WIREDGOV

An independent report, based on six investigations, published today by the Health Service Ombudsman and the Local Government Ombudsman reveals:

• Significant and distressing failures in service across health and social care;

• One person died as a consequence of public service failure. It is likely the death of another individual could have been avoided, had the care and treatment provided not fallen so far below the relevant standards.

• People with learning disabilities experienced prolonged suffering and poor care, and some of these failures were for disability related reasons;

• Some public bodies failed to live up to human rights principles, especially those of dignity and equality;

• Many organisations responded inadequately to the complaints made against them which left family members feeling drained and demoralised.

The Ombudsmen recommend that NHS bodies and councils urgently confront whether they have the correct systems and culture in place to protect individuals with learning disabilities from discrimination, in line with existing laws and guidance.

Health Service Ombudsman, Ann Abraham, together with the Local Government Ombudsman, Jerry White, uncover these failings and offer a series of recommendations in Six Lives: the provision of public services to people with learning disabilities. The report responds to complaints brought by the charity Mencap on behalf of the families of six people with learning disabilities who died whilst in NHS or local authority care between 2003 and 2005. The cases of Mark Cannon, 30; Warren Cox, 30; Edward Hughes, 61; Emma Kemp, 26; Martin Ryan, 43 and Tom Wakefield, 20 and were brought to public attention in Mencap’s 2007 report Death by Indifference.

Speaking about the Six Lives report, Ann Abraham, Health Service Ombudsman for England said:

“The recurrence of complaints across different agencies leads us to believe that the quality of care in the NHS and social services for people with learning disabilities is at best patchy and at worst an indictment of our society.

“Six Lives has highlighted distressing failures in the quality of health and social care services for people with learning disabilities. No investigation can reverse the mistakes and failures but if NHS and social care leaders take positive steps to deliver improvements in services, this may bring some small consolation to the families and carers of those who died.”

Local Government Ombudsman, Jerry White, said:

“Six Lives shows that on many occasions basic policy and guidance were not observed, the needs of people with learning disabilities were not accommodated and services were unco-ordinated. The complex factors which led to these failures to protect vulnerable individuals demonstrate the need for stronger leadership throughout the health and care professions – this report is not solely a concern for specialists in learning disabilities.”

The Ombudsmen make three key recommendations:

First, that all NHS and social care organisationsin England should review urgently:

• the effectiveness of the systems they have in place to enable them to understand and plan to meet the full range of needs of people with learning disabilities in their areas;

and

• the capacity and capability of the services they provide and/or commission for their local populations to meet the additional and often complex needs of people with learning disabilities;

and should report accordingly to those responsible for the governance of those organisations within 12 months of the publication of the Ombudsmen’s report.

Secondly, that those responsible for the regulation of health and social care services (specifically the Care Quality Commission, Monitor and the Equality and Human Rights Commission) should satisfy themselves, individually and jointly, that the approach taken in their regulatory frameworks and performance monitoring regimes provides effective assurance that health and social care organisations are meeting their statutory and regulatory requirements in relation to the provision of services to people with learning disabilities; and that they should report accordingly to their respective Boards within 12 months of the publication of the Ombudsmen’s report.

Thirdly, that the Department of Health should promote and support the implementation of these recommendations, monitor progress against them and publish a progress report within 18 months of the publication of the Ombudsmen’s report.

The investigations found maladministration, service failure and unremedied injustice in a number, but not all, of the 20 bodies investigated (three Councils, 16 NHS bodies and the Healthcare Commission).

The Ombudsmen found that many organisations compounded their failures by poor handling of the complaints made against them and by a reluctance to offer apologies. Most of the bodies concerned have since apologised for their mishandling of the families’ initial complaints and have provided information on improvements they have made. Financial compensation has also been offered.

From 1 April 2009, a single comprehensive complaints process spanning both health and adult social care will come into effect. The new process will focus on resolving complaints locally with a more personal and co-ordinated approach. The Healthcare Commission will be removed as a second tier complaint handler for complaints about the NHS and the Ombudsmen will provide the second and final tier of the new system across both health and adult social care.

Six Lives: the provision of public services to people with learning disabilities can be downloaded here. For further information or interview requests please contact 0300 061 4996.

An overview of upheld complaints accompanies this release.

Details of the remedies secured in the four cases where the Ombudsmen upheld complaints are included in the individual investigation reports.

Notes to editors

Six Lives contains six individual case reports (three of which span health and social care) together with an overview report which draws out common themes and learning from these cases.

In February 2009 the Parliamentary and Health Service Ombudsman published Ombudsman’s Principles. The Ombudsman’s Principles bring together the Principles of Good Administration, Principles of Good Complaint Handling and Principles for Remedy. They were published to help public bodies in the Ombudsman’s jurisdiction by promoting a shared understanding of what is meant by good administration, good complaint handling and a fair approach to providing remedies.

The Parliamentary Ombudsman, the Health Service Ombudsman and the Local Government Ombudsman are appointed by the Crown and are completely independent of the Government, the NHS and local government. Ann Abraham holds both posts as UK Parliamentary Ombudsman and also Health Service Ombudsman for England. Her role is to provide a service to the public by undertaking independent investigations into complaints that government departments, a range of other public bodies in the UK, and the NHS in England, have not acted properly or fairly or have provided a poor service.

There are three Local Government Ombudsmen in England and they each deal with complaints from different parts of the country. Local Government Ombudsmen investigate complaints of injustice arising from maladministration by local authorities and certain other bodies. Jerry White is the Local Government Ombudsman who published this joint report with Ann Abraham.

There is no charge for using the Ombudsmen’s services.

Kirsten Connick 0300 061 4996 press@ombudsman.gsi.gov.uk

Overview of upheld complaints in Six lives: the provision of public services to people with learning disabilities