six lives

[shc]

The LGO part of the reports

and also the relevant extracts of their reports to Gloucestershire County Council and LB Havering.. odd how they don't match



Parliamentary & Local Government Ombudsman Press Release
http://www.ombudsman.org.uk/news/press_ ... 09_02.html
http://www.lgo.org.uk/GetAsset.aspx?id= ... AfAAwAHwA0

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.”

Gloucestershire County Council

• Arrangements for transition from residential school to adult care fell significantly below a reasonable standard.

• Some of this maladministration was for disability related reasons.

• The Council failed to live up to human rights principles of dignity and equality.

• Poor complaint handling.

The Local Government Ombudsman’s Annual Letter Gloucestershire County Council for the year ended 31 March 2008

I have no concerns about the way the Council’s complaints procedure is operating.


Jerry White June 2008

London Borough of Havering

• Contributed to public service failure which resulted in an avoidable death.

• Failure to provide and/or secure an acceptable standard of care and consequently the care home resident’s safety was put at risk.

• Less favourable treatment for reasons related to disability.

• The Council failed to live up to human rights principles of dignity equality and autonomy.

• Poor complaint handling.

The Local Government Ombudsman’s Annual Letter London Borough of Havering for the year ended 31 March 2008

Your Council’s complaints procedure and handling of complaints I referred 16 complaints back to the Council in 2007/2008 as it had not been given a reasonable chance to deal with them before I became involved. The proportion of premature complaint decisions for your Council is slightly lower than the average for all authorities. I am not aware of any issues that give cause for concern in this respect .

Tony Redmond June 2008

[ABH]

Interesting report title given the fact that it's all about the avoidable death of 6 people. Proves once again that annual letters to councils are a farce as is any suggestion that the LGO are effective in controlling council maladministration.

[shc]

All that the Ombudsmen have actually done is confirm the findings of a 2006 report by Mencap

Death by Indifference

http://www.mencap.org.uk/displaypagedoc.asp?id=284

... and all the Ombudsmen have actually done is identified that they are part of the problem.. through their own reports



What Mencap wants to happen

Mencap is demanding an independent inquiry into the six cases outlined in this report. We want them investigated together – not in isolation

Mencap is calling for an urgent independent inquiry into these six cases. We want the NHS to accept that there is institutional discrimination and do something about it. We want the underlying common causes identified and acted on. We and the families who have lost loved ones want to understand why they died and exactly what lessons the NHS needs to learn to avoid further tragedies. This is not to apportion blame but to encourage an honest and open debate that will lead to change.

An independent inquiry is needed to bring about cultural change. It will put pressure on ministers, and senior management in all parts of the NHS to focus on the treatment of people with a learning disability. It will reinforce the need for increased training for all medical professionals, and the need to revise policies and procedures for treating people with a learning disability.

Mencap wants confirmation that the confidential inquiry into the premature deaths of people with a learning disability will take place

In 2001, Valuing Peoplecalled for a feasibility study into such an inquiry. In June 2004, Mencap’s Treat me right! report called for the confidential inquiry into premature deaths. It has still not commenced. A feasibility study has been conducted, but no announcement has been made as to when or if the confidential inquiry will take place.

A confidential inquiry is important because until all those people who died prematurely can be identified, no one will really know the size and scope of the problem.

However, even when this happens it is likely to be a further five years before systemic change might take place in the NHS. Our proposal for a formal investigation does not negate the need for a confidential inquiry. In fact, it would be a very useful precursor to it, and would act to speed up the pace of change.


Mencap wants major improvements to the investigation of complaints against the healthcare system

We want the complaints system to be able to get to the heart of the matter. When somebody dies it is crucial to know how they died and whether their death was avoidable. The current system investigates the specific, often narrow complaint that is made, and fails to deal with these underlying questions.

In particular, the Healthcare Commission’s complaints procedures and funding should be reviewed. The Commission should be resourced to carry out its functions efficiently. We want the Healthcare Commission to simplify and speed up the complaints system, so that families can understand what happened and why – within a sensible time frame, and with the least possible additional stress. It should be able to take responsibility for the complaint until it is concluded or sent on to the Ombudsman, rather than pass the responsibility back to the complainant.

