Social worker made ‘unwarranted personal attack’ on woman in safeguarding report, finds ombudsman

    Safeguarding practitioner's report based on flawed investigation into woman's concerns about her mother's care that relied almost entirely on verbal accounts of care home staff, says watchdog

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    A social worker subjected a woman an “unwarranted personal attack” after failing to properly investigate safeguarding concerns she raised about her mother’s care, the Local Government and Social Care Ombudsman has found.

    Bradford council failed to follow its safeguarding procedure when the woman, known as Mrs X, raised concerns about her mother, Mrs B who had dementia and was a fully NHS-funded resident in a care home. The ombudsman found there was “an almost complete reliance” by the safeguarding social worker who investigated the concerns on the verbal reports of the care home staff, which led to a report that accused Mrs X of verbally abusing staff and raised safeguarding concerns about her.

    The council was also at fault for the safeguarding social worker – who has now left its employment – sharing Mrs X’s email with the care home, despite her asking for it to remain “private and confidential”.

    Bradford has accepted the watchdog’s recommendations to pay Mrs X £1,000 in recognition of the “significant anxiety and distress” it caused her by its handling of the safeguarding concerns, and a further £500 because of failings in the way it subsequently handled her complaints. It has also agreed to put in place a system of checks and balances to “ensure the validity of its finalised safeguarding investigations”.

    Mrs X raises safeguarding concerns

    In March 2018, Mrs X raised concerns about the care and treatment of her mother in the home in an email to a safeguarding social worker. She said that her mother was often left in a wet pad and that faeces which she smeared around her face and in her mouth had not been properly cleaned away. She also complained that her mother’s medication was not being administered correctly as there were part-tablets left on her lips or in her mouth. The points about Mrs B being left in a wet pad and having medication on her lips were also raised by a speech and language therapist (SLT) in a safeguarding alert to the council the previous month .

    The email was marked “Private and Confidential please” because Mrs X feared her mother might become the target of reprisals if the home became aware of the complaint.

    The safeguarding social worker said that she would be visiting the care home and looking at file notes, as well as visiting Mrs B. She then passed on Mrs X’s email to the care home.

    In April, Mrs X emailed both the safeguarding social worker and Mrs B’s own social worker two photographs, one showing medication on and around her mother’s mouth, and the other appearing to show faeces on her mouth. Mrs X said she had visited that morning with a dentist who was going to extract a tooth. They were both concerned about the amount of medication around Mrs B’s mouth, but the care worker told Mrs X it was slow-release medication which had been given at 7am.

    On the advice of the dentist, Mrs X checked with a pharmacist who told her the medication had been left far too long if it had been given over two hours previously and Mrs B could not have ingested the whole dose. Mrs X asked for this incident to be added to the safeguarding concerns raised as one of neglect. She also said she had been forced to clean faeces off her mother’s face herself because this hadn’t been done properly, despite care staff saying she had been cleaned.

    Mrs X accused of intimidating and abusing care staff

    Later that month, the safeguarding social worker emailed Mrs X to say that she had spoken to care staff, and been told Mrs X had previously been told to stop giving her mother inappropriate food and extra fluids outside of professional recommendations, saying she should stop doing so. On 1 June the safeguarding social worker sent Mrs X the conclusions and recommendations from her safeguarding investigation.

    She wrote: “I have made extensive enquiries and have discovered that staff have been intimidated, abused and placed under extreme pressure to do what (Mrs X) has dictated: often outside the care plans ….I feel the [Mrs X’s ]allegations are unfounded: however, I am left with serious safeguarding concerns around the behaviour and actions of (Mrs X).”

    She added that if necessary legal advice should be taken with a view to Court of Protection proceedings.

    Among the recommendations were requests for Mrs X to stop providing any personal care outside of the care plan for her mother, to stop feeding her ‘inappropriate foods’ outside her care plan, to stop the ‘undignified and unnecessary’ inspection of Mrs B’s genital area, to recognise how many incontinence pads were allocated and either stop asking for ‘unnecessary’ changes or pay for additional pads herself and to stop being rude or abusive to the care staff. She recommended staff report any inappropriate feeding or intervention by Mrs X and record any incidences of rudeness towards them.

