Care home workers failed to call an ambulance for a vulnerable elderly stroke victim for more than five hours, the Local Government Ombudsman has found.

The woman, who was being cared for at a Nottingham City Council-run home, suffered a stroke at 7.30am but it was not until her daughter arrived at lunchtime that the emergency services were summoned.

During an investigation in response to the daughter’s complaint about the council, the LGO heard that both the home’s manager and a deputy were aware of the woman’s situation, but both thought the other had called for assistance.

When the ambulance finally arrived just after 1pm it was too late to take the woman to the specialist stroke unit at City Hospital. She has been left incontinent and unable to walk and her previous speech and communication difficulties were exacerbated. She now lives with her daughter in another area of the country.

Nottingham City Council carried out a safeguarding investigation and concluded that there had been neglect, and agreed to provide refresher training on recognising and responding to strokes to care staff. They will also display posters throughout their homes and have changed the procedure for calling the emergency services to ensure calls are made at the earliest opportunity.

The council wrote to the woman’s daughter after their investigation, apologising for the incident but said it could not hold anyone to account for what happened because of conflicting accounts given by the two staff members involved. The ombudsman has found that the council’s explanation for this “lacks credibility”.

Dr Jane Martin, Local Government Ombudsman, said:

“This is a deeply concerning case, compounded all the more by the fact that staff at the home had recently received stroke awareness training.

“The care home’s neglect to call the ambulance service jeopardised the woman’s health and fundamentally compromised her dignity. This delay denied the woman the vital specialist medical treatment she so obviously needed.

“This case serves as a stark warning to councils and other care providers that the correct systems should be in place to deal with serious incidents such as these to ensure that this does not happen in future.“

The LGO has recommended that Nottingham City Council make a remedy payment of £2,500 to the family to acknowledge their distress.

The council has also been encouraged to reconsider its previous conclusions about staff accountability in the case and ensure that all care staff receive appropriate stroke awareness training.

The council has also been asked to review the impact and effectiveness of that training and properly satisfy itself that all staff recognise the signs and symptoms of a potential stroke and the need to act quickly in seeking emergency medical attention.

The LGO will be sending a copy of its report to the Care Quality Commission to ensure it is made aware of the ombudsman’s concerns.

Article date: 30 July 2013