription.) The recovery worker asked CGL’s doctor if the diazepam prescription could be held at the service as well and this was confirmed by the doctor. The recovery worker tried to phone Mr Y, but she could not get through to him. They spoke a couple of days later and the recovery worker told Mr Y he would need to attend CGL’s offices to collect his prescription for methadone and diazepam when he attended his weekly appointment with her. Mr Y and the recovery worker spoke again a few days later and the latter said again that he needed to attend to collect the prescription because of poor engagement.
26. The case records show Mr Y’s drug screening on 21 January came back negative for benzodiazepines and positive for both methadone and heroin. The recovery worker appears to have taken the results over the phone from a toxicology laboratory. However, the following day, the recovery worker did urine screening tests at CGL’s offices and noted Mr Y tested positive for heroin, methadone and benzodiazepines. And the urine screening the following week was positive for heroin, methadone and benzodiazepines.
27. In February, Mr Y told the recovery worker he did not have time to complete consent forms. The recovery worker told Mr Y he needed to attend the office the following week for his prescription. He completed the consent forms to share information with his partner at the next meeting with the recovery worker.
28. For the next four months, Mr Y attended appointments with the recovery worker each week at the same time he collected his prescription.
29. In the middle of March, the recovery worker and Mr Y held a care plan review. The recovery worker noted Mr Y would not discuss his care plan at any length and noted he was anxious.
30. Mr Y had a medical review with an NMP at the end of March. The plan was to continue weekly collection of the prescription. The records suggest urine tests continued to come back positive for heroin in March and April and when discussed with Mr Y, he could not say why he had used or said he used because he was feeling stressed, could not sleep, was in pain and was hearing voices. The recovery worker noted she gave Mr Y advice about other ways of managing stress.
31. In May, the recovery worker discussed Mr Y’s progress in a clinical meeting with colleagues, noting he continued to use heroin on top of his methadone and diazepam. The plan was to hold a review with Mr Y and the NMP. The recovery worker sent a text to Mr Y with the date and time, the records indicate Mr Y attended the appointment late and was verbally abusive to staff which resulted in staff calling the police because he would not leave.
32. Mr Y and the recovery worker spoke on the phone and she advised him of the new time for his medical review and he needed to attend because it would go ahead anyway and it was best he had input into decisions. Mr Y attended the review. The record said he was to remain on the same weekly prescription collection regime because he was continuing to use heroin illicitly.
33. There was phone contact between Mr Y and the recovery worker in June and a discussion about arrangements for medication during Mr Y’s forthcoming holiday. There are no records of scheduled appointments with the recovery worker in June.
34. At the end of June, Mr Y told the recovery worker he was still using heroin now and then. The NMP reviewed Mr Y. They wanted Mr Y to collect his medication and prescription daily at the chemist, but Mr Y said he could not because of transport problems and so the NMP and recovery worker confirmed a change to three days a week collection. The notes indicate Mr Y refused to give his preferred days of the week. The recovery worker texted him after the appointment to say he could collect his prescription on Tuesday, Thursday and Saturday.
35. At the start of July, the recovery worker noted she had spoken to Mr Y and his partner who told her he had not had diazepam because the prescription was not at the pharmacy. The recovery worker contacted the pharmacy which said it did not have the diazepam prescription, only the prescription for methadone and Mr Y had missed Tuesday’s dose (of methadone), but he had collected it on Wednesday. The recovery worker noted the diazepam prescription was still in CGL’s offices and arranged for it to be taken to the pharmacy. The recovery worker spoke to the NMP who agreed Mr Y could have the diazepam for that day (despite missing two days’ prescribed doses). The team leader spoke to Mr Y’s partner and advised he could collect the diazepam from the pharmacy. A text from Mr Y’s phone suggested he or his partner had bought diazepam illicitly for the previous two days.
36. Mr Y’s partner then spoke to the recovery worker to say Mr Y had no way of getting to the pharmacy on a Saturday.
37. The recovery worker spoke to the chemist who confirmed on 8 July that Mr Y had missed two days’ collection.
38. Mr Y and the recovery worker spoke, he said he was not happy with her and was giving consent for his sister to speak to CGL. The recovery worker’s case note suggested she told Mr Y she was going to speak to her team leader about Mr Y being unhappy with the service.
39. CGL sent Mr Y a text on 9 July to offer an appointment on 15 July. CGL also instructed the pharmacist not to dispense Mr Y’s prescription, as he had missed three days of medication.
40. The appointment on 15 July was an assessment to restart treatment because Mr Y had missed several doses of medication. It took place with the recovery worker and NMP. The agreed plan was to restart methadone at 30 ml, continue on diazepam 40 mg and to review in one week, for Mr Y to provide a clean urine sample, provide recovery support and encourage Mr Y to attend recovery groups. The record noted Mr Y had been using heroin illicitly on the day of the appointment and on the previous day.
41. Mr Y called the recovery worker two days later to say there was an issue with his diazepam collection. The records then end because Mr Y died. According to the coroner’s report, the death was not due to drug related issues.