    In her response, Mrs X questioned why the safeguarding concerns she had raised weren’t mentioned in the report. She said she couldn’t understand how the safeguarding social worker had reached her conclusions about her behaviour without discussing the allegations with her beforehand and asked why no attempt had been made to verify her allegations by discussing them with any other member of her or Mrs B’s family, or with the speech and language therapist (SLT) or dentist.

    Long delay in response to complaints

    A few days after receiving the report, Mrs X complained to the council that:

    • Her safeguarding concerns hadn’t been investigated.
    • The safeguarding social worker had not discussed the counter-allegations with her or her family before publishing her conclusions, or supported her mother to be represented, in defiance of the council’s safeguarding policy.
    • The safeguarding social worker had circulated her initial email marked ‘private and confidential’ without her permission to the care home, and asked whether this was a data breach. She said the investigation had made the situation worse as she was now reluctant to raise any matters of concern at the home.

    The council acknowledged the complaint on 14 June and said it would aim to respond within 20 working days; but it failed to respond until 10 September, by which time the safeguarding social worker had left its employment. The response partially upheld the first two complaints, saying, on the second, that the safeguarding social worker had not been able to discuss the complaint with Mrs B because of a lack of capacity and it was unclear whether she would have invited responses from Mrs X on her mother’s behalf. It was inconclusive on the third, saying there was no trail to prove the safeguarding social worker had sent Mrs X’s email to the care home.

    As a result Mrs X asked the council to escalate the complaint to the second stage, which did not report until May 2019, when the council fully upheld two of the complaints, completely acknowledging that there had been insufficient communication with Mrs B’s family in the investigation and that there had been data breach in the safeguarding social worker sending the email to the care home.

    Mrs X then complained to the ombudsman saying she wanted the original investigation and report overturned by the council. She said that the safeguarding social worker’s accusations against her had been “personal and hurtful as well as untrue”, she was subject to “unpleasant behaviour from a small group of carers who were angry that she had reported them”, with the whole experience affecting her emotional wellbeing.

    Multiple failings

    The ombudsman said the safeguarding concerns which Mrs X, the SLT and the dentist raised were “minimised in favour of the counter-evidence the safeguarding social worker said she obtained at the care home”.

    “There was an almost complete reliance by the safeguarding social worker on the verbal reports of the care home staff, that led to a report which amounted to an unwarranted personal attack on Mrs X, and which Mrs X had no opportunity to discuss before it was finalised,” the watchdog said.

    The watchdog said the council failed to follow the safeguarding process correctly when Mrs X’s concerns were not logged on its database. Additionally, the safeguarding social worker said Mrs B lacked capacity to communicate her views yet there is no evidence that she completed a capacity assessment under the Mental Capacity Act 2005 to determine this.

    The ombudsman said the council was at fault when Mrs X’s email was shared with the care home, despite her explicitly asking for it to remain confidential. The council has apologised for this and put additional training in place.

    It also failed to respond to Mrs X’s complaints properly. The first response partially upheld complaints which should have been fully upheld (one of which, about the safeguarding procedure, it later upheld completely). It reached an inconclusive finding on the complaint that the safeguarding social worker had forwarded Mrs X’s email, when Mrs X had already provided the evidence this had happened in her original complaint submission.

    The response to both complaints were delayed, causing Mrs X further injustice. Mrs B has since died and the ombudsman said a fresh investigation of the original complaints was unlikely to be effective given how long had passed. But he recommended that the council ensure that Mrs X’s response to the allegations made by the safeguarding social worker against her are put on file, with an acknowledgment from the council that the investigation was flawed, which the council has agreed to do.

    A spokesperson from Bradford Council said: “We take on board all the points mentioned by the ombudsman and we will ensure that this leads to improvements in the way we work in future. Our standards fell below those we normal expect on this occasion.

    “Our thoughts are with Mrs. X and we apologise for the distress caused to her because of this.”

