London Borough of Hammersmith & Fulham (18 019 910)

Category : Adult care services > Assessment and care plan

Decision : Upheld

Decision date : 30 Sep 2019

The Ombudsman's final decision:

Summary: Mr B complains the Council did not review his mother’s care package for several months after he raised concerns. He says he could not provide the level of care his mother needed and this caused him distress and physical injury. The Ombudsman finds the Council is at fault for delays in arranging a review.

The complaint

  1. The complainant, who I refer to as Mr B, complains the Council did not respond to his requests for a review of his mother’s care package. I refer to Mr B’s mother as Mrs C.
  2. Mr B says the Council did not provide adequate care to his mother or support to him as her carer. He says he telephoned the Council repeatedly to say he was not coping with his caring role but received no response. He says this caused him distress as he had to carry on without support. He also says he suffered injuries to his back from moving and lifting Mrs C.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I considered the information Mr B provided and spoke to him about the complaint. I then made enquiries of the Council. I sent a copy of my draft decision to Mr B and the Council for their comments.

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What I found

  1. Mrs C was an elderly lady, who suffered from several health problems. She needed help with personal care and often to mobilise. She was also at risk of falling from her bed during the night.
  2. Mrs C had four children but only had regular contact with Mr B, who was her main carer. The Council appears to have provided some level of care or support to Mrs C since 2012. In March 2017 the Council completed a full initial assessment and put in place a care plan that included two visits a day from care workers to help with personal care. The package of care remained in place until February 2018, when Mrs C was admitted to hospital in a confused state.
  3. When the hospital discharged Mrs C the package of care resumed. The Council does not appear to have reviewed the care package at this time. However, it carried out a carer’s assessment for Mr B in March 2018.
  4. The carer’s assessment found Mr B was happy to continue in his caring role but would like more support. Mr B said he was now staying at Mrs C’s house overnight more frequently because she slept badly and more often fell from bed. He said Mrs C had become incontinent since the last assessment and he had to support with personal care and changing her pads. Mr B said he felt socially isolated, often felt low moods because of the caring role and was limited in gaining employment.
  5. The assessment found Mr B was at risk of continuing stress and possibly physical damage from lifting Mrs C. The Council offered Mr B moving and handling training, but he declined. It put in place a personal budget of £300 for Mr B, which appears to be so he could take a break away. The assessment form says paid carers and neighbours could support his mother during this time.
  6. Mr B says that from between April and June 2018 he started to call the Council frequently and leave messages that said he was not coping and needed more support. He says it was often late at night or during the early hours of the morning that he called as these were the times he was struggling most.
  7. The Council does not have records of any calls from Mr B until July 2018. At this point a council officer spoke to Mr B who said he was not coping and needed support urgently. The officer sent a request for an urgent review of both Mr B and Mrs C’s support packages.
  8. Mr B did not hear back. The Council’s records show he called again two months later, in September 2018. Mr B’s comments suggest he called more times in between, again possibly out of hours. Mr B said his mother’s health had worsened, she was injuring herself and the care package was not now meeting her needs. The council officer saw the review was overdue so sent a further request for the review team’s immediate attention.
  9. The following day the Council allocated the case for a review. However, two days after that Mr B called to say Mrs C had sadly passed away.
  10. Mr B complained to the Council. The Council apologised to Mr B as it said it could have arranged a review sooner. It said the reason for the delay was because of a large volume of requests at that time. The Council says it was going through a service wide transformation, with new staff, systems and procedures. It says this likely played a part. The Council accepts it provided a poor standard of service to Mr B and Mrs C and apologises for this.


  1. The Council accepts there was fault in the level of service it provided to Mr B and Mrs C. It says its new systems are now embedded and it has improved quality monitoring. It apologises and offers to work with Mr B to help improve the quality of its service. The questions I must address are, in what there is fault, what level of injustice it caused and whether I would recommend the Council provide a substantially different remedy.
  2. I considering the fault I have looked at the following issues:
    • Annual review
    • Requested review

Annual review

  1. Councils should review a person’s care plan at least once a year. The Council assessed Mrs C and put in place a care plan in March 2017. A review was therefore due in March 2018. However, it does not appear the Council reviewed the care plan before she passed away in September 2018.
  2. The Council says Mrs C’s care plan would have been reviewed when she was discharged from hospital in February 2018. However, it has provided no evidence of any review. The correspondence provided suggests it simply reinstated the existing care package.
  3. It is fault that the Council did not conduct an annual review of Mrs C’s care plan. The Council did conduct a carers assessment for Mr B. It put in place support for Mr B in terms of a personal budget to allow him a break. However, during that assessment Mr B said his mother’s needs had increased. That she had become incontinent and he was having to provide more care at night.
  4. This itself may have been enough for the Council to consider a review of her support package. It adds to the fault that it did not conduct an annual review when one was due by this point.