The family’s request for Mr Y’s records and their complaint to CGL

42. One of Mr Y’s relatives contacted CGL in July 2019 to ask for copies of Mr Y’s case records. I do not consider this was a formal complaint and it was expressed as a request for information. There was an exchange of emails and in September a manager said the relative could not have copies because Mr Y had not consented. The relative said Mr Y gave verbal consent the week before he died. The relative also said Mr Y’s mother consented. The manager emailed the relative refusing access to records because Mr Y only gave verbal consent to share information. There were more emails but still no agreement from CGL about sharing records. The relative chased CGL for an update in November.
43. At the end of January 2020, a manager from CGL emailed the relative to say CGL would share records. It appears the relative received copies of the records because she referred to them in her formal complaint to CGL in July 2020. She said:
• she had contacted CGL several times in the week before Mr Y’s death to discuss concerns because Mr Y felt the recovery worker was not listening to him;
• it took six months and a lot of emails to get copies of Mr Y’s records. Mr Y had given verbal consent to discuss his treatment with her and the consent form should have been updated;
• when the family did get the notes, they were refused a meeting to discuss their concerns;
• Mr Y and his partner complained at the end of June and in July about his prescription pick-up days and also asked to change his recovery worker as he was unhappy with the service. He was unclear about the days he was supposed to collect his prescription and this meant he did not receive his medication as prescribed;
• the policy says diazepam should only be prescribed at 30 mg for a short period of time for symptomatic relief only.
44. CGL’s first response to the complaint in September 2020 said:
• Mr Y attended appointments weekly or fortnightly between January and the start of May 2019;
• from May to his death, there was limited evidence of appointments being offered. There may have been a gap in case recording. But there was regular phone and text contact between Mr Y and the recovery worker;
• Mr Y had regular medical reviews with the NMP in line with policy;
• staff involved with Mr Y’s care made appropriate use of senior staff support, and used a person-centred approach, offering Mr Y choices;
• there was evidence the service user plan was reviewed in line with policy but there were no clear goals or timeframes. This was a quality issue;
• he was going to be offered a new recovery worker because he was unhappy with the current worker;
• the outcome of an NMP review at the end of June 2019 was to increase methadone collection from once to three times a week. This was after Mr Y said he had been using heroin illicitly. Mr Y refused to state his preferred days, so the NMP set the days and Mr Y was informed of the details by text;
• the recovery worker contacted the pharmacy about the diazepam prescription, who said they did not have it. The prescription was found in CGL’s safe. The NMP advised on the safety of starting diazepam after two missed doses and Mr Y was told he could collect it. This incident was not reported or investigated in line with policy;
• a restart appointment took place in the middle of July after Mr Y missed three methadone doses. Mr Y was going to have seven days’ supervised consumption, but he said he could not get to the pharmacy. The local pharmacy refused to dispense. The decision to prescribe a week-day consumption and weekend take away was a compromise due to transport issues and to prevent missed doses. There were no documented concerns about suicide.
• At the restart appointment, Mr Y was also prescribed diazepam at 40 mg daily with three times weekly collection (Tuesday, Thursday, Saturday). His diazepam collection days should have been amended to be in line with the methadone collection regime because it had been agreed he did not need to attend the pharmacy at the weekend.
• Diazepam is in most cases used short term to treat symptoms when detoxing from other substances. However, this did not apply to Mr Y and he had been on diazepam since 2018 when CGL took over the service from the previous provider. Staff tried to encourage him to reduce the dose and work towards detoxing, but he declined.
