Disabled teenager left without vital medical equipment after council housing failures, Ombudsman finds

Date of article: 18/06/2026

Daily News of: 19/06/2026

Country:  United Kingdom - England

Author:

Article language: en

A disabled teenager was left unable to use their wheelchair or access essential medical equipment following major surgery, because of avoidable failures by a London council, the Local Government and Social Care Ombudsman has found.

The Ombudsman’s investigation into London Borough of Barking and Dagenham found that a family including a teenager, who is unable to walk and has extensive care needs, remained in unsuitable accommodation for almost 18 months due to accumulated delays and other failures by the council.

A representative on behalf of the family told the council the teenager could not use their wheelchair inside the flat, there was no space for a mobile hoist to help move them, and all  changes of the teenager’s position had to be carried out manually, posing a health and safety risk to the teenager and their carers.

After being clearly informed the property was unsuitable, Barking and Dagenham failed to consider whether the family might be legally homeless. It also delayed by five months completing an Occupational Therapy (OT) assessment, requested by the teen’s hospital. This meant they underwent major surgery before the council had gathered the basic information needed to understand the family's circumstances. Following the surgery, all transfers had to be completed by hoist – equipment the family had no room to store or use in their current home.

The council also failed to properly explain a decision about the family’s rights to housing or inform them of their right to appeal. There was also an eight-month delay in the council issuing a formal complaint response.

Amerdeep Clarke, Local Government and Social Care Ombudsman, said:

"This case is a stark reminder of what can happen when processes fail a vulnerable child. The teenager underwent major surgery and came home to a property where they could not use their wheelchair, could not access their medical equipment, and could not move around with the dignity and independence they deserved. That is a deeply troubling outcome, and one that may have been avoided had the council acted promptly.

"There are clear lessons here for all councils. The legal duty to consider whether a family may be homeless is triggered at a low threshold. It does not require a formal application or a visit to a specific department. Occupational Therapy assessments must be completed without undue delay, particularly where a person's medical needs are pressing. And when residents raise complaints, councils must respond fully and on time.

"I welcome the fact that Barking and Dagenham has accepted all of our recommendations. The action plans they have committed to, on homelessness and OT waiting times, should prevent similar injustice in the future. I would encourage councils across the country to reflect on this case and consider whether their own processes meet the standards residents should expect."

The Local Government and Social Care Ombudsman remedies injustice and shares learning from investigations to help improve public, and adult social care, services. In this case the council has agreed to apologise to the family and pay them £1,200. It will also meet with them to explore their housing options.

The Ombudsman has the power to make recommendations to improve processes for the wider public. In this case the council has agreed to improve guidance to complaints officers. It has also committed to producing action plans, with senior-level monitoring, setting out how it will identify potential homelessness cases at any point of contact and reduce OT waiting times.

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Serious failings after patient wrongly issued morphine on discharge

Date of article: 19/06/2026

Daily News of: 19/06/2026

Country:  United Kingdom - Wales

Author:

Article language: en

The Complaint

We launched an investigation after Mrs P complained about care provided by Betsi Cadwaladr University Health Board to her late husband, Mr P, at Wrexham Maelor Hospital in March 2024.

The investigation considered whether it was clinically appropriate to prescribe Sevredol (morphine sulphate) to Mr P and whether he and his family were provided with sufficient information and support to minimise the safety risks associated with the prescription.

What we found

We upheld both complaints.

The investigation found that Mr P was mistakenly issued morphine sulphate on leaving hospital. The prescribing consultant had prescribed the medication for use in hospital only and believing, wrongly, that Mr P had been taking it before admission.

There was a series of failures by the medical and pharmacy teams to carry out expected checks which would have identified this error. These failings were compounded by poor communication and a lack of effective multidisciplinary working. As a result, the medication was issued against the prescriber’s intentions.

There was also a failure to document appropriate clinical reasons for the prescription, given that opioids are not recommended for migraine or headache treatment under relevant guidance.

Mr P was given a controlled medication without being made aware of the risks or given guidance on safe use, including the risk of potentially fatal unintentional overdose. We concluded that it was not safe to provide Mr P with Sevredol in these circumstances.

Tragically, Mr P died of a morphine overdose 2 days later. While it was not possible to determine whether the hospital supply directly caused his death, supplying morphine sulphate in error, without appropriate advice, significantly increased the risk of accidental overdose. This was an extremely serious injustice to Mr P and his family.

We noted that patient safety should always be the priority and that the desire to arrange prompt discharge may have contributed to insufficient attention to the safety of the prescription.

The Health Board missed opportunities to identify and address these failings during its own investigation. The investigation was not sufficiently robust or objective and did not obtain independent medical advice which would likely have identified the failings. Complaint handling fell well short of the Duty of Candour.

This is the second successive public interest report involving the Health Board to identify shortcomings in relation to the Duty of Candour.

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:

“This case highlights a series of failures in prescribing, checking and communication which led to a patient being supplied with a controlled drug in error. This represents an extremely serious injustice to Mr P and to his family. These failings should have been identified and addressed at an earlier stage.

