A local authority has been criticised by the Local Government and Social Care Ombudsman after failing to provide a specialist chair to a man with Parkinson’s disease, who died still waiting for it.
The watchdog found Lancashire council at fault after its nine-month delay meant the man, identified as Mr D, spent the final weeks of his life bedbound because he didn’t have a suitable seat.
The authority also initially failed to correctly identify the cause of the delay after the man’s wife, Mrs D, complained. It subsequently admitted that “human error and pressures of work” were to blame.
The ombudsman told the council it must “consider what action it can take to ensure human error does not prevent someone from receiving the services they need”, and urgently fill vacant occupational therapist (OT) positions.
‘Too low and soft’
Problems with Mr D’s riser chair were identified by an NHS OT who visited his home on 11 February 2016 and found it to be “too low and too soft”. The OT identified the need for an assessment with a view to replacing it and made a referral to the council.
After a misunderstanding between Mrs D and the council, the referral was passed for allocation for assessment by a social care support officer (SCSO) on 19 February. But the authority did not visit Mr D until two months later, on the same day he received an additional diagnosis of vascular dementia. During the visit, Lancashire’s OT identified the need to make changes to the front steps of Mr D’s home, loan an inflatable lifting chair, and buy a new riser/recliner chair from a contractor.
The steps were altered promptly. While the loan chair also arrived quickly, Mrs D was unable to reach anyone at the council who could show her how to use it.
“Mrs D says she tried calling the council but never got an answer so she gave up,” the ombudsman’s report said. “She says this left her having to pick her husband off the floor whenever he slid out of his chair, sometimes with the help of neighbours.”
No record of calls
The situation did not change over the summer of 2016, during which time there is evidence of the council OT sending one email, in August, to a contractor, urging them to visit Mr D.
While the OT told the ombudsman she had previously made several calls to the contractor, there was no record of this. The ombudsman found that it was “likely” that no contact with the contractor was made before the August email.
By the time the contractor visited Mr D, on 16 September, he was in hospital following a fall. The same day he was discharged, 3 October, the council OT passed the contractor’s quote for a new chair to her manager and another officer.
Later that month, an NHS OT contacted the council OT asking for an urgent call back about Mr D’s situation. A few days afterwards the council OT’s manager told her the chair quote had been “overlooked”, allegedly because it had been sent to the wrong email – something the ombudsman found “difficult to understand” as it had gone to two officers.
‘Failure to identify root cause’
On 12 November Mr D died, having spent his last six weeks mostly in bed. When Mrs D complained to the council in January 2017, it apologised but incorrectly told her that there had been a “change in seating companies”, which had contributed to the delay in his chair arriving.
Michael King, the Local Government and Social Care Ombudsman, said that Mr D “should not have had to spend his last few weeks bedbound” and that the council had “failed to identify the root cause” of the delay.
Lancashire council agreed to apologise for the faults identified by the ombudsman, and to pay Mrs D £750 in light of the distress she had suffered. It also agreed to take action to ensure officers manage their work “effectively and without delay” and to produce a schedule for filling OT vacancies.
A spokesperson for the council said it had now apologised “fully” and had “drawn up an action plan to address the shortcomings identified in the ombudsman’s report”.
“When things go wrong, lessons can only be learned to improve future services if the correct causes are identified,” King said. “I am pleased Lancashire County Council agreed to my recommendations, but I would urge it to reflect on my report and consider what action it now needs to take so other people are not similarly affected.”