• There was no written consent to share information form on file, although there is a 2019 note saying it had been completed with regard to sharing information with Mr Y’s partner. Mr Y gave verbal consent to share information with his sister in July, but not in writing. CGL’s policy says consent before death should be considered when responding to information requests.
• There was a recording error in the information to the Care Quality Commission.
45. The first response recommended the following.
• Frequency of sessions to be agreed and recorded on the service user plan
• All offered, unattended, attended and cancelled appointments to be documented on file.
• Training to recovery workers in goal setting.
• Auditing of service user plans for quality.
• Refresher training on incident reporting.
• When a patient has more than one medication prescribed by CGL, the collection regime should be the same to avoid confusion.
• An apology for the delay in sharing information.
• Managers to read the data protection policy and refer to it when requests are received.
• All patients to have an up-to-date consent form on file.
• External reports should be ‘quality assured’ (checked for accuracy).
46. Mr Y’s family were unhappy with CGL’s first response. There was supposed to be a meeting with them in October 2020, but CGL cancelled this because a key member of staff was absent. CGL rearranged the meeting for a date in November, but Mr Y’s family cancelled it because of technology problems and because of COVID-19 issues. A senior member of staff spoke to another relative. It appears another date was not sorted because of lockdown restrictions. A meeting with the family took place in May 2021. An internal note about the meeting said, as a result of the complaint, CGL had changed its processes as follows.
• Amended the data protection toolkit in March 2020 to include additional access to records for relatives of service users.
• Amended the incident reporting policy so a different service would complete an incident report where there was a conflict of interest.
• CQC notifications would be checked by the central quality assurance team.
• All front-line staff had attended training on risk review and care planning.
• Recruited a quality lead to oversee monitoring and auditing.
• Organised refresher training on incident reporting.
47. The note also suggested the request for records had taken too long to deal with and the relative could have been offered an alternative way of making the request, such as by having a parent make the request. It went on to say the CQC notification was incorrect with regard to medication doses and this appeared to be human error.
48. Following the meeting, CGL sent a final complaint response in October 2021 which included input from a psychiatrist not involved with Mr Y’s care. The final response apologised for the delay and explained:
• Mr Y was transferred into the service on 40 mg of diazepam. This was higher than the recommended dose of 30mg. The service took a person-centred approach when Mr Y declined a reduction in the dose. A long-term prescription is allowed in exceptional cases where the patient has mental health problems and this is not unsafe when the patient is tolerant. Enforced reduction may cause mental distress including suicidal thoughts and mistrust and anger in services. There was a balance between the risks and benefits.
• Its specialist advice was that Mr Y’s treatment was within relevant clinical guidelines and avoided coercive approaches to changing doses of diazepam. The reasoning may have been implicit in this case.
• There needed to be a cogent rationale (good reason) for departing from policy and procedure.
• CGL took too long to deal with the request for records and the data policy was changed as a result.
• The correspondence did not mention the three-stage complaints procedure or the right to appeal the outcomes at either stage one or two. CGL was sorry for the impact on the family. Leaders would receive refresher training in complaint handling.
• There would be a review of the benzodiazepine policy to include discussing reduced doses when patients ‘fall off’ prescriptions and plans being made explicit about the reasons for prescribing them.
49. CGL’s final response did not mention the family’s right to complain to the Ombudsman.

