Mrs M’s son, Mr N, suffered from drug-induced psychosis and acquired brain injury.  He received a package of care, funded jointly by Gwynedd Council (“the Council”) and Betsi Cadwaladr University Health Board (“the Health Board”), and provided by Cartrefi Cymru (“CC”), a registered domiciliary care provider.  Mrs M complained about:

a) the care given to Mr N by CC

b) failings in communication between the Council, the Health Board and CC, resulting in CC not receiving comprehensive documentation/risk assessments/care plans for Mr N.

Sadly, Mr N choked while eating alone in his bedroom, and died despite first aid being administered by his carer.

The Ombudsman found that the Council and the Health Board jointly funded Mr N’s care, with the Council being the lead commissioner. However, despite there being an overarching, general contract with CC for the provision of care, there seemed to be no documentation showing the awarding of the contract and the specific terms relating to Mr N, and the respective responsibilities of the parties.  This amounted to maladministration on the part of both the Council and the Health Board. In addition, there was no documentation to show that the Council, as lead commissioner, had monitored the delivery of the service under the contract.

Although the Ombudsman could not say with any certainty that any of the bodies had seen a risk assessment relating to the risk of Mr N choking, CC should have carried out its own choking risk assessment in view of Mr N’s obvious vulnerabilities.

The Ombudsman upheld the complaint against all three bodies. However, he did not conclude that any of the failings he identified had caused or contributed to Mr N’s death.  However, Mrs M would be left with the uncertainty that, but for the failings, things might have been different.

The Ombudsman made the following recommendations:
(a)  The Council and the Health Board

1. Within one month of the issue of the report, both the Council and the Health Board should apologise to Mrs M for the failings I have identified.

2. Within three months of the issue of the report, both the Council and the Health Board should  review their respective contract governance arrangements to ensure that contract management is in  line with good practice (as contained in the Contract Management Principles and the principles in  the Wales Procurement Policy Statement).

(b) The Health Board

3. Within three months of the issue of the report, the Health Board should remind staff members  with responsibility for managing a service user’s Care and Treatment Plan and care package of the  need to ensure they comply with the requirements of NICE Clinical Guideline CG136 and the Mental  Health (Wales) Measure 2010 and the Mental Health Act 1983 Code of Practice.

(c) CC
4. Within one month of the final report, CC should apologise to Mrs M for the failing I have  identified.

5. Within three months of the final report, CC should remind members of staff with responsibility  for delivering care plans of the importance of ensuring all relevant assessments are carried out,  and the care package reviewed, as soon as possible after being contracted to provide care.