I am also concerned that the Health Board has again fallen short of the Duty of Candour, and I expect it to ensure that the spirit and requirements of the Duty are fully embedded in everyday practice.

I am issuing this report as a public interest report to ensure that the Health Board publicly demonstrates how it has learned from the failings identified, the action it is taking in response to them and to provide reassurance that similar failings will not occur in future. I also consider it important that lessons are learned more widely across NHS Wales, and that other health boards review their own arrangements to ensure that robust processes are in place.”

Our Recommendations

We made a number of recommendations, which Betsi Cadwaladr University Health Board accepted. These included:

  • Apologising to Mrs P and making a financial redress payment to her for issuing Sevredol without ensuring it was safe, and for failing to provide appropriate advice about the risks of its use
  • Sharing learning points with all medical and pharmacy staff, and reminding them of their responsibilities under relevant guidance
  • Carrying out a full review of processes and practices within medical and pharmacy teams.
 

Read the full report here

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Communication failures led to wrong treatment that left five-year-old girl traumatised

Date of article: 05/06/2026

Daily News of: 12/06/2026

Country:  United Kingdom

Author:

Article language: en

Effective communication is a critical tool in preventing harm. This has been highlighted in a case where a child was left bleeding and in severe pain after being wrongly prescribed a vaginal pessary following an appointment with a physician associate (PA). 

The case exposed multiple failures in the five-year-old’s care and led to her mother being questioned about possible sexual abuse.  The practice has committed to learn from this complaint and strengthen its systems to prevent the same mistake happening again.

The value of effective communication for public services and its importance in maintaining citizens’ trust and confidence forms a central part of the long-term strategy of the Parliamentary and Health Service Ombudsman (PHSO) published in April.  

There was no discussion between the PA and GP before the GP authorised the prescription based on the PA’s recommendation. There was also no questioning of the prescription by the pharmacy that dispensed it.  

The girl was taken to a GP practice in East Midlands in March 2023 with itching and vaginal discharge. A PA suspected thrush and recommended a Clotrimazole vaginal pessary and cream. Her mother, who believed her child was being treated by a GP, questioned the treatment and the size of the pessary, but was reassured that it was appropriate. 

In 2024, the Government commissioned the Leng Review to address concerns about the safety and rapid deployment of PAs and Anaesthesia Associates (AAs) within the NHS. Following the publication of that review last year, the Government accepted its recommendations, including about improving the identification and supervision of PAs. They are in the process of implementing them.  

After the mother administered the pessary, a treatment which should not be given to a pre-pubescent child, the child began to bleed and scream in pain. Her mother described the experience as deeply distressing and psychologically traumatising for them both. The mother says the cream also burnt her daughter’s skin. 

At a later appointment with an out-of-hours doctor, the girl, still in pain and distressed, asked the doctor not to examine her internally. Combined with her symptoms, this led the GP to raise concerns about possible sexual abuse and to have discussions with safeguarding services about this.  

As part of those discussions, a consultant explained that the symptoms were caused by the pessary and cream, not sexual abuse. While the out-of-hours doctor acted appropriately, the mother said the experience was distressing, embarrassing, and further added to her trauma. 

An investigation by PHSO found failings by all involved. The practice inappropriately prescribed the treatment as a pessary should only be given to someone who is sexually active and the pharmacy did not do the necessary clinical checks before dispensing it. 

Rebecca Hilsenrath, Chief Executive Officer of PHSO, said, 

This is a deeply troubling case in which a child suffered physically and psychologically and was left traumatised by her experience. What makes this all the more concerning is that it could so easily have been avoided by better communication between the professionals involved in caring for this young girl. 

 

“The breakdown in communication meant that the checks and balances designed to make sure patients are treated appropriately and kept safe were not followed. Poor communication is a recurring theme in our investigations and the NHS must make sure it operates with candour and clarity both between professionals and in relation to patients and their families. 

 

“I welcome the Government’s commitment through the Leng Review to providing clarity and structure around these roles for the benefit of patients, PAs and doctors.” 

PHSO’s investigation found that the prescription given was not appropriate as the child’s symptoms were consistent with vulvovaginitis, not thrush, and a pessary tablet should not be given to a five-year-old.  

PAs do not have prescribing rights and their work must be supervised by a doctor who signs the prescription following a discussion. No discussion took place between the GP and PA. Pharmacists should contact the prescriber when there are queries relating to a prescription. There is no evidence that the pharmacy did this. 

The Ombudsman recommended that the practice and pharmacy write to the girl’s mother to apologise for their failings and acknowledge the impact on her and her daughter.  

PHSO also recommended both organisations make service changes to ensure this does not happen again, that the practice pay the girl’s mother £1,000 and that the pharmacy pay her £500. Both organisations have complied with our recommendations.

The practice has taken action to strengthen and improve its processes. It introduced an electronic prescribing alert to flag intravaginal pessary prescriptions for children, requiring additional review before authorisation. It also carried out a review of the scope of practice for the PA, particularly in relation to the assessment and treatment of children, taking into account current professional guidance.  

