Northumberland health and social care bodies “failed” man who died

A vulnerable man who died after discharging himself from hospital was let down by “significant failings” in his care, an investigation has found.

The man, known as Mr B, suffered from heart issues and seizures and was found dead at his home in November 2019.

The Local Government and Social Care Ombudsman criticised the way a number of bodies had supported him.

It said his sister, Ms A, who brought a complaint, had faced “considerable… uncertainty and distress”.

The ombudsman criticised the “combined faults” of Northumberland County Council, the Cumbria, Northumberland and Tyne and Wear (CNTW) NHS Trust, and Coquet Medical Practice.

Northumbria Healthcare NHS Foundation Trust was accused of failing to properly assess Mr B’s mental capacity while he was an inpatient.

Found dead at home

The ombudsman’s report said between 2017 and 2019 numerous services attempted to engage with Mr B, with limited success.

In November 2019, he was taken to Northumbria Specialist Emergency Care Hospital in Cramlington where doctors concluded he had heart problems, flu and a respiratory tract infection.

He discharged himself in the early hours against medical advice.

Mr B’s GP and social worker persuaded him to return but his objection to having a cannula put in his arm raised concerns about his capacity to make decisions about his treatment.

He left hospital again that night to go to his father’s house, but was not there when an ambulance later arrived.

Police found him at home the following morning, unwilling to return to hospital. Three days later he was found dead.

‘Significant failings’

Ms A complained Northumbria Healthcare Trust had “inappropriately allowed Mr B to discharge himself from hospital”.

The ombudsman could not say whether Mr B should have been kept in hospital, nor whether further inpatient treatment would have saved his life but said the uncertainty had caused “distress and upset” to Ms A, which was an “injustice”.

The trust was told to apologise to her and acknowledge its faults, and to offer a £300 “symbolic payment”.

It was also told to produce an plan to prevent similar failings.

Northumberland County Council admitted it had made “significant failings” in not acting on referrals and not formally assessing Mr B’s capacity to make decisions.

The ombudsman said the authority’s adult social care and safeguarding failings “likely undermined” Mr B’s trust of professionals but it was not clear whether the outcome might have been different.

The council told the Local Democracy Reporting Service it had “identified a number of improvements to our services which have already been implemented”.

Coquet Medical Practice acknowledged it did not recognise Mr B was vulnerable quickly enough and said it would make changes.

CNTW accepted it failed to provide timely or adequate support and also said “several improvements” had been made.


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