◆200903 'Distressing failures' led to deaths of people with a learning disability
◆200903 Feature of the month ―― The health ombudsman report
◆20090324 Press release 09/02 Parliamentary and Health Service Ombusman
◆200903 'Distressing failures' led to deaths of people with a learning disability
'Distressing failures' led to deaths of people with a learning disability
The Health Ombudsman's report on the six deaths featured in 'Death by indifference' has revealed 'significant and distressing failures'.
The Health and Local Government Ombudsmen have published their findings on the events surrounding the deaths of six people with a learning disability who died in NHS care.
The six people, highlighted in Mencap's 'Death by indifference' report, include Mark Cannon, who died aged 30. He was admitted to hospital with a broken leg, but died of bronchopneumonia after a catalogue of serious failings that left him in severe pain. The Health Ombudsman, Ann Abraham, concluded that he died as a consequence of public service failure. She also concluded that it was likely the death of Martin Ryan could have been avoided.
The Health Ombudsman's report reveals ‘significant and distressing failures' in health and social care services. People with a learning disability experienced ‘prolonged suffering and poor care', and some of these failures were for disability related reasons.
"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," said Ann Abraham. The report recommends that NHS and social care organisations in England urgently review the effectiveness of the systems and services they have in place.
Mark Goldring, Mencap's chief executive, said: "The reports confirm the findings in 'Death by indifference' of the widespread failure by health professionals to provide the proper level of care and highlight an appalling catalogue of neglect of people with a learning disability."
The Ombudsman did not, however, find service failure regarding the practice of any GP. This is despite evidence that doctors failed in their duty of care and legal responsibilities under the Disability Discrimination Act.
"Although the reports are a big step forward for people with a learning disability, it is not the end of the journey for all the families," said Mark Goldring. "We will continue to fight for justice for the families and, with them, consider referring the individual doctors who failed in their duty of care to the General Medical Council."
◆200903 Feature of the month ―― The health ombudsman report
This March the health ombudsman published her final report on the deaths of six people who died in NHS care. For the families it was a chance for justice, but has it given them the answers they wanted?
When Mencap published Death by indifference in July 2007, it sent shockwaves across the health sector. The report detailed the deaths of six people with a learning disability who had needlessly died while in NHS care.
The families of the six people were promised a specific investigation into the events surrounding the deaths of their loved ones. The health ombudsman, Ann Abraham, published these findings at the end of March.
While the ombudsman criticises health services for examples of maladministration and the way that complaints were initially dealt with, she does not find service failure regarding the practice of any GP. This is despite evidence that doctors failed in their duty of care and legal responsibilities under the Disability Discrimination Act.
Mencap’s head of campaigns and policy, David Congdon, says that the ombudsman should have been more critical of the GPs: “This was a missed opportunity to send a clear message to all health professionals that the rights of people with a learning disability must be respected, including their right to good-quality health care.”
Warren Cox died following appendicitis, aged just 30. Here his parents give their reaction
Peter and Wendy Cox are adamant that their son, Warren, died needlessly because of failures by NHS medical staff.
They say that doctors did not correctly diagnose his complaints or act with the urgency warranted by his pain. They think that Warren received less favourable treatment because of his learning disability, and above all they feel that the word of the medical professionals was taken above their version of events at every turn.
But the ombudsman’s report has found that Warren’s death was not avoidable and does not uphold a single complaint lodged by his family. After fighting for answers for more than four years, Peter says: “It feels like it’s been a waste of time. It’s rough justice.”
Three visits by doctors
In August 2004 Warren became distressed and was visited by doctors on three occasions. Each time Peter and Wendy asked whether anything was wrong with his appendix or if he had a bowel blockage and were told that this was not the case.
Warren’s condition seemed to improve, but a few weeks later he again fell ill ? his doctor put it down to a viral infection. On 25 September 2004 Warren’s stomach had swollen, he could not take down food and he was crying with pain.
When the out-of-hours GP arrived, Peter and Wendy maintain that he gave no indication of the seriousness of Warren’s condition. He advised that Warren be taken for an X-ray, but as the department didn’t open until 9am, the Coxes decided not to take him immediately.
Throughout the night Warren seemed to be in more pain. It was only when Peter again called the out-ofhours GP, that an urgent (but not emergency) ambulance was arranged.
Warren died within two hours of reaching the hospital. When Wendy noticed that his colour had changed she alerted a nurse, who realised that Warren had stopped breathing. His death certificate lists peritonitis following a burst appendix, and bowel blockage.
To Peter and Wendy, it is clear that the doctors overlooked Warren’s symptoms. “If one of them had said to us ‘get him to a hospital’ he might still be here,” says Wendy.
Understandably, the Coxes are angry about the ombudsman’s report. They feel that it effectively blames them and clears the doctors of any wrongdoing. “How can they say they realised Warren was dangerously ill, but not call an emergency ambulance?” says Wendy.
“You start asking ‘were we wrong?’” says Peter. “But we did everything right and trusted the doctors.”
Peter says that the ombudsman is simply safeguarding the doctors. While some complaints were upheld in four of the six deaths, Peter says that none were upheld for Warren because there were no other witnesses during his final hours. “There’s only me and Wendy against the doctors,” he insists. “And they haven’t listened to us.”
What will Peter and Wendy do next? They talk about going to the European Court of Human Rights and making a claim for clinical negligence, but going over Warren’s story countless times has been emotionally draining. “It feels like we’ve been beaten,” says Wendy. “We’ll never give up, though, otherwise you’ll always think that they got away with it.”
◆20090324 Press release 09/02
Parliamentary and Health Service Ombusman
24 March 2009
Ombudsmen’s report calls for urgent review of health and social care for people with learning disabilities.
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;
・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 email@example.com
製作：堀田 義太郎＋安部 彰