A woman who died after going without home care was failed by a social worker who did not make contact with her after immigration officials closed down her care agency.
A serious case review also posed questions over the truthfulness of the senior practitioner’s record that she telephoned Gloria Foster the day after CareFirst 24 was closed down for alleged employment of illegal immigrants. Surrey council has suspended two members of staff who are facing disciplinary action over the case.
Foster, 81, who had a range of complex needs, including dementia, was found dehydrated and with extremely low blood pressure by a district nurse on 24 January this year. She had gone without care since 15 January, when Sutton-based CareFirst 24 was raided by immigration officials and the Metropolitan Police. She was taken to hospital and, despite her condition initially improving, she died on 4 February.
While Surrey and Sutton councils contacted and advised or found alternative care for the rest of CareFirst24’s clients, Surrey did not do the same for Foster. Though a self-funder, Foster was known to Surrey council, having had a care package with CareFirst24 arranged for her by the authority in 2007, and having had her needs reviewed on five subsequent occasions, the latest being in March 2011.
Disputed phone call
In addition, the Police gave Surrey a full list of CareFirst24 clients on the day of the raid, including Foster’s name. The social worker – a senior operational lead – was tasked with contacting Foster. On 25 January, she recorded that she phoned Foster on 16 January but received no answer. However, the SCR found that Surrey council’s telephone records – both mobile and landline – did not contain a record of the call, and the Met Police confirmed that no incoming calls were made to Foster on that day.
The SCR said the council needed to investigate the absence of any record of the call being made and the “veracity of recording of key events”. However, even if the social worker had made the call, the SCR found that her practice was “not defensible” and “[seemed] negligent” for not following up with a home visit given Foster’s history and the complexity of her needs.
The review found that she failed to consult Foster’s file, which would have revealed her history of multiple mental and physical health problems and contact details for two donees of power of attorney. The practitioner “compounded the omissions by not making it abundantly clear to her manager that she had not made contact with Mrs Foster”.
Management was also criticised, however, for not checking that Foster had been contacted and for “signing off” the practitioner’s work. In her records, the social worker said that, in hindsight, she should have visited Foster but had wrongly assumed that, as a self-funder, she was able to arrange her own care.
In its individual management review on the case, Surrey council said “there was a set of circumstances where an error may have been more likely to happen”. Though the SCR suggested the “sheer volume of communication” required by the closure of CareFirst24 may have contributed to the failing, it said the council needed to assure itself that social work culture or workload pressures were not to blame, though there was no evidence of this being the case.
The council was also criticised for its care management of Foster following her initial assessment in 2007. Though she was a self-funder, the council had created an expectation that she would receive annual reviews, found the SCR. However, these ceased in March 2011.
Hospital trust criticised
While other agencies largely escaped significant criticism from the review, commissioned by Surrey Safeguarding Adults Board, Epsom and St Helier Universities NHS Trust “missed opportunities” to share information following three hospital admissions in 2011-12. Not one led to a review of her social care needs, and Surrey council was not informed about the latter two, in October and December 2012.
“If multiprofessional re-assessment or referral to adult social care had happened on any one of these three occasions then Mrs Foster may not have been in the situation where she became a victim of her care agency ceasing to trade and the subsequent failure to arrange an alternative.”
Responding to the review, Surrey council’s strategic director for adult social care, Sarah Mitchell, said: “We are very sorry for our failure to help Gloria Foster to get the support she needed. This report points out we should have done more and we completely accept that.
“While we have already made changes following this dreadful case we’ll now act on these findings to do all we can to prevent anything like this happening again. Two members of staff have been suspended and we’ll be taking disciplinary action in light of these findings.”
The SCR panel was chaired by Simon Turpitt, the independent chair of Surrey Safeguarding Adults Board, and the report was written by social care consultant Vic Citarella. Its key recommendations included that:-
- Surrey Safeguarding Adults Board should provide multi-agency on best practice in case recording;
- Health and social care agencies should have clear arrangements in place for multi-disciplinary assessment, review and care co-ordination of people with complex needs, irrespective of funding arrangements for their care;
- Surrey council should continue its focus on improving its organisational and social work cultures, including by controlling workloads;
- Disciplinary action taken in the light of the SCR by Surrey council should examine the veracity of case records and the absence of any record in telephone systems of the social worker’s telephone call to Foster.
Improve your safeguarding practice
For practice advice, expert speakers and the chance to network with your peers, attend Community Care’s forthcoming conference on safeguarding adults at risk in care homes and hospitals. Register now for your discounted place at the event on 4 December in Birmingham.