The Ombudsmen strike again (on DOLS)

Just a quick post to draw your attention to a recent finding by the Local Government Ombudsman and the Parliamentary and Health Services Ombudsman relating to the DoLS.  It’s a terribly sad story, the Ombudsmen summarise it as:

A retired South Yorkshire miner was prevented from going home to die beside the brother he had lived with his whole life, because of a string of errors by the five organisations tasked with looking after him, an investigation has found.


The dying man told carers that he did not want to die in a hospital or a care home, but his wishes, and those of his brother, were not dealt with appropriately, amounting to service failure, the report said.

His brother, who was his primary carer, pleaded with NHS staff to respect the man’s wishes to die at home. A meeting to discuss the case was delayed by a month, in which time the man died in hospital, ten miles from his home.

The complaint investigated five organisations: the GP surgery, the hospital trust whose staff were involved in decisions about the location of RK’s care after he was discharged from hospital, two local authorities – one who funded the care and one who contributed to decisions being made, and the PCT who also funded the care at a later date.  The Ombudsmen found that all five organisations were at fault for not using the deprivation of liberty safeguards when they should have done:

3. We have found that all five organisations involved in RK’s care shared responsibility for taking proper account of the law, in particular of the Deprivation of Liberty Safeguards that were designed to prevent people without capacity from being deprived of their liberty unfairly. They failed to do so. That was service failure. As a result, RK remained deprived of his liberty in a manner that did not take proper account of the law. This situation caused his brother a great deal of distress. That injustice arose from the service failure we found. We uphold TK’s complaint about all five organisations.

The five organisations were Derbyshire County Primary Care Trust (PCT), Moss Valley Medical Practice, Chesterfield Royal Hospital NHS Foundation Trust, Derbyshire County Council and Sheffield City Council.

The full report is available here.  The Independent also ran an article about this case.


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