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.
More ombudsman decisions
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.
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.”