LGO issues first dual jurisdiction report into council and care provider

The Local Government Ombudsman has issued its first ‘dual jurisdiction’ report into a local authority and a care home following a complaint of neglect of an elderly woman.

The LGO’s report covers the actions of both Oxfordshire County Council and Caring Homes Healthcare Group, which runs the Huntercombe Hall Care Home.

The Ombudsman launched an investigation after a man (Mr X) complained that his wife had been left severely dehydrated and suffering from oral thrush after a week-long respite stay at the care home.

The woman, who had advanced dementia, required full assistance in all areas of daily living, and could not say when she was hungry or thirsty. She struggled to swallow and needed a thickening agent added to her drinks.

Mr X privately arranged and funded his wife’s stay at the Henley-on-Thames home and spoke to the carers there about her special circumstances. When he returned to pick her up, he described her as ‘less responsive and limp’ and her mouth had a coating of white spots.

Mr X contacted the care home’s GP and the woman was taken to hospital, with paramedics administering intravenous fluids through a drip. The woman stayed in hospital for three weeks; her records showing dehydration and problems with her kidneys.

Mrs X passed away just a week after being discharged from hospital.

During her stay in hospital, hospital staff made a safeguarding referral to Oxfordshire County Council. Mr X also complained to the provider about his wife’s care.

The care home responded to the man’s complaint but found no shortfalls in its treatment of Mrs X.

Oxfordshire conducted its own investigation, but at no point involved the husband.

The county council did not conduct a strategy meeting, but asked for a report from the provider. According to the LGO, “it did not chase that report swiftly when the provider was slow to respond – potentially putting other vulnerable residents at risk”.

Oxfordshire’s report appeared to accept the provider’s version of events, but also recorded a finding of ‘neglect – partially substantiated’.

The LGO said the council did not recognise the inconsistency in the care provider’s records for Mrs X and an account given by the GP who saw her on the day she left the home.

Oxfordshire closed the initial assessment, taking no further action. The Ombudsman said it was not clear if it told the provider it had come to a finding of partial neglect, or told the Care Quality Commission and its own contract department about the findings.

The LGO’s investigation also found that the county council did not act in accordance with the law and relevant government guidance. “It did not adhere to Department of Health statutory guidance on safeguarding adults and failed to follow its own policy and procedure relating to safeguarding investigation,” the Ombudsman said.

Oxfordshire has apologised to Mr X and been asked by the LGO to pay him £250 for the time and trouble he has been through in pursuing the complaint and £500 for the distress caused.

The LGO said it also welcomed the “robust and extensive” improvements the council had made to its policies and procedures during the investigation.

The LGO also recommended that the Caring Homes Healthcare Group should provide Mr X with a full written apology for its failure to provide adequate care to his wife and also apologise for its failure to deal with his complaint properly. The Ombudsman also called on the provider to waive the full fee for her stay in the home.

The LGO said its report would be shared with the Care Quality Commission.

Dr Jane Martin, Local Government Ombudsman, said: “Neither the care provider nor the council’s investigations were up to the standard I expect, and failed to give the family proper answers as to what went wrong. Organisations can only learn from events like these if they conduct thorough and searching investigations.

“I welcome the significant steps Oxfordshire Council has already taken to improve its policies, procedures and staff training in this area and am pleased it has agreed to my further recommendations. I now call on the care provider to reflect upon my report and implement the remedies I have recommended.”