Comments from the Council

50. I asked the Council how it monitored CGL’s complaint handling. The Council told me it held quarterly performance meetings with CGL and informal monthly meetings. The quarterly meetings included information about complaints, responses and a summary of complaints received. The Council told me it intended to change procedures so they include the following.
• A standard agenda item in the monthly meeting including an overview of each complaint (documented in the minutes).
• A change to the contract to specify the Council receives copies of any complaints that escalate beyond stage one and copies of final reports and correspondence.
• A requirement for CGL to provide evidence of how they are going to ensure learning from complaints is put into practice.
• A requirement for CGL to provide commissioner/council contact details to the complainant after they complete each stage of the complaint process. This gives complainants the opportunity to get support from the Council which can help mediate if appropriate.

Was there fault and if so did this cause injustice?

CGL continued to prescribe diazepam above the recommended dosage despite a negative urine test result in January 2019

51. The case records reported one negative test for benzodiazepines on 21 January, but this result was taken over the phone from a toxicology laboratory. The recovery worker noted positive tests the following day and a week later both from urine samples taken at CGL’s offices. There may have been an error in the recording of the 21 January result. I cannot say whether the error was by the laboratory which may have given incorrect information to the recovery worker or by the recovery worker in noting the information incorrectly on the case record. However, given the following day’s positive result and another positive result the following week, it is likely Mr Y was positive for benzodiazepines in January. I do not consider the error caused specific injustice.
52. CGL’s benzodiazepine prescribing to Mr Y was not in line with CGL’s policy and procedures as described in paragraph 19 and this was fault. In particular:
• the prescription was above the maximum dose of 30 mg as set in the policy;
• there was no treatment plan involving planned reduction. The policy says maintenance treatment will not be offered, however it appears Mr Y had been on a prescription of 40 mg since 2018. The only mention of any reduction was a suggestion by one of CGL’s doctors in January 2019 and this was not acted on;
• contrary to CGL’s final complaint response, there were no documented discussions between January and July 2019 with Mr Y about reducing the dose with the aim of coming off diazepam; and
• there is no evidence the file was audited between January and July 2019 to check Mr Y was on a reduction regime.
53. CGL’s final complaint response noted national guidance allowed long-term benzodiazepine prescriptions in exceptional cases. I accept clinicians may depart from policy when there are appropriate reasons to do so, however, there is no documentation in the case records to support a departure in Mr Y’s case and so the rationale is not clear. Without a documented reason for departing from standard practice, and no review specifically addressing Mr Y’s benzodiazepine use, it appears CGL left Mr Y on a regime from 2018 without considering whether it needed to be addressed and changed. This was against policy and was fault.
54. The fault I have described in the previous two paragraphs caused a loss of a chance to review the appropriateness of Mr Y’s long-term prescription of diazepam and to offer him a planned reduction programme. I cannot conclude on a balance of probability what the outcome would have been for Mr Y. But there is avoidable uncertainty for Mr Y’s family about what the outcome might have been.

Mr Y did not get his prescriptions for diazepam and methadone for eight days from 8 July 2019.

55. There was a clinical decision to change Mr Y’s collection regime from weekly to three times a week at the end of June. This took place following a review with Mr Y’s input and his preferences were taken into account. There is no fault because this was in line with CGL’s MAT policy. The evidence indicates Mr Y continued to use heroin on top and was not attending regular sessions with the recovery worker in June. So it was appropriate to change to a more supervised regime as this was in line with the aim of reducing the risk of Mr Y disengaging with treatment completely, as stated in the MAT policy.
56. CGL accepted in its complaint responses that Mr Y’s diazepam prescription was not available at the chemist. This was fault. The records suggest Mr Y did not have diazepam for two days and purchased it illicitly as a result of the prescription not being where it needed to be, placing him at risk. CGL also accepts that there was no reporting of this incident in line with its incident reporting procedure. This was an additional fault.
57. The records indicate Mr Y’s full prescription was available at the pharmacy once the diazepam prescription was sorted and that Mr Y did not attend the pharmacy for three days to collect it. So, CGL instructed the pharmacist not to dispense it and then offered Mr Y a restart appointment within a week. This was in line with the MAT policy (with the aim of reducing risk and to support Mr Y to resume treatment) and so there is no fault.

