The Ombudsman's final decision:
Summary: Ms B complains that her mother, Mrs C, received inadequate care which resulted in her falling and suffering significant injuries. There is insufficient evidence to conclude that the care Mrs C received caused her to fall. However, the carer was at fault in moving her after the fall instead of seeking medical advice. In recognition of the uncertainty about whether this may have contributed to her injuries, the care provider has agreed to make a payment to Mrs C.
- Ms B complains about the care her mother, Mrs C, received which resulted in her falling and suffering significant injuries.
The Ombudsman’s role and powers
- We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
- If we are satisfied with a care provider’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)
How I considered this complaint
- I have considered all the information provided by Ms B, made enquiries of the care provider and considered the documents it provided.
- Ms B and the care provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
- Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.
What I found
Legal and administrative background
- The Health and Social Care 2008 (Regulated Activities) Regulations 2014 (the regulations) set out the requirements for safety and quality in care. The Care Quality Commission (CQC) issued guidance in 2015 on meeting the regulations (the guidance). We consider the regulations and the guidance when determining complaints about poor standards of care.
- Regulation 12 of the 2014 regulations states that care must be provided in a safe way including:
- assessing the risks to the health and safety of service users of receiving the care or treatment;
- doing all that is reasonably practicable to mitigate any such risks; and
- ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
- Mrs C was elderly and frail and lived alone. She was receiving a package of care from the care provider to help with personal care, assisting to the toilet and providing breakfast and lunch. Mrs C moved around the house with the assistance of a Zimmer frame but needed someone next to her when mobilising.
- The care provider completed a risk assessment and care plan. The care plan stated that Mrs C was at high risk of falls. It stated that, when mobilising Mrs C, carers should walk at the side of her to reduce the risk of falling.
- On 28 April 2020 Mrs C suffered a fall and sustained serious injuries.
- Ms B says one of the carers, Ms X, was assisting Mrs C to the bathroom. Mrs C stood up from her armchair with the aid of her Zimmer frame in front of her. She began to turn to her left to pass her chair and Ms X should have been behind her. Instead, she was in front of Mrs C and unable to intervene as Mrs C fell. She landed on the cast iron fire. Ms X assisted Mrs C into her chair and then telephoned Ms B’s sister, Ms D, who lives nearby. Ms D called an ambulance and Mrs C was taken to hospital.
- Mrs C suffered multiple injuries including a broken rib and a dislocated shoulder. She can no longer use one of her arms and so cannot use her Zimmer frame, feed herself or use the commode safely alone. As a result, she has had to move in with Ms B. Mrs C suffered severe pain and was on morphine for several months.
- Following the accident Ms B complained to the care provider. It completed an investigation including obtaining a statement from Ms X. The care provider wrote to Ms B with the outcome of its investigation. The managing director said her understanding of the incident was that, on entering the property, Ms X asked Mrs C if she needed to go to the toilet. Mrs C replied ‘yes’ so Ms X got the Zimmer frame so Mrs C could stand up. As Mrs C stood up, Ms X held onto the frame to steady her. Ms X walked to get behind Mrs C but, as she was doing this, Mrs C lost her balance and landed on the fire. Ms X helped Mrs C into her chair and then telephoned Ms D.
- The managing director concluded this was an unforeseeable accident. Ms X was positioning herself into the correct position to assist Mrs C when she fell. She said carers should not try to break someone’s fall unless it was safe to do so and, if Ms X had tried to intervene, she could have injured herself as well. The managing director accepted Ms X should have been more aware of potential other injuries and called for assistance before moving Mrs C. She apologised for the pain and distress caused to Mrs C and her family.
- Ms B was not happy with the care provider’s response. She says Ms X’s failure to prevent her mother’s fall meant she suffered significant injuries resulting in loss of independence and a decline in her health. She says that, had the incident not happened, Mrs C would still be living in her own home.
- The care provider completed a mobility assessment and a falls risk assessment. The mobility assessment stated that Mrs C used a walking frame and required support with walking, specifically “someone walking at side of me to make me feel confident and reduce risk of falling”. The assessment states, “carer to walk at the side of me”. The falls risk assessment stated that Mrs C had a high risk of falls and suffered from dizziness and needed support moving from a sitting position to standing.
- The care plan made carers aware that Mrs C was at high risk of falling and stated, “I use walking frame but need someone at the side of me when I’m walking”.
- It is clear from these documents that the care provider had assessed Mrs C as needing someone at the side of her when walking and that she needed support moving from a sitting to standing position, but it does not state that the carer should stand in a specific position when supporting Mrs C to stand. I am satisfied the falls risk assessment considered relevant factors including Mrs C’s history of falls, her posture and gait, her transfer abilities, her balance and orientation and her aides and appliances. In these circumstances, I cannot question the merits of the assessment.
- In her statement Mrs C says Ms X “helped me off my chair but wasn’t standing behind me to support my body. I fell sideways onto the electric fire grate”.
- Ms X in her statement said that, as Mrs C stood up and was holding onto the Zimmer frame, she “walked to get behind her” and, as she was doing this, Mrs C lost her balance and fell.
- Only Mrs C and Ms X were present when the accident happened. There are no independent witnesses to the incident. I consider there is insufficient evidence to reach a safe conclusion about precisely what happened. So, I cannot say that, on the balance of probabilities, the fall would not have happened if the carer had been standing in a different position.
- The care provider accepts it would have been best practice for the carer to call for assistance before moving Mrs C following the fall. I find it was wrong for the carer to move Mrs C. She should have obtained medical assistance before doing so. It is not clear whether this contributed to Mrs C’s injuries and she will never know whether or not this is the case. I consider the care provider should make a token payment to Mrs C in recognition of this uncertainty.
- I am satisfied the care provider carried out a proper investigation into the incident. In the absence of independent evidence to establish exactly what happened when Mrs C fell, there is nothing we can add to the investigation already carried out.
- As Mrs B considers the care provider is responsible for Mrs C’s injuries, it is open to her to seek legal advice about the prospect of court proceedings.
- The care provider has agreed to pay Mrs C £300 in recognition of the uncertainty about whether moving her following the fall contributed to her injuries.
- I do not uphold Ms B’s complaint that the care provided to Mrs C was inadequate and caused her to fall.
- I find the carer’s actions in moving Mrs C following the fall instead of seeking medical assistance caused her an injustice.
- I have completed my investigation on the basis that the care provider has agreed to implement the recommended remedy.
Investigator's decision on behalf of the Ombudsman