Public Statement from Ombudsman

Date of article: 15/04/2024

Daily News of: 16/04/2024

Country:  United Kingdom - Wales

Author: Public Services Ombudsman for Wales

Article language: en

PSOW announced last week that an independent review will take place to provide assurance that there has been no bias in its decision making and that the organisation continues to deliver an independent, fair and impartial service.  This follows the recent resignation of a member of staff following inappropriate and unacceptable social media posts.

I recognise that it is essential that this review has the confidence of the Senedd and stakeholders across local government.  Whilst I remain confident that James Goudie KC would have carried out the review with integrity, impartiality and professionalism, it is evident that concerns have been expressed by several people.

I have listened to these views and have concluded that to continue would lead to a lack of confidence in the review and its findings. I have therefore reconsidered the appointment and will be seeking another person to lead this work instead.

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Staffs home refuses to refund care costs following Ombudsman investigation

Date of article: 11/04/2024

Daily News of: 12/04/2024

Country:  United Kingdom - England

Author: Local Government Ombudsmen for England

Article language: en

A Staffordshire care provider has refused to refund a man’s estate after the Local Government and Social Care Ombudsman found it put too restrictive care in place for the last nine months of his life.

The man, who had dementia, attempted to take his own life while living in the Barrowhill Hall Care Home in Rocester, run by MOP Healthcare Ltd. Consequently, the care home put in place one-to-one care for 24 hours a day.

This cost the family an extra £2,520 a week. The family complained that the man did not need this level of care, particularly when his dementia progressed, and it was draining the man’s resources. They said as result, he had paid more than £100,000 for this care on top of his normal fees.

An Ombudsman investigation found MOP Healthcare Ltd did not properly assess the man’s mental capacity after he attempted to take his life, and failed to progress a legal document called a ‘Deprivation of Liberty safeguard’ properly.

The company did not consider other less-restrictive options for his care, despite his social worker and a community psychiatric nurse advising he could be kept safe with less limiting measures in place.

The Ombudsman asked MOP Healthcare Ltd to pay the family £1,000 for the distress of having to bring the complaint and review its staff training and how it tracks Deprivation of Liberty safeguards applications to its local council, to ensure similar faults do not happen again. The provider has agreed to these recommendations.

However, the Ombudsman also asked the provider to consider the lower cost had it accepted professionals’ recommendations to reduce the level of care and pay the man’s estate the difference. It has not agreed to carry out this recommendation.

Ms Amerdeep Somal, Local Government and Social Care Ombudsman, said:

“The provider has told us it will not pay the financial recommendation we have made because it says the family could have moved the man from his home at any time.

“I am not satisfied with this provider’s response. It shows no regard for the distress faced by the family witnessing their relative under constant supervision for the last nine months of his life, to the extent this was not lifted even when he was receiving end of life care.

“I will be sharing our findings with the care regulator, the Care Quality Commission.”

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Man suffered psychosis after Trust failed to inform him of steroids side-effects

Date of article: 10/04/2024

Daily News of: 11/04/2024

Country:  United Kingdom

Author: Parliamentary and Health Service Ombudsman

Article language: en

A man who suffered a psychotic episode which lasted for weeks was not fully informed about potential extreme side-effects of taking steroids medication, England’s health service Ombudsman has found.

Andrew Holland was prescribed steroids in early January 2022 by Manchester Royal Eye Hospital after losing vision in his left eye and suffering a severe infection in his right eye.

The 61-year-old from Manchester was given the medication as treatment for eye inflammation, but soon began suffering from disrupted sleep and severe headaches.

These side-effects developed into more serious ones, including becoming aggressive, psychotic, and inexplicably wandering the street at different times of the day and night.

Andrew began having hallucinations of seeing people, animals, and dust on people, leaving him confused and scared after not knowing what was happening to him for a month.

After several hospital visits due to his symptoms, Andrew attended Manchester University NHS Foundation Trust’s emergency department in mid-January with a severe headache and later became an inpatient.