There was a failure to update Mr Y’s records to record his consent and this meant it took six months to get copies of records

58. On receiving the family’s request for access to Mr Y’s records, CGL should have established whether the application was from one of Mr Y’s executors/personal representatives or a person with a potential claim arising from his death. There is no evidence CGL did this. Instead, officers took legal advice and then no action. CGL should have supplied the records within 40 days unless there was a note from Mr Y saying he did not consent, which there was not. CGL’s failure to act in line with the Access to Health Records Act 1990 was fault causing avoidable distress and inconvenience to the family who sought information relating Mr Y’s care and treatment.

CGL sent an incident report to the Care Quality Commission (CQC) which contained incorrect information

59. CGL accepted in its complaint response that its report was inaccurate (contained the wrong doses). This was fault but no injustice arose from it.

CGL took too long to complete the complaints process

60. There was fault in complaint handling. According to CGL’s complaints’ procedure, the first response should have been within 28 days of the complaint in July 2020. The first response was not until September 2020. This was a delay of over a month, was not in line with policy and was fault.
61. The family tried to escalate their complaint. CGL took until October 2021 to provide another complaint response. I note some of this was not within CGL’s control (meetings did not take place because of COVID-19 restrictions). However, complaint handling in this case was not in line with the regulations summarised in paragraph 11 because there was not a comprehensive response addressing all the issues within six months of the complaint. The delay caused avoidable distress to Mr X and other family members who had been involved in complaining.
62. Neither the complaint responses nor CGL’s complaints policy mention a complainant’s right to refer their complaint to us. This means staff in CGL who are responsible for complaint responses are not aware of the legal requirement to tell complainants about us (see paragraph 11) because the complaints procedure does not tell them this.

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Agreed action

63. I recognise CGL has taken actions as a result of this complaint as set out in paragraph 45. But I do not consider they will minimise the risk of recurrence, so I am making additional recommendations.
64. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with CGL, I have made recommendations to the Council.
65. The Council will apologise to Mr X for the avoidable distress. I recognise CGL has already apologised in its complaint responses, but the Council retains responsibility for services it commissions and so it is only right that it apologises for the failings identified in this statement. It should do so within one month of my final decision.
66. Within three months of my final decision, the Council will:
1. implement the suggested action to improve oversight of CGL’s complaint handling in paragraph 49;
2. ensure CGL updates its complaints procedure to signpost the LGSCO;
3. ensure all CGL’s complaint responses inform the complainant of the right to contact us, providing our details in writing;
4. ensure CGL has amended its benzodiazepine policy so that it deals with exceptional cases where patients are maintained on long-term prescriptions so their case records set out a ‘cogent rationale’ for departing from the usual policy to reduce dosage with the aim of stopping; and
5. ensure CGL audits all patients who are taking benzodiazepines to make sure they are on an appropriate reduction programme in line with the benzodiazepine prescribing policy or there is a record of a cogent rationale for departing from policy
67. I will require evidence of compliance such as minutes of performance meetings where complaints are discussed, copies of revised policies and procedures and copies of audit reports.

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Final decision

68. Mr X complained about support and treatment for drug dependency to his late relative Mr Y. The Council which commissioned Change Grow Live, was at fault because there was no review of Mr Y’s long-term prescription of diazepam, no audit of the file and a failure to deal with a request for records within legal timescales in the Access to Health Records Act 1990. There was also a failure to advise Mr X of his right to complain to us. This caused avoidable distress. The Council needs to apologise and ensure Change Grow Live takes action to minimise the chance of recurrence set out in the statement.
69. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman