A vulnerable patient with suicidal thoughts was found dead in a river after being let down by two trusts in East Anglia, an investigation by the Parliamentary and Health Service Ombudsman found.

The man went to Norfolk and Norwich University Hospitals NHS Foundation Trust, with his partner, because he was feeling suicidal and admitted as an acute patient. He was on the ward for more than 16 hours without adequate support.

He was eventually assessed by a doctor and then waited all night for the crisis team from the neighbouring trust, Norfolk and Suffolk NHS Foundation Trust, to see him and they did not attend until 9am the following morning. He was assessed by a mental health nurse who discharged him and recommended he attend his GP surgery and get counselling.

He was found dead three days later.

Parliamentary and Health Service Ombudsman Julie Mellor said:

"It is unacceptable that a vulnerable man received such little support when he so desperately needed it.

"A bit more time, care and attention by the Trusts may have resulted in a different outcome for him."

The Parliamentary and Health Service Ombudsman found the initial treatment completed by the Norfolk and Norwich University Hospitals NHS Foundation Trust was inadequate. However the decision to not detain the man under the Mental Health Act was reasonable.

Norfolk and Suffolk Trust's crisis team's failure to attend the man was unreasonable particularly given the length of time he waited to be assessed. The eventual assessment and discharge completed by the mental health nurse was not comprehensive.

The man's partner, Trezza Azzopardi said:

"Norfolk and Norwich Hospital Trust's behaviour has been arrogant, dismissive and shambolic. They have compounded my distress by their complete lack of respect for me or my partner.

"They would have continued to ignore me if not for the fact that I contacted the Ombudsman Service. In its findings, the Ombudsman Service has vindicated me in my belief that the Trusts had failed my partner and myself."

The Ombudsman Service recommended both Trusts apologise to the woman and tell her the lessons they learned from her complaint. They were asked to submit action plans to meet their obligations under the NHS Mental Health Crisis Concordat – a set of standards patients should receive in crisis care.

Julie Mellor said: "It is absolutely crucial both Trusts learn from their mistakes and implement our key recommendations."

The Parliamentary and Health Service Ombudsman investigates complaints from individuals about UK government departments, and other public organisations, and the NHS in England. It carries out adjudications independently, without taking sides, providing a final decision on people's complaints. The Ombudsman Service investigates 4,000 cases a year and upholds around 42 per cent.

ENDS

Notes for editors

1. For further info contact: Ben Miller on 0300 0614324
2. The coroner's inquest reached a narrative verdict, which is a statement surrounding someone's death, without attributing the cause to an individual.
3. NHS Trusts are expected to work within the new Mental Health Crisis Concordat (HM Government, 2014). The crisis concordat is jointly developed between professional groups and NHS Trusts. The concordat provides quality statements, including standards to receive help in a crisis with the same urgency as physical health problems. The concordat also asks for a 'local declaration' in which the standards are implemented locally between key agencies.
4.   Both Trusts agreed to consider the recommendations of the concordat, working jointly with organisations tasked to assist implementation, such as NHS England, to plan strategies to ensure they work within the concordat and the good practice recommendations.

Contact: Ben Miller

The Local Government Ombudsman (LGO) is highlighting examples of some of the errors that can be made by English schools admissions panels after finding problems with two different appeals processes in Hull and London.

The LGO looks at complaints about the way many schools appeal panels operate – whether the council or the school itself is the admissions authority, and this week it has issued reports into Kingston upon Hull City Council and St Ursula’s Convent School in Greenwich's handling of two appeals.
 

In Hull, a mother complained to the LGO that the council had not considered the special circumstances which led to her making a late application for a place at a nearby school.  She did not apply by the deadline because her son was seriously ill in hospital in another city.

By the time she did make the application the council had already allocated places, and there were none left. The mother unsuccessfully appealed. But she was not given all the information she was entitled to before the hearing and the correct procedures were not followed during the hearing either. This meant that she could not be satisfied she had all the information needed to make her appeal, or that her appeal was considered fairly.

