This really is no way to die

A really depressing report by the Parliamentary and Health Service Ombudsman (PHSO) and the Local Government Ombudsman (LGO) has just been published on the LGO website.  It details how a retired South Yorkshire miner, RK, was prevented from going home to die beside the brother he had lived with his whole life, because of a string of errors by his GP practice (Moss Valley Medical Practice), Chesterfield Royal Hospital NHS Foundation Trust, Derbyshire County Primary Care Trust, Derbyshire County Council and Sheffield City Council (I make no apologies for naming the bodies).   Collectively, the organisations failed to activate the DOLS safeguards in the manner that they should have been so that the man was deprived of his liberty at the end of his life in a manner that did not take proper account of the law and caused his brother a great deal of distress.  The PHSO and LGO called on the five organisations involved to apologise to the surviving brother for causing him distress, and to each pay him £200, a total of £1,000.

The full sorry saga really has to be read to be believed, but almost the most concerning aspect is that, as the report noted at paragraph 134 “the organisations did not, more than three years later, identify what went wrong in this case. That suggests that there may be an ongoing lack of understanding of the Mental Capacity Act 2005 and the safeguards.”

The LGO and PHSO set out in consequence a detailed set of recommendations to seek to ensure that the DOLS safeguards are embedded and routinely applied by staff in these circumstances, and that the results of the review  (and any resulting action plans) should be shared not just with them but also with RK’s brother.