Ombudsman criticises council for standard of safeguarding investigation

A council’s safeguarding investigation “was not robust enough” after care workers did not follow emergency procedures to ensure a vulnerable woman received the correct medical attention, the Local Government and Social Care Ombudsman has found.

The woman, who was being cared for by Reading Borough Council’s care provider, the Radis Group, was elderly and had health conditions including lung disease.

She lived alone, and received three calls a day from care workers. However, the Ombudsman’s investigation found, when she fell ill in July 2017, care workers failed to follow the provider’s procedures and alert her GP in a timely manner.

The woman was eventually admitted to hospital but died the next day.

The woman’s son complained to the Ombudsman when they were unhappy with Reading’s investigation into their complaint.

The Ombudsman’s investigation found faults with the care provider’s actions, including that it did not follow its own emergency procedures, that workers missed a lunchtime visit, that care logs were incomplete or there were questions about their accuracy, and information was not passed on between workers.

Reading Borough Council has agreed to:

• apologise to the man;
• discuss with him whether he wishes the council to provide a lasting tribute in memory of his mother;
• pay him £100 to acknowledge the time and trouble he has had in bringing his complaint;
• ensure the care provider has trained all staff on its emergency procedures, and the procedures to follow when a service user is ill; they will also be trained on accurate and complete record keeping;
• review its adult social care complaints procedure to clarify how it deals with complaints against commissioned care providers, and how it will ensure serious complaints are independently investigated;
• remind staff involved in adult safeguarding enquiries of the importance of ensuring enquiry reports are factual and accurate.

Michael King, Local Government and Social Care Ombudsman, said: “The woman in this case was clearly unwell when care workers made their visits. We cannot say whether earlier medical intervention might have resulted in a better outcome for her, but the family has been left not knowing whether their mother and grandmother might have survived had care workers acted differently.

“Councils can outsource care but they cannot outsource responsibility for that care, which is why we are finding the council at fault for the actions of the care provider.

“I’m pleased the council has accepted its responsibilities, and welcome its readiness to make the procedural changes we have recommended to try to avoid the issue reoccurring.”