Reports on investigations where a death was involved

list of published reports from 1 April 1998

Key to findings

MI = Maladministration and injustice

M = Maladministration, but no injustice

NM = No maladministration found

LS = Local settlement report (until 31 March 2003)

FR = Further (second) report issued

2007/2008

None

2006/2007

Authority Ref no Date/Finding

Sheffield City C 05C06420 20 February 07 MI

care services provided by contracted agency - late and missed calls - no system of monitoring and taking action to ensure services provided in full - elderly woman died after fall in home when hurrying to switch light on so that home help could see door entry keypad - home help did not report fall - home help dismissed and agency terminated contract with council.

2005/2006

Authority Ref no Date/Finding

Blackpool BC 03C17141 23 February 06 MI

elderly, disabled woman, both legs amputated, receiving care from private company under contract with council - failure to visit - later found on floor and taken to hospital, where she later died from a stroke, heart attack and hypothermia suffered while lying unattended - council had not taken action over complaints about private company's poor performance - failure to recognise risks - failure to identify most vulnerable service users and carry out risk assessment - failure to investigate niece's complaint thoroughly.

West Lancashire DC 04C12312 9 June 05 MI

Severely disabled son of complainant - council tenant - installation of bath - delays - poor communications with occupational therapist - failure to follow council's own guidance - son died shortly after complaint made to LGO.

2004/2005 - 2002/03

None

2001/2002

Authority Ref no Date/Finding

Sheffield City C 00C10708 21 June 01 LS

are of elderly man who died - failure to monitor level of care - financial abuse by a carer - internal complaints procedure upheld complaints & agreed to reimburse sum not accounted for - compensation to estate and family

2000/2001

Authority Ref no Date/Finding

Nottingham City C 98C03621 17 April 00 LS

and Nottinghamshire CC 99C03198

Death of severely disabled child - staff at care home wrongly informed police without making checks - staff refused to co-operate with internal complaints procedure.

Staffordshire CC 98B04580 28 November 00 MI

and Bedfordshire CC 98B04581 NM

Death of couple's disabled son in registered care home - investigation of death - inspections of home - complaints procedure - review panel - delay

1999/2000

Authority Ref no Date/Finding

Nottinghamshire CC 98C02295 30 September 99 MI

rehabilitation of adult son from alcohol addiction - course in North Somerset - client discharged himself early - death from drug overdose - failure to investigate care home fully - death not the fault of the council - failure to investigate complaint

North Somerset C 98C04033 30 September 99 MI

rehabilitation of adult son from Nottinghamshire from alcohol addiction - client discharged himself early - death from drug overdose - failure to follow up issues identified at inspections - lack of aftercare plan not the fault of the council

Barking & Dagenham LB 97A03081 21 December 99 LS

Failure to provide aids and adaptations for home - complainant's wife who died of cancer - delay.

Bexley LB 97A04002 21 March 00 MI

complainant's grandmother placed in nursing home, later died - Health Service Ombudsman found deficiencies in care - council's responsibility for monitoring the standard of nursing care of residents it has placed in residential home.

1998/1999

Authority Ref no Date/Finding

St Helens MBC 97C02492 16 December 98 MI

delay in response to request for social worker to visit complainant's son, who had drinking problem - death by heart attack - unlikely that swifter action would have prevented death

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