Council’s safeguarding failings had ‘serious consequences’ in case of man subject to poor care

Ombudsman criticises Windsor and Maidenhead for not identifying root cause of repeated serious pressure sores suffered by man following inadequate care by agency

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Safeguarding failings meant a council did not identify the root causes of the repeated pressure sores that a man suffered following discharges home from hospital, leading to “serious consequences”. The man later died of sepsis.

The Local Government and Social Care Ombudsman found that the man, Mr C, was subject to inadequate care by an agency commissioned by Windsor and Maidenhead council, and that the provider failed to raise his repeated serious pressure sores as a safeguarding issue with the authority.

This was then compounded by the council’s failure to properly complete two safeguarding enquiries into the issue, following referrals by other agencies, while faults in its care planning meant Mr C was left with a care package that health professionals had deemed unsafe.

Mr C died four days after he was found at home by ambulance staff with faeces leaking out of his pad, soiled bed sheets and with the dressing on his pad soiled and old. His ex-wife had called the ambulance 12 minutes after care workers had left him, reportedly in a “fine” condition.

Injustice to man and family 

The ombudsman said the council’s faults caused injustice to the man and his family, adding: “Sadly, Mr C, who suffered the main injustice from the council’s fault, has passed away and therefore any injustice to him cannot be remedied.

“However, I do not underestimate the injustice the family has suffered by witnessing what was happening to Mr C. The family will always wonder what would have happened if things had not gone wrong.”

Windsor and Maidenhead has agreed to implement the ombudsman’s recommendations to apologise to Mr C’s family in acknowledgement of its fault and pay £1,000 for the distress caused.

It has also strengthened its quality assurance process and panel procedure for approving care packages, while also introducing a framework for managing people with complex needs, including those who refuse care.


Fully reliant on care staff

Mr C was an older man with no mobility in the lower part of his body, meaning he could not leave his bed and was entirely reliant on care workers for all his needs. The council commissioned the agency to provide four care calls a day, each involving two care staff.

His ex-wife, Ms B, said in the two years before his death he had several hospital admissions because of pressure sores, where he would recover before deteriorating again when discharged home.

In July 2018, he was admitted again, in relation to which the district nursing team, ambulance and hospital all separately made safeguarding referrals to the council  because of serious and multiple pressure sores, there not being enough food in the house and findings that the agency was not completing personal care.

The council triggered a safeguarding enquiry, for which Mr C told a social worker that he was sometimes left in an unchanged pad and, on occasions, care staff did not turn up or only one did, when two were required.

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Safeguarding enquiry not completed

However, while a strategy meeting was held in September 2018 and it was implied that the care agency would carry out the safeguarding enquiry, the ombudsman found it wasn’t completed.

“The agency never provided a report or any care records and the council’s safeguarding enquiry was allowed to drift, the ombudsman said. “It appears the council focused on Mr C’s care plan without formally addressing the safeguarding allegations against the agency and this was a mistake which had later serious consequences.”

In relation to the care plan, Mr C, capacitously, said he wanted to go home, rather than go into a care home, and wanted the agency to keep caring for him because he liked the carers who did the first two calls. At the same time, his family said the four calls were insufficient and felt he should go into a care home.

In October 2020, the council proposed a care plan with six calls a day, including night time calls, with the existing agency providing the first two calls, and the authority finding another agency to deliver other calls.

Additional care visit declined

However, when the plan was implemented in November, when Mr C returned from hospital, it was just for five calls a day and the council was not able to find another agency to co-deliver the care. Mr C then declined the fifth call of the day, saying he had never had a call at this time, would not pay for it and it was not needed, as he now had a mattress that moved, to minimise pressure sore risk.

The ombudsman found that there was no explanation of why the plan was changed from six to five calls a day, which was a fault, and there was further fault when Mr C declined the fifth call.

A tissue viability nurse and district nurse had told the council that four calls a day was insufficient and unsafe but the council failed to take action, the ombudsman found.

Insufficient consideration of care home option

It also did not consider a care home placement – despite appearing to agree with the family that it was the best option – because Mr C, with capacity, wanted to go home. While the ombudsman stressed that it could not force Mr C to go into a care home, it should have done more to explain the options and associated risks to him.

It also appeared that he was not told that he would pay no more for the fifth call of the day – because his assessed contribution was at the maximum level for his income – despite this being one of the reasons he refused it.

After further serious pressure sores were identified in December 2018, the district nursing and tissue viability nursing teams lodged further safeguarding referrals.

15 hours without care

The tissue viability nurse had found him in a wet soiled pad, with a build-up of filth around his groin, which he said was sore. Mr C also told a social worker he had gone 15 hours without care over Christmas.

The council then organised a safeguarding strategy meeting, in January 2019, with the enquiry continuing after Mr C’s death.

The ombudsman also found fault with the second enquiry: “The council asked the agency to carry out the enquiry and provide the report, but this did not happen. The last communication about the enquiry was in April and the matter was allowed to drift again without any conclusion. This was fault.”

A council spokesperson said: “We recognise the findings in this report and have apologised to the family involved.

“We are pleased that the ombudsman stated we had already implemented a number of service improvements as a result of the complaint and did not recommend any other service improvements.”

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