The PA and GP involved underwent additional training to reinforce appropriate prescribing standards and supervision requirements. Processes at the practice have also been strengthened to ensure that supervisory discussions are clearly documented before prescriptions are signed. 

The girl’s mother, 38, said, 

I had huge guilt for doing what the PA, who I thought was a GP, told me and feeling as if I had inflicted this trauma on my daughter.   

 

“But I trusted what the doctor told me. How are we meant to trust healthcare professionals now? The prescription went through three professionals and no one picked it up or questioned why this was being given to a child. 

 

“My daughter is neurodivergent, so it has been even harder for her to move on from the harm this caused. This deeply affected her and added to the struggles she already faces every day, I don’t think she will ever move on from it. 

 

“I have three neurodivergent children and have been battling for them to receive the right education services they need, and then I had to deal with this. It was a breaking point for me and caused so much stress for the whole family.”  

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Council left domestic abuse survivor and child without a home by ignoring its own legal duties

Date of article: 21/05/2026

Daily News of: 26/05/2026

Country:  United Kingdom - England

Author:

Article language: en

South Gloucestershire Council turned away a domestic abuse survivor and her young children when they urgently needed help, after fundamentally misapplying the law designed to protect victims, the Local Government and Social Care Ombudsman has found.

The mother fled domestic abuse in 2023 and moved with her child to a refuge. When told she would need to leave the refuge, she approached South Gloucestershire Council for homelessness help. Despite a formal risk assessment showing she faced severe and escalating danger, the council refused to help because she did not have a local connection to the area.

The council considered whether the mother could live in a different area near her family. This was despite being told the mother had applied for a non-molestation order against her former partner who had travelled there to try to find her.

South Gloucestershire then referred the mother back to the area she had fled, telling her she would be safe if housed "three miles" from unsafe addresses, without any basis in law or guidance for this approach.

When the mother's support worker repeatedly challenged the council's decisions, citing the relevant law and the Government's own Homelessness Code of Guidance, the council dismissed the challenges and insisted the guidance did not apply.

The council then closed the mother's case without resolving her housing situation, leaving her with no accommodation and no clear way of getting help.

Amerdeep Clarke, Local Government and Social Care Ombudsman, said:

"This vulnerable family sought help from South Gloucestershire Council and the risks she faced were clearly documented. Yet the council turned her away, sent her back towards danger, and then simply closed her file.

“What concerns me most is that these decisions were not made in error by a single officer acting alone. They were made and maintained with managerial awareness, in the face of accurate challenge. That suggests this is not about one bad decision, it may reflect a wider misapplication of the law that could be affecting other domestic abuse survivors right now, in South Gloucestershire and potentially elsewhere.

"No victim of domestic abuse should face the prospect of being referred back to the area they fled. The law is clear on this and councils must understand and follow it.

"I am pleased that South Gloucestershire Council has accepted our recommendations and taken steps to put things right for this family. Its commitment to train housing staff should hopefully ensure that no other family is let down in this way.

"This case should serve as a wake-up call for every council in the country. Getting this wrong does not just cause distress. It puts lives at risk."

The Local Government and Social Care Ombudsman remedies injustice and shares learning from investigations to help improve public, and adult social care, services. In this case the council has agreed to apologise to the mother and pay her £1,000 in recognition of the significant distress caused.

The Ombudsman has the power to make recommendations to improve processes for the wider public. In this case the council has agreed to provide training or guidance to housing staff to ensure they understand their duties to people at risk of domestic abuse.

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Ombudsman's findings - May 2026

Date of article: 25/05/2026

Daily News of: 26/05/2026

Country:  United Kingdom - Scotland

Author:

Article language: en

Since March, we have published 31 decisions of full investigations.

52% of our recently published investigations show evidence of poor complaints handling. These issues can have fundamental, negative impacts on complainants’ lives and wellbeing.

In one case published this month (202401974), a family made life changing decisions based on uncertainties around a potentially terminal cancer diagnosis. They then had to go through a lengthy complaints process, adding unnecessary strain at a deeply distressing time, despite clear opportunities to identify failings much earlier.

These cases demonstrate both the severity and breadth of the issues we handle, with findings ranging from misdiagnosis and delays in healthcare to the administrative handling of benefit payments.

In another case (202401604), we found failings in how Midlothian Council managed the end of an adoptive placement due to irreconcilable behavioural difficulties and a breakdown in the relationship. The findings included weaknesses in the accuracy of assessment reports, information sharing between authorities, and the involvement of the adoptive parent in ongoing care planning.

Our recommendations focused on improving decision making and governance, including ensuring that reports are balanced, evidence-based, and fully reflect all relevant information, and that clear processes are in place for case transfer, independent oversight, and post-placement review.
 

This case highlights the role our work plays in improving how services make and record decisions affecting vulnerable children, helping to ensure greater transparency, accountability, and better outcomes in future.

Read our latest findings

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