Mencap has supported the families of the six people presented in this report at all stages of the complaints process, some from the first stage of the complaint through to the conclusions made by investigations carried out by the Healthcare Commission. We know how appalled they are by the time it has taken, how confused they are by the process, and how angry and disappointed they are when the investigation concludes having not answered the fundamental questions – did their loved one die unnecessarily and if so how could that have happened?

[shc]

http://www.whatdotheyknow.com/request/g ... b_havering

[lilian]

Disgusting state of affairs! Go get them Mencap!

[shc]

What has come out of the independent inquiry

is that there are faiings in both the Healthcare Commission (jurisdiction of Parliamentary Ombudsman) and Local Authority Complaints (jurisdiction of the LGO) systems.

The only difference is that every year the LGO writes to the Council's and identifies to them that there is nothing wrong with their complaints systems...

so is there any wonder that the Council's will be confused.. when the LGO then writes to them identifying that:

a) their procedures and failure to follow them violate human rights;
b) their complaints system is not fit for purpose
c) there has been service failure
d) there has been discrimination

The CLAE (Parliamentary Ombudsman and Local Government Ombudsman) over the last ten years (98 -2008)has arranged about 118 Local Settlements for Glocs CC and LB Havering. Havering has had 17 MI reports issued.

It must have come as quite a shock to Jerry White that Glocs CC was in such a state of disarray and that this had not previously been identified. Whilst Redmond having issued 17 MI reports against Havering must have had some idea. It will be interesting to see if the Council's have reported their failures to themselves and also what steps they have put in place to correct the problems

[shc]

An interesting Harrow link..


http://www.communitycare.co.uk/Articles ... eview.html

Mencap demands inquiry into Harrow's care review

Mencap is calling for an investigation into Harrow Council’s care review process which it claims is “riding roughshod” over a key learning disability policy.

The charity complained to the council after the reviews of six people’s care were arranged at short notice without involving key stakeholders and after copies of review documents were withheld from service users and their advocates.

Deven Pillay, chief executive of Harrow Mencap, argued that the council carried out a number of “quick” reviews as part of its cost cutting strategy during the consultation period to assess whether to change its eligibility criteria to “critical” needs only.

[shc]

NB DELAY

http://24dash.com/news/Local_Government ... sabled-man

A council spokesman said: "Havering Council would like to apologise again to Mr Cannon's family, both for the quality of care that Mr Cannon received at the Grange six years ago, when he broke his leg, and for the further distress caused to them while pursuing their complaints to the council.

"We accept the Ombudsman's view that the quality of care that Mr Cannon received at the Grange on the night he injured his leg was not of an acceptable standard. It is a matter of extreme regret to us that complications during his treatment in hospital resulted in his untimely death and we fully understand the grief that his parents felt and still feel to this day.

"Since the incident in 2003, we have made changes in our respite care procedures for adults with learning disabilities."

Published by Jon Land for 24dash.com in Local Government , Health
Tuesday 24th March 2009 - 8:55am

[shadow]

Janet Street-Porter [Independent]

The Health and Local government Ombudsman has compiled a damning report on the levels of care given to six adults with learning difficulties who died at the hands of the NHS. It finds "distressing failures", and serious deficits in the way complaints were dealt with.

Can we please adjust our values? The avoidable death of just one person is appalling. But when that person has learning difficulties, it's criminal. Needless to say, no one has lost their jobs as a result of the deaths of Mark, and Martin.

How many people have been sacked as a result of an LGO's investigation over the last 10 years...NONE!

http://www.independent.co.uk/opinion/co ... 53330.html

Thomas

[shc]

Janet Street Porters full qoute.. with below this some qoutes from Gloucestershire County Council Minutes of 18 February 2009

I cried when I read that Martin Ryan had died in Kingston Hospital at the age of just 43, after a breakdown in communication with staff led to a failure to feed him not for a week, but 26 days. Martin was born with Down's syndrome and epilepsy. He died because he couldn't tell anyone what was happening to him. I hope the staff who were working on that ward never forget the image of Martin dying. Martin was brave. The cause of death was listed as pneumonia, but many would disagree. His parents have been offered just £40,000 compensation – a pittance compared to the deals Max Clifford secured for Jade.

