Somerset County Council and Somerset Partnership NHS Trust failed to implement their joint policy on the administration of medicines and there was a general lack of co-ordination of care, the Local Government Ombudsman (LGO) has decided.
Staff were unaware of the joint policy’s existence, and the document only came to light following the ombudsmen’s investigation into a man's death.
The 38-year-old, who had complex physical health needs as well as some mental health problems, was well-known to both the local authority and the Trust, receiving regular visits throughout the day from a variety of nurses, social workers and carers.
However, nobody took responsibility for monitoring and administering the many drugs the man needed and he died of an overdose in July 2009.
LGO Dr Jane Martin said: "Although I cannot say that these failures caused the man’s death, I can say they may have contributed to it. The picture I have seen is one of a gradual decline in the man’s health with no effective intervention to prevent it."
She recommended a financial payment to the man’s family, of £2000 from each authority, in recognition of the stress and strain that the situation had put them under.
If necessary, they should also fund bereavement counselling up to the value of £500.
Parliamentary and Health Service Ombudsman Julie Mellor said: "It is crucial that the NHS and local authorities communicate with each other to ensure patients’ needs are met. One missed opportunity by staff can lead to tragic consequences. Staff need to feel empowered to intervene and alert others when they have concerns about a patient."