LGO criticises council after woman left severely malnourished in care home

The Local Government Ombudsman has sharply criticised a council and urged it to pay £4,000 after a vulnerable dementia patient lost a third of her body weight while living in the care home it contracted to look after her.

In a report the LGO said the woman (Mrs X) had entered the care home in 2010, when her weight was around 61kg. Mrs X has aphasia (problems with understanding and speaking due to damage to part of the brain, usually caused by a stroke), arthritis and osteoporosis.

When Mrs X entered the home, her care plan included instructions that she needed supervision with her mobility and transfers (changing position), help with personal care, help to take medication, to have adequate food and drink and encouragement to interact as she was in a low mood.

By the time she left that home in December 2013, however, her weight was just 41kg.

Mrs X’s family complained to Wokingham Borough Council about the care she received while in the home. They said she was understimulated and when not supported when walking, had fallen and broken her hip.

The council accepted that it had not supported the placement for the whole time the woman was there. It said it did not review her care as it should because of an administrative error.

Wokingham also accepted it had not advised Mrs X’s daughter that she could contact officers if she had concerns.

The council admitted Mrs X’s weight was of concern, that there was no activities co-ordinator in place and that the Care Quality Commission’s inspection concluded record keeping was poor.

Wokingham apologised to the family and offered them £500.

However, Mrs X’s family was not happy with the council’s response and complained to the Ombudsman, who found fault with the authority.

The LGO’s investigation was critical of the lack of activities organised at the home. It also heavily criticised the care provided for the woman who left the home malnourished, and with a Body Mass Index of just 15 (government guidance says a healthy BMI is 18 to 25), and the lack of action taken to address her weight loss.

The LGO also criticised the care home’s record keeping, and that staff did not seek specialist support for her low weight. The investigation also found failings in the way the home planned and carried out risk assessments around falls and mobility for the woman.

In its report the LGO called on Wokingham to pay Mrs X £3,500 and her daughter £500.

The council has said it has carried out quality visits to the care home in light of the family’s complaint.

The LGO has also urged the council to ensure its future contract monitoring visits to the care home include checks of:

• nutrition care plans, food and fluid charts and weight charts;
• falls monitoring, falls risk assessments and falls/mobility care plans; and
• care plans for activities and records of activities on offer.

Dr Jane Martin, Local Government Ombudsman said: “This case highlights the need to remind councils that when contracting out services to third parties, they cannot contract out the accountability for those services. Sadly, this is an example where a vulnerable woman and her family have suffered because their council has neglected its duty to them.

“In this case the woman was bored, lost a considerable amount of weight and her wellbeing was not promoted. Fortunately, since moving to a different care home she has regained weight and is now within a healthy range.

“I now urge Wokingham council to consider seriously my recommendations and take on board the changes it needs to make to ensure other people do not suffer in this way.”