Royal Borough of Kensington & Chelsea (19 008 936)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 18 Mar 2020

The Ombudsman's final decision:

Summary: Ms X complains the Council failed to provide appropriate care and support to her grandmother, Mrs Y, causing Mrs Y to suffer a painful death. The Ombudsman finds the Council at fault causing Mrs Y and her family distress. He recommends the Council provides an apology, makes a payment and acts to prevent recurrence.

The complaint

  1. Ms X complains the Council failed to properly plan for Mrs Y’s discharge from hospital and failed to ensure she had appropriate care and equipment upon discharge. Ms X says Mrs Y died slowly and painfully as a result.

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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. We may investigate matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)
  3. 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 spoke to Ms X and I reviewed documents provided by Ms X and the Council. I gave Ms X and the Council the opportunity to comment on a draft of this decision and I considered the comments provided.

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What I found

Leaving hospital

  1. If you spend time in hospital the Council will carry out a discharge assessment to see what help and support you may need when you leave. The Council will ensure this is in place upon discharge.
  2. Any assessment must be person-centred, involving the individual and any carer that the adult has, or any other person they might want involved.

What happened

  1. Mrs Y had a package of care at home arranged by the Council. She received three daily visits from one carer.
  2. Mrs Y went into hospital on 30 December after a fall.
  3. The Council has provided a copy of the hospital’s needs based assessment of Mrs Y. The Council’s records show a Council officer discussed discharge planning with Mrs Y’s family, leading to a referral for reablement care.
  4. The Council completed a reablement assessment on 8 February and decided Mrs Y needed two carers to help with all daily tasks, including transfers. Carers were to visit Mrs Y four times daily at 8am, 12pm, 4pm and 7pm. The Council’s records show it arranged for a hospital bed at Mrs Y’s home before discharge.
  5. Mrs Y arrived home from hospital at 5pm on 14 February. Ms X complained she was left on a chair until carers arrived at 7pm. The Council told Ms X to raise this with the hospital.
  6. The Council’s records show Mrs Y’s family suggested additional equipment in her home to assist her, including a fall sensor. The Council has not provided evidence it considered or responded to this.
  7. On 22 February Ms X complained the carers were leaving Mrs Y in a high backed chair between visits, which she felt was unsafe. Further, they were not arriving on time or completing household chores as they should.
  8. The Council has not provided any evidence it considered or addressed Ms X’s concerns. It has also not provided any evidence an Occupational Therapist (“OT”) considered what equipment Mrs Y may need to assist her at home either before or soon after discharge.
  9. Mrs Y went into hospital again on 5 March after a fall out of bed.
  10. The Council’s records show its social worker assessed Mrs Y as having capacity to make decisions about her care though it also discussed discharge planning with her family. Ms X expressed concern that Mrs Y did not have regular carers and they were not motivated to encourage Mrs Y to get up and do things. The Council has not provided any evidence it considered or addressed Ms X’s concerns.
  11. The Council completed a reablement assessment on 19 March, deciding Mrs Y would have two carers visit four times daily as before. This says an OT will review her needs again once she is home.
  12. The Council completed a care and support plan on 20 March and Mrs Y left hospital on the same date. The care plan says Mrs Y’s advocate, a family member, should raise any concerns about carers with the Council.
  13. The Council’s records show an OT tried to visit Mrs Y on 22 March but could not access the property. They rearranged to attend on 27 March.
  14. On 22 March Mrs Y’s care agency reported Mrs Y had a hospital bed but no railings and was at risk of falls. The Council says it ordered rails for delivery the next day.
  15. Mrs Y went into hospital again on 25 March. On the same date Ms X complained about her carers. She said they had failed to complete the log book, left Mrs Y without food and drink and Mrs Y had suffered falls. An OT called Ms X to discuss this but could not reach her.
  16. The Council’s records show it discussed discharge planning with Mrs Y’s family.
  17. Mrs Y left hospital on 29 March and resumed reablement care. Ms X asked the Council who would provide Mrs Y’s care. The Council said it was the same agency but it would review how things were going with the carers in a few days. During that visit, the OT noted Mrs Y was suffering pain in her foot and did not want to leave her bed. However, there is no evidence the Council considered the quality of care provided or updated Ms X.
  18. On 15 April Ms X asked the Council for a cantilever table to allow Mrs Y to reach her drinks. The Council ordered this.
  19. An OT visited Mrs Y on 18 April. Carers told the OT Mrs Y had only left bed once on returning form hospital. A physiotherapist recommended they continue to care for Mrs Y in bed and not try to transfer her. The carers asked for a hoist but the OT said it was not safe to introduce new equipment. The carers also asked for cot sides as Mrs Y’s feet sometimes slid off the bed. There is no evidence the Council decided to order these.
  20. The Council has provided a copy of a care assessment of Mrs Y, started on 8 April and completed on 20 April. This shows Mrs Y’s advocate, who is a family member, supported Mrs Y during the assessment. The assessment reports Mrs Y is at risk of pressure sores but has none currently and her skin condition is good. Further, that her advocate is happy with the carers.