Requested review

  1. The records provided by the Council show Mr B first requested a review in July 2018. I do not have any documentary evidence that Mr B called between April and June 2018 or that he called several times.
  2. I do not question that Mr B called the Council or left messages. However, without records of those calls I cannot say whether the Council could or should have responded. As Mr B says, the calls were often during the early hours and at times when he was distressed and pleading for help. I cannot say how clear the messages were about who he was and how to get back in contact with him. If Mr B left clear messages that council officers could respond to, they should have passed these on to the relevant team. However, without any file notes or recordings, I do not have enough evidence to make a finding on this point.
  3. Mr B did call the Council in July 2018 and made it clear he was struggling and felt the care package was no longer working. The Council accepts it could have actioned a review sooner. Normally we would say a timeframe of four to six weeks is acceptable in terms of arranging a review. However, in this case Mr B was clearly distressed and asking for urgent help. The review request was marked as urgent. This suggest the Council should have arranged a review at the earliest opportunity.
  4. It did not allocate the case for a review for two months. This is fault. It is also not clear how long it would have taken to arrange a date for a review, or how far into the future that date would have been, after it allocated the case.

Consideration of Remedy

  1. Mr B says the impact of the fault is that he continued caring for his mother with a care plan that did not provide adequate support for him or his mother. This caused him distress and physical injury from moving his mother. He asks the Council to pay compensation and wants to be confident the Council has learnt lessons and does not repeat the failures.
  2. The Ombudsman cannot provide compensation payments for physical or emotional injury as only a court has this jurisdiction. However, we can consider whether a financial remedy is appropriate to remedy any injustice caused in terms of distress or a loss of service.
  3. If the Council has offered a remedy, and it is not substantially different to what we would recommend, we will not interfere. In this case I welcome the Council’s apology and its offer to work with Mr B to improve its service. However, while I recognise the resource pressures on the Council, in my view this does not remedy the personal injustice to Mr B.
  4. I cannot say what the outcome of a review would have been so cannot make a finding of quantifiable loss of service. However, Mr B clearly suffered unnecessary distress and uncertainty while waiting for a review.
  5. The wait of two months after his request may not be very long over the normal acceptable timeframe but the Council marked it as urgent. It was aware Mr B was struggling to cope and an annual review had been outstanding for seven months. The carers assessment identified an increase in needs, so an annual review at that time may have helped to avoid some of the distress to Mr B. I therefore consider the fault and the injustice to Mr B is significant and at the higher end of what I would recommend for distress. I recommend the Council pay Mr B £300.
  6. The Council has included an apology in its response letter to Mr B. However, this is only in relation to the delay between July and September 2018. I recommend the Council apologise for this and for not conducting an annual review from March 2018 onwards.
  7. In terms of learning, I accept the Council’s recognises where it went wrong an its new system is in now place. There is no specific remedy I can recommend for the Council to improve its services as the fault is around standards the Council will already be aiming to achieve.
  8. I do not make a specific recommendation about the Council working with Mr B to learn from the case, as I cannot say exactly what this would entail. However, I would encourage the Council to follow through with this, should Mr B be willing to engage.

Agreed action

  1. The Council has agreed to, within a month of this decision:
    • Apologise to Mr B for the delay in reviewing his and his mother’s support plans, and for not carrying out an annual review of his mother’s care package.
    • Pay Mr B £300 for the distress this caused.

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Final decision

  1. The Council is at fault for delays in arranging a review of Mrs C’s needs and Mr B’s needs as her carer. The Council has agreed to apologise to Mr B and make a payment to recognise the distress this caused.

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Investigator's decision on behalf of the Ombudsman

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