In London, the LGO has asked St Ursula’s Convent School to reconsider a girl’s application for a place after its panel twice failed to consider her appeal properly.

In this case, the girl’s mother complained to the LGO that the appeal hearing was not carried out properly. At the time the LGO recommended that the admission authority rehear the appeal with different panel members and a different clerk and the admission authority agreed to this.

However, the mother again complained after the second panel refused her appeal.

The Ombudsman’s investigation found that the second panel failed to balance the mother’s special reasons for wanting her daughter to attend the popular school against the school’s case that it was full which panels must do at stage two of the appeal process.

The panel did not properly record its reasoning behind the decision not to admit the girl, and its decision letter was not signed by the chair.

This led to the mother having the uncertainty that her daughter might have been admitted to the school had the process been conducted properly.

In the last year (2013-2014) the LGO received 747 complaints about schools admissions appeals and upheld a quarter of those complaints  investigated in detail.  In a recent focus report on Schools Admissions Appeals, it highlighted some key issues from upheld complaints, including children not being considered under the correct ‘excepted’ criteria, infant school admissions looked at under the wrong criteria, and poor clerking of appeals hearings and record keeping.

Dr Jane Martin, Local Government Ombudsman, said:

“As highlighted in our recent focus report into the schools admissions process, it is important that appeals panels have a completely transparent process for considering applications for places.

“Information and guidance offered to parents should be clear, and parents should be given all the information and evidence they need to appeal a decision ahead of any panel taking place.  It is crucial that panels consider the full admission details, make reasoned choices based on clear evidence, show evidence of that reasoning and inform families of the full decision.  The schools admission process can be an emotional time and it is essential that parents have trust in the fairness of that process.

“I would urge other admissions authorities to see the lessons from these complaints as an opportunity to make sure that their appeals processes are as open and transparent as possible.”

Parents who have concerns about the way that their appeal for a school place was considered can complain to the LGO, as set out in the School Admissions Appeal Code and the Local Government Act 1974. This does not include complaints about admission appeals to academies or free schools as they are not in the LGO’s jurisdiction.

El Diputado del Común recibe en la oficina de Santa Cruz de Tenerife a la Presidenta de la Asociación Canaria del Alquiler Vacacional (Ascav).

El Diputado del Común advierte contra los recortes en el tratamiento y prevención de esta patología que hoy conmemora su día mundial

Santa Cruz de La Palma, a 4 de febrero de 2015.- El Diputado del Común, Jerónimo Saavedra, muestra su preocupación por que las políticas de recortes en las administraciones públicas afecten a la prevención en la lucha contra el cáncer, la necesaria atención sanitaria, así como la investigación oncológica para curar esta enfermedad, cuyo día mundial se conmemora en la jornada de hoy.

La importancia de un diagnóstico temprano, la concienciación de la promoción de factores ambientales y conductuales que ayuden a prevenir la aparición de la enfermedad, así como la necesaria atención oncológica y su investigación son factores que, a juicio del Diputado del Común, deben marcar la agenda del Sistema de Público de Salud, para combatir una patología que en España representa la segunda causa de mortalidad.

Jerónimo Saavedra llamó la atención también sobre la necesidad de que los tratamientos contra el cáncer no dependan del nivel económico de los pacientes o de las políticas económicas que marca cada territorio en cuanto al gasto sanitario. “El acceso a los tratamientos innovadores para luchar contra el cáncer y cualquier otra enfermedad debe ser universal”, añade el Diputado del Común.

Por último, Jerónimo Saavedra destacó la labor altruista que llevan a cabo entidades civiles como la Asociación Española contra el Cáncer, cuya tarea de concienciación sobre la realidad de esta enfermedad y el apoyo que presentan a las personas que sufren esta patología y sus familiares son dignos de elogio y reconocimiento en una jornada como la de hoy.