Mark Cannon, an epileptic with learning difficulties, died at the age of 30, in Barking, Havering and Redbridge NHS hospital. He was admitted in agony with a broken leg, and it took three days for a pain team to attend to him. He died eight and a half weeks later, having lost 40 per cent of his blood. Mark was brave. A report has said his death was unnecessary but I'm sure that's not a lot of help to his grieving parents.

The Health and Local government Ombudsman has compiled a damning report on the levels of care given to six adults with learning difficulties who died at the hands of the NHS. It finds "distressing failures", and serious deficits in the way complaints were dealt with.

Can we please adjust our values? The avoidable death of just one person is appalling. But when that person has learning difficulties, it's criminal. Needless to say, no one has lost their jobs as a result of the deaths of Mark, and Martin.

http://www.gloucestershire.gov.uk/index ... leid=22495

E. Questioner's Name: Cllr Evans

At the cabinet meeting of the 4th February 2009 the portfolio holder for community and adult care stated that the administration would be mounting a legal challenge to the recent CSCI report. In particular he refers to the category of "SAFEGUARDING ADULTS" and the grade awarded of "POOR". Will he say who the selected legal team are that will represent the authority and what the cost will be?

Respondent's Name: Cllr Hicks

The Monitoring Officer is responsible for the delivery of all legal advice to the Council. Advice is still being sought on this matter and it would not serve the Council's interests for me to say anything further at the present time.

D1. Questioner's Name: Cllr Brown

Is the delay of 48 years in the progress of road and footway adoption on the Spitalgate Estate in Cirencester a county record?

Respondent's Name: Cllr Waddington

I wonder if Cllr Brown has been misinformed on the facts. Up to 1974, adopting roads and footways on this estate was the responsibility of the former Cirencester Urban District Council. In the previous 13 years, although CUDC adopted the estate roads there is no evidence this was done for the footways. Consequently the County Council did not accept responsibility for footway maintenance here. In 2006, the Ombudsman received a complaint on this very issue from a local resident, but did not feel there were grounds for an investigation.

[ABH]

D1. Questioner's Name: Cllr Brown

Is the delay of 48 years in the progress of road and footway adoption on the Spitalgate Estate in Cirencester a county record?

Respondent's Name: Cllr Waddington

I wonder if Cllr Brown has been misinformed on the facts. Up to 1974, adopting roads and footways on this estate was the responsibility of the former Cirencester Urban District Council. In the previous 13 years, although CUDC adopted the estate roads there is no evidence this was done for the footways. Consequently the County Council did not accept responsibility for footway maintenance here. In 2006, the Ombudsman received a complaint on this very issue from a local resident, but did not feel there were grounds for an investigation.

?Am I missing something? How is this related to six lives?

[shc]

Yes

The Gloucestershire County Council had sight of the six lives report well before it was released.

There is no mention on their website in the minutes that they gave it any consideration.

When identifying that CSCI had identified them as poor they identified that the Monitoring Officer was responsible (Note legal challenge)..

... and note the fact that the Monitoring Officer did not think that they needed to bring the six lives report to the attention of the Council

[ABH]

So just what purpose does the addition of irrelevant planning permission information serve?

[shc]

Because Glocs identified that the LGO has never found fault with them...
(trust and confidence) in both Glocs and the LGO..

This is the first MI report againts Gloucestershire County Council in TEN YEARS.. and the LGO has identified that their complaints system is not fit for purpose. So what other problems has the LGO disguised (20 Local settlements) as well as probably a whole lot of additional complaints that were not examined.

[shc]

There are associated FoI requests with both

LB Havering

http://www.whatdotheyknow.com/request/s ... s_report_2

and

Glocestershire CC

http://www.whatdotheyknow.com/request/six_lives_report

[shc]

More Planning

http://www.lgo.org.uk/news/2009/mar/fau ... -facility/

There were faults in the way Bradford City Council granted permission for a low security psychiatric facility, finds Local Government Ombudsman, Anne Seex. In her report, issued today (24 March 2009) she says “…residents' concerns about safety and security were not properly addressed by the planning authority…” but finds that the Council’s failures did not lead it to approve an application that would otherwise have been refused. She is pleased that the Council has agreed to implement her recommendations for a remedy.