    4 Responses to Social worker made ‘unwarranted personal attack’ on woman in safeguarding report, finds ombudsman

    1. Anita December 3, 2020 at 10:28 am #

      No doubt vindication of how SWE has improved our practice. Carry on tweeting how wonderful you are to each other SWE while in our world social workers you are meant to be regulating behave disgustingly.

    2. A Man Called Horse December 3, 2020 at 11:08 am #

      I think part of the problem is here that Social Workers are not trained investigators like the Police are and often have to investigate very complex issues without much support. My first first point is that this was alleged neglect by a care home, which potentially could have been reported to the Police as clearly what was allegedly happening here could be happening to other residents as well. No mention of if CQC was involved? Also the Local Authority Contract monitoring if they had concerns could have placed a temporary embargo on further LA funded placements. Clearly the Social Worker should not have allowed the care home to know for sure who had reported them to the Safeguarding Team, however, it is likely they would have worked it out that it was the family member even if they could not be totally sure. In my experience counter allegations are common and then the Social Worker gets totally overwhelmed with investigating two seperate sets of allegations. Any investigation like this is of course is very time consuming and Social Workers will have many other cases to manage at the same time. As was rightly pointed out a Mental Capacity Assessment should have been completed to determine if the individual could consent to the investigation and to try to establish if they could give any account of events, again quite time consuming and if as now during a pandemic probably not very easy to do if you don’t have access to the care home. It also seems to me that CQC are not doing their job and clearly don’t monitor care home nearly enough due to lack of resources and not enough staff. Clearly leaving faeces around anyone’s mouth at a care home is going to constitute neglect if proven. It would seem on the balance of probability that since this was witnessed by an additional third party that it should have been proved. In terms of evidence it should not have been difficult to establish if the Social Worker had clearly identified to the care home who had raised the complaint, probably would be an email trail, clearly this is a breach of data protection, protecting the identity of the person raising the complaint. I think again here that neglect was likely proven and that this should have prompted CQC to investigate but mostly they don’t attend any meetings and rarely get involved in even doing a visit due to lack of resources.Often the Social Worker will feel like a one man band with many Local Authorities not even having a dedicated Safeguarding Team with its own social workers. Safeguarding is just another duty bolted on to the day to day general work of Social Workers. Over the last 10 years of Austerity Safeguarding has been weakened due to constant restructures to save money and Police resources to investigate have also clearly been cut. How good Safeguarding is depends upon having resources to investigate and joined up work with the Police and others involved in monitoring care homes. The Social Worker here is not totally without some responsibility, however, the structures they work in have been decimated by cuts especially in deprived areas of the country where safeguarding referrals are increasing due to a general decline in the wellbeing of the local population. Another Social Worker takes a bullet here for poor practice and very little recognition that the organisations they work in and for are under enormous pressure financially 24/7 easy to blame the worker without looking at the bigger picture. We now have Social Work England to protect the public from Social workers but who do they have to protect them from forcing them to work in underfunded and flawed structures?

    3. Alan Murtagh December 3, 2020 at 3:20 pm #

      You may well be right. However, given the Ombudsmans reported comments and conclusions regarding the social worker almost exclusively relying on the providers evidence, it’s not as if a serious attempt was made at a rounded investigation. No amount of austerity blaming can excuse that negligence. Admitted, Safeguarding is not just for social workers but aren’t we constantly being told social workers are champions of human rights and uniquely skilled at safeguarding? Social Worker England is a self promoting quango of the failed, its neither capable or competent to protect the public. It has no interest in supporting social workers having the resources they need to work to their best. Mates telling other mates how wonderful they are doesn’t inspire confidence but perhaps gets them an extra biscuit from their Conservative overseers.

    4. Eugenie Clements December 6, 2020 at 1:36 pm #

      Hang on, if the reports of feaces and medication errors are correct, you can’t seriously excuse poor practice on overwork. Its not about you lot, this is your job. When you fail, real people suffer and are harmed. Not challenging your bosses over lack of resources and big case loads is tantamount to some of you lot not botheting to do your jobs. We had a fantastic social workers supporting our dad. She was brilliant because she was honest with us and also told her bosses when she was asked to do things without support and resources. If you want to stand up for us, stand up to your bosses. If you don’t, accept the harm caused as your own failure and not as theirs.