  21. Mrs Y went into hospital again on 21 April. On 30 April Mrs Y’s family reported concerns the carers were not always attending at the same time. There is no evidence the Council considered or addressed these concerns.
  22. The Council’s records show they discussed discharge planning with Mrs Y’s family.
  23. On 9 May the hospital completed a needs assessment. This reports Mrs Y is bed bound. The Council will need to decide whether a hoist is appropriate in the long term or whether she will remain bed bound. It says carers will need to monitor pressure areas and assist Mrs Y to turn regularly. The Council decided Mrs Y needed a full package of care on discharge rather than reablement.
  24. The Council completed a care and support plan on 22 May. This says Mrs Y will remain bedbound on discharge and will be cared for in bed. But, an OT will assess her at home to see if a hoist is suitable. The plan records Mrs Y’s advocate, a family member, has been involved in the care planning process.
  25. The Council’s records show Mrs Y was due to leave hospital on 21 May but on contacting her family found they were unaware of this. The hospital then delayed discharged until 23 May. The Council’s records suggest family were present on discharge.
  26. On 24 May Mrs Y’s family reported she was depressed and not eating. The Council suggested they speak to her GP.
  27. On 5 June Ms X told the Council she was concerned about the level of care provided to Mrs Y. She wanted the Council to review the care arrangements sooner than the planned six week date. Ms X queried why the Council did not invite Mrs Y’s family to the discharge planning meeting. Ms X did not want Mrs Y to remain bed bound and noted she had severe sores and was at risk of falling out of bed.
  28. The Council’s records show it referred Mrs Y for an OT assessment on 6 June.
  29. Ms X told the Council district nurses were aware of the bed sores. She asked for the carers to lift Mrs Y out of bed but the Council said the OT would have to assess Mrs Y first.
  30. On 23 June Ms X complained to the Council about its poor communications, the lack of appropriate care and equipment following Mrs Y’s latest discharge and the delay in an OT assessment.
  31. An OT visited Mrs Y on 27 June to review manual handling and care. They ordered a mobile hoist to enable carers to assist Mrs Y to leave her bed.
  32. Mrs Y went into hospital again on 3 July. On 4 July the hospital raised safeguarding concerns.
  33. The Council’s note of a multi team meeting on 9 July says Mrs Y has sores which may have arisen due to lack of care from carers as reported by Ms X.
  34. The Council responded to Ms X’s complaint on 12 July. It explained various professionals were involved in Mrs Y’s care but suggested communications were good. It did not address concerns over care and equipment in any detail but suggested there had been no undue delay in the OT assessment.
  35. There is no evidence the Council properly considered or addressed Ms X’s concerns about the quality of care provided by the carers.
  36. On 15 July the Council held a meeting with Mrs Y’s family to discuss discharge.
  37. The Council’s records show Mrs Y’s discharge from hospital was delayed to allow treatment of her pressure sores. On 14 August Mrs Y moved into a care home to continue treatment.
  38. On 16 August a Council officer contacted Ms X to update her. The Council’s records say Ms X disputed the sores arose due to poor care at home, rather they were the result of an unsatisfactory discharge from hospital without a proper handover.
  39. The Council recorded the hospital’s safeguarding alert on 19 August. This says Mrs Y’s pressures sores deteriorated while at home despite the care package and district nurse involvement. The Council decided to fully investigate the concerns.
  40. Ms X passed away on 4 October.
  41. The Council planned a safeguarding meeting on 30 October but says it took place on 16 December because of lack of availability of relevant persons.
  42. In response to enquiries the Council says the safeguarding meeting concluded the allegation of neglect of care was substantiated. It said there is evidence of a multi-agency delay in the provision of care and support. The neglect could have been avoided if the care was organised in a timely manner by Community Health and the Council. The cumulative result of lack of communication, delay in assessments by the District Nurses, Social Work Team and Occupational Therapy service, amounted to neglect in care. However, the neglect did not cause or accelerate Mrs Y’s death. This was discussed and confirmed in the safeguarding meeting by the health professionals in attendance.
  43. The Council’s Safeguarding Adults Manager concluded the different services should coordinate more robustly with each other and respond more swiftly in case of emergencies. The communication between hospital and community-based service needed to improve to avoid delay in assessments and service provision. The Manager asked the Council to complete a Lessons Learnt exercise and an Action Plan for improvement, which the Council says it is still working on. The Council says it will share the results with Mrs Y’s family.
  44. The Council says the Social Work and OT Team have strengthened their duty system to respond more swiftly to service users/their relatives and other professionals. They will do this by using an escalation process to inform the manager in case there is a risk of neglect or delay in service provision. And, by encouraging managers to communicate with their duty staff to avoid lapse in communications.
  45. In comments on my draft decision Ms X emphasised the Council only acted to provide equipment to Mrs Y after she chased it. And, the Council would not have arranged an OT assessment in June if she had not called as she did.


