Sheffield City Council (05C06420)
Adult care services Maladministration causing injustice
20 February 2007
An elderly woman who died after an accident in her home was “failed by the system which was supposed to protect her” said the Ombudsman. Sheffield City Council had no effective system for dealing with missed or late calls by contracted agency staff to vulnerable service users. The woman’s son had complained about this to both the agency and the Council, but nothing had been done.
This was the third report in 12 months where the Ombudsman criticised a council’s handling of contracted agencies that provide care services, and the second where an elderly service user died. The Ombudsman said “It can never be acceptable for elderly people whose care is the responsibility of the Council to have to wait long periods of time for their next meal or for their medication to be given. Councils must respond to reports of missed or late calls by agency staff and follow up complaints by or on behalf of vulnerable services users as a matter of urgency. It cannot be left to routine compliance checks to find out whether planned services are really being delivered.”
‘Mr Shore’ (not his real name for legal reasons) complained about the poor home care service offered to his late mother. He said that staff working for the agency that was contracted to provide the home care service often missed calls or arrived late.
In January 2004, an incident occurred that led to Mrs Shore’s death. A home help arrived and, as it was dark, she banged on the living room window to alert Mrs Shore to put on the kitchen light, so that the home help could see the digital keypad that operated the door lock. Mrs Shore was unsteady on her walking frame and fell onto a corner of the table as she tried to hurry to the kitchen to switch on the light. The home help let herself in, helped Mrs Shore off the floor and wrote up the daily log without mentioning the fall.
Mrs Shore died two weeks later. She had eight broken ribs as a result of the fall, but the first doctor who attended her did not diagnose the problem correctly, and so she did not receive appropriate treatment soon enough to prevent the onset of pneumonia. The home help was dismissed by the agency for failing to report the incident, and the agency itself terminated its contract with the Council in April 2005.
The Council did not realise, until Mrs Shore’s death, that it had not responded to Mr Shore’s earlier complaint. Even then it did not contact him until after he contacted the Council again in May 2004. Arrangements for a Review Panel to look at the complaint were flawed, and the result did not satisfy Mr Shore, who knew that the real issue of missed and late calls had not been resolved.
The Ombudsman found that the Council’s failure to take up complaints of missed calls promptly with the care agencies was maladministration. The failure to monitor the actions of the agencies sufficiently rigorously and to take action when problems were identified led to unnecessary suffering and distress for Mr Shore’s mother and possibly for many others. The Council also delayed in dealing with Mr Shore’s complaints, leaving him with the impression that the Council did not care about its elderly and vulnerable clients.
Since then, to address these issues the Council has:
- improved training for staff;
- made the monitoring of contracts more rigorous; and
- improved links between care managers and agencies.
In addition, the Council has agreed to the Ombudsman’s recommendations that it should:
- undertake an independent evaluation of its new procedures;
- pay Mr Shore £500 for his time and trouble in bringing the complaint; and
- to pay £1,000 to Mr Shore which he may use to establish a memorial to his mother, if he chooses, or else pay to her estate.
Date Published: 03/02/09