He was diagnosed with steroid induced psychosis, with symptoms including hallucinations, insomnia and behaviour changes.

Andrew attended the Trust again in early February, where he was described as having ‘steroid mania’ and was advised to cease taking the medication.

Later that month, he was taken to another Trust where he was described as having ‘steroid psychosis’. He was eventually discharged in mid-February after the psychotic episode ceased.

Though no failings were found with Manchester University NHS Foundation Trust in prescribing Andrew with steroids for the eye condition, the Ombudsman discovered a missed opportunity to fully inform him of potential extreme side-effects. He was therefore unable to make a fully informed decision about whether to take them or not.

The Trust apologised for an ‘unsatisfactory experience’. However, the Ombudsman found relevant guidelines were not followed. Moreover, there had been no acknowledgement of mistakes in communication about the side-effects. Nor was any attempt made to correct them.

Following the partly-upheld complaint for not informing Andrew of the potential extreme side-effects, the Ombudsman recommended the Trust pay £700 compensation in recognition of the distress and worry he experienced.

The Trust has also been asked to write to Andrew to acknowledge something went wrong in communicating the side-effects and to apologise for the distress, anxiety and upset this ultimately caused.

The Ombudsman has also recommended an action plan be produced by the Trust to address how it will learn and improve from this case.

Andrew Holland said:

“It was terrible. I went in and out of about three different hospitals.

“I don’t know what I was capable of. Apparently, I had the ambulance sat outside for about half an hour while I insisted on doing my ironing before I went with them. It was just crazy.

“I’m not really blaming the doctor and it’s very rare to get a reaction off them.

“I had a bad reaction and I suppose you could have a reaction to any kind of pills.

“I was seeing all sorts. It was crazy. There was a bear at the end of the garden one day and a burglar coming over the garage roof.

“I just took what they told me to take. I wouldn’t like to go through that again and I wouldn’t wish it on anyone either. 

“I want people to be aware of this that it can happen. I don’t know why it went against me but it happened. It can happen to anyone, I suppose.

“The case worker did a great job – they were fabulous. They kept me informed and told me everything that was going on.”

Rebecca Hilsenrath, Chief Executive of the Parliamentary and Health Service Ombudsman, said:

“This must have been a terrifying experience. It is an act of trust to put yourself under the care of others and trust depends on information and understanding. No one wants to suffer a psychotic episode – no one should do so as a result of medication without fully understanding and accepting the risk.

“Trust is also dependent on recognition of mistakes, and on steps being taken to ensure they are not repeated.

“This case shows the power of making a complaint and how it can prevent others from experiencing similar issues in the future.” 

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Statement from the Public Services Ombudsman for Wales

Date of article: 09/04/2024

Daily News of: 11/04/2024

Country:  United Kingdom - Wales

Article language: en

Following the allegation of political bias, made against a former officer of PSOW, the Ombudsman has (today) announced that an independent review will be conducted to provide assurance that its code of conduct processes are sound, free from political bias and that lessons are learned from what has happened.

The Ombudsman, Michelle Morris, fully accepts that PSOW now needs to rebuild trust in the work of the organisation on complaints against Councillors.  The remit will include reviewing discretionary decisions previously made, by the former officer and her team, not to investigate complaints when applying the Ombudsman’s processes.

The review will be led by James Goudie KC and is expected to report this summer.

 

Notes

  • The Ombudsman’s process includes the application of a two-stage test, first whether the evidence suggests that a breach of the Code of Conduct has occurred and second, whether an investigation is required in the public interest.
  • 10% of the Office’s caseload last year were complaints against Councillors;
  • 90% of caseload were complaints about public services, specifically:-
    • NHS Bodies – 46%
    • Local Authorities – 37%
    • Housing Associations – 12%
    • Welsh Government & Sponsored Bodies – 2%
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Welsh Government fails to ensure local authorities are providing sufficient accommodation for Gypsies and Travellers

Date of article: 04/04/2024

Daily News of: 05/04/2024

Country:  United Kingdom - Wales

Author: Public Services Ombudsman for Wales

Article language: en

The complaint

The Ombudsman launched an investigation after Mr A and Mr B complained about the way Welsh Government dealt with a complaint they had made regarding the provision of accommodation for Gypsies and Travellers.