24/03/09

http://www.thetelegraphandargus.co.uk/n ... care_home/

How did kidnapper get job in care home?

A root-and-branch inquiry has been ordered into how a criminal with convictions for robbery, kidnap and sexual assault landed a job at a Bradford residential home.

Waheed Qayum, 27, went on to steal more than £20,000 from the bank accounts of two elderly and vulnerable residents at Fairmount Gardens residential home in North Park Road, Heaton. He was jailed for 30 months by a Bradford Crown Court judge last week......

... Bradford Council Adult services spokesman said that, though private nursing homes were registered and monitored by the CSCI, Adult Services monitored their contracting arrangements.

The spokesman said: "Fairmount Gardens had failed to follow procedures in terms of care planning and recruitment processes. A number of meetings took place in 2006 with the company managers, CSCI, Social Services managers and the local Adult Protection Unit.

"Once we became aware of financial irregularities the matter was reported immediately to the police and CSCI.

"Following discussions between the Council, CSCI, and the home, the owners agreed to close it. The relocation of the residents and the closure of Fairmount Gardens took place towards the end of 2006."

6:11am Monday 3rd March 2008

[lilian]

The above story doesn't suprise me.

In camden the council continues to give public funding to two highly unsuitable and in my view dangerous 'advocates' who told malicious lies to the police about being harassed by an elderly, disabled and very poorly resident they had a few months earlier 'befriended', The police in turn visited this elderly man in his home and intimidated him into being silent.

Complaints were made to camden council, camden police, and local councillors about these two unpleasants, but the complaints were ignored and these two 'advocates' continue to have access to hundreds of vulnerable residents - camden council still keeps funding them and pushing them forward as genuine and trustworthy 'advocates'.

[shc]

http://www.equalityhumanrights.com/en/n ... eport.aspx

24 Mar 2009

Commission to act on the recommendations of the Health Services Ombudsman Report

‘The failures identified by the Ombudsman demonstrate the urgent importance of acting to instil a culture of respect for human rights in our health and social care services. The evidence suggests that the hospitals in question failed not only to uphold human rights principles, but showed utter disregard for people's most fundamental needs. Basic adjustments may have avoided these deaths.

'In taking forward the Ombudsman's specific recommendation, the Commission will work with the Care Quality Commission to make sure that equality and human rights become an everyday consideration in health and social care inspection.

‘In addition, the Commission has also secured a firm commitment and timetable for implementation for routine health checks for people with learning disabilities, and is working with the Department for Health on developing a disability equality training programme.

‘Independent advocates, who enable people with learning difficulties to speak out, could have made a major difference in the cases covered by the Ombudsman report. That is why through the Commission's grants programme we will support the development of approaches to independent advocacy and why we are currently supporting training for independent advocates on human rights.'

The report recommends 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.’

http://www.guardian.co.uk/society/2009/ ... or-philips

Equalities watchdog in crisis

27 March 2009 21.30

The equalities watchdog was in crisis tonight as a fourth senior official threatened to resign, citing growing "anxiety" over the organisation's direction.

Speaking at the end of a week in which three high-level figures announced their departure, Sir Bert Massie said he too was considering his position. The former chairman of the Disability Rights Commission, and one of the 16 commissioners who run the Equalities and Human Rights Commission (EHRC), he sent a written warning to colleagues, which was read out at a board meeting on Thursday, expressing concern at the performance of the watchdog.......


.......An equality lawyer, who also asked not be named, said: "The problem is that 'fairness', unlike equality, has no basis in law. It's a much more nebulous concept. Fairness is not about protecting the rights of those who have experienced discrimination, it's about being fair to everyone, including businesses and white men."

[shadow]

Stephen O'Brien (Shadow Minister, Health; Eddisbury, Conservative) | Hansard source

To ask the Secretary of State for Health when he plans to respond to the Health Service Ombudsman's Six Lives report.

http://www.theyworkforyou.com/wrans/?id ... g268139.r0

Thomas