  1. Ms X repeatedly raised concerns about the quality of care provided to Mrs Y but there is no evidence the Council properly considered these concerns or provided a response to Ms X. This is fault.
  2. The Council should have considered what equipment Mrs Y may need in place at home before she left hospital to ensure she would be safe at home. However, the evidence suggests the Council did not always complete OT assessments at the appropriate times. This is fault.
  3. Mrs Y was bedbound when she left hospital on 23 May and at risk of pressure sores. However, the Council’s OT did not assess her and order a mobile hoist until 27 June. This amounts to fault.
  4. The Council accepts it neglected in its care of Mrs Y due to poor communication, delay in assessments and delay in care and support. This is fault.
  5. Mrs Y suffered a shortfall in care however, I cannot recommend a personal remedy for any distress as she has since passed away. And, the Ombudsman cannot say the Council’s actions caused Mrs Y’s death. Rather, the Coroner’s Court would be the appropriate body to make any such finding.
  6. Ms X wants the Council to take action to prevent recurrence. Having considered the Council’s response to enquiries I am satisfied the Council has recognised the need for better communications with service users and relatives. It is also working on an action plan to address the delays in assessment and service provision. The Council says it will share a copy of its action plan with Ms X and I will make a recommendation to this effect.
  7. Ms X has suffered distress because the Council did not address her concerns and uncertainty as to the impact this had on Mrs Y. I will therefore make further recommendations in recognition of the injustice to Ms X.

Agreed action

  1. To remedy the injustice set out above the Council should carry out the following actions within two months of the date of my decision:
    • Provide Ms X with a written apology;
    • Pay Ms X £500 in recognition of the distress and uncertainty she has suffered;
    • Provide Ms X and the Ombudsman with a copy of its Action Plan for improvement, produced in response to the safeguarding investigation.
  2. The Council has accepted my recommendations.

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Final decision

  1. I find the Council at fault in its provision of care to Mrs Y. The Council has accepted my recommendations and I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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