Mr A and Mr B complained that Welsh Government had failed to ensure that the local authorities in the areas in which they lived, were taking action to meet the accommodation needs of Gypsies and Travellers as required by the Housing (Wales) Act 2014.

Mr A and Mr B also complained that Welsh Government did not deal properly with a complaint they made about this matter.

 

What the Ombudsman found

The Housing (Wales) Act 2014 introduced a legal duty on local authorities to produce Gypsy and Traveller Accommodation Assessments (GTAAs) and submit them to Welsh Government for approval. If an approved GTAA shows need for accommodation for Gypsies and Travellers the Housing (Wales) Act 2014 requires a local authority to use its powers to meet that need.  Welsh Government had committed to annual monitoring of local authorities to ensure that local authorities were acting on the findings of their GTAAs.

The Ombudsman found that whilst the legal duty to provide accommodation for Gypsies and Travellers, where needed, falls to local authorities, Welsh Government had failed to fulfil its critical leadership role in ensuring this happened. No monitoring of approved GTAAs had taken place since January 2020. Welsh Government had also failed to engage appropriately with the local authorities where the complainants live and had failed to assess updated GTAAs from both local authorities despite them being submitted over 2 years ago in December 2021 and February 2022

This constrained the ability of these local authorities to carry out their duties and caused frustration and distress to Mr A and Mr B, and potentially other members of the Gypsy and Traveller community in Wales, whose accommodation needs remain unmet. GTAAs are intended to address the lack of understanding of the accommodation needs of Gypsies and Travellers in Wales and ensure they can access culturally appropriate accommodation. The identified lack of accommodation available meant that Mr A has not been able to provide support to his family and that Mr B and his family continue to endure a prolonged period of homelessness.

The Ombudsman also found that Mr A and Mr B’s complaint was not dealt with in accordance with Welsh Government policy. Welsh Government wrongly classified their complaint as one that could not be considered under its policy and took an excessive amount of time to inform Mr A and Mr B of this.

“There have been significant failings by Welsh Government which has failed to fulfil its leadership role to ensure local authorities were taking action to meet the need for accommodation for Gypsies and Travellers.  Delay and inaction by Welsh Government has led to stagnation and constrained the ability of local authorities to meet the accommodation needs. The lack of available accommodation has meant that Mr A has potentially been unable to live with his wider family and provide support to them and Mr B and his family have been homeless for a number of years. This is an injustice to them and a source of great stress and frustration.

When Mr A and Mr B complained to Welsh Government about these failings, they were incorrectly told that their enquiry did not fall within the scope of its complaint policy. The time taken to tell Mr A and Mr B this was excessive. The poor handling of their complaint was further evidence of maladministration on the part of Welsh Government and contrary to our Complaints Standards Authority Principles of Effective Complaint Handling”

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

The Ombudsman’s recommendations

The Ombudsman recommended that Welsh Government  should apologise to Mr A and Mr B and pay them £1,000 each for the failings she identified and the impact upon them.

In addition, the Ombudsman recommended that Welsh Government should:

  • ensure that it informs local authorities clearly of the requirement to continue to take steps to meet identified need in approved GTAAs whilst updated GTAAs are being assessed by Welsh Government
  • determine whether to approve the revised GTAAs submitted by local authorities
  • set out a plan for how it will review the GTAA process and monitoring arrangements.
    • remind staff who deal with complaints of the importance of responding in a timely manner. It should also ensure that all staff who deal with complaints receive training on its complaints policy and how it should be applied.
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Active facets

Link to the Ombudsman Daily News archives from 2002 to 20 October 2011