Summary: Ms X complained that carers dropped her while lifting her using a hoist. She said the hoist strap was not securely attached. Ms X also complained about the way the Council responded to her complaint about the incident, and that it did not contact her for weeks afterwards. Ms X said being dropped caused her injury, and she is now reluctant to engage with care services because of a lack of trust. She also said the Council’s response made her feel dismissed. We find the Council at fault for the way it conducted its enquiry. This caused Ms X injustice because it denied her an opportunity to be involved in the process and give her version of events, and it caused uncertainty. The Council has agreed to apologise to Ms X and make improvements to its service.

The complaint

1. The complainant, who I refer to here as Ms X, complains that carers dropped her while lifting her using a hoist. She says the hoist strap was not correctly secured. She complains about the way the Council responded to her complaint about the incident. She also complains that the Council and care agency did not check on her for five weeks after she was injured.
2. Ms X says as a result of being incorrectly secured in the hoist, she was dropped which injured her arm and hip. She says she is still in pain from it. She is now reluctant to engage with care services because of a lack of trust. She says she feels dismissed.

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The Ombudsman’s role and powers

3. 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)
4. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
5. 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)
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

7. I considered the information and documents provided by Ms X and the Council. I spoke to Ms X about her complaint. Ms X and the Council had an opportunity to comment on an earlier draft of this statement. I considered all comments and further information received before I reached a final decision.
8. I considered the relevant legislation, statutory guidance, and policies, set out below. I also considered the Ombudsman’s published guidance on remedies.

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What I found

What should have happened

Safeguarding enquiries

9. Under section 42 of the Care Act 2014, councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves.
10. It is not for the Ombudsman to reinvestigate the safeguarding referral but to consider whether the council conducted a suitable investigation in line with its safeguarding procedures.

Reporting incidents

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
12. Regulation 12 says incidents that affect the health, safety and welfare of people using services must be reported internally and to relevant external authorities/bodies. This includes incidents that have potential for harm.

What happened

13. Ms X has care and support needs. At the time of the incident in question, Ms X was receiving care provided by the Council as part of a reablement package. A care agency provided Ms X’s care on behalf of the Council.
14. In May 2020, two carers were moving Ms X from one place to another within her home, using a hoist. The hoist strap was not correctly attached on one side. Ms X says the carers dropped her.
15. Two days later, Ms X told the Council she “went down with a bang”. As a result, Ms X said she could not lean forward or twist, and her hip hurt. The Council apologised for the incident and told her there was a full investigation ongoing.
16. The next day, Council Officer A (an independence and wellbeing practitioner) spoke to Ms X about the incident.
17. The Council received a safeguarding referral about the incident. The Council made some enquiries to see if it should do a formal section 42 safeguarding enquiry.
18. The Council’s informal enquiries said the Council tried to call Ms X once but there was no answer. In the box asking whether the adult at risk wanted to proceed with an enquiry, it says “don’t know”.
19. The outcome of the Council’s enquiries was that it would not proceed to a section 42 safeguarding investigation. It said no harm had been caused.
20. In June, the Council wrote to Ms X. It said there did appear to have been an error in not securing one side of the hoist strap. It said when the carers identified this error, they lowered Ms X down to secure the strap correctly. The Council said the carers denied dropping Ms X. The Council said there were insufficient details to confirm she was dropped.
21. The Council said it was concerned that the loose strap and anxiety caused to Ms X were not fed back to the Council or recorded on the daily care notes. It said the care agency had taken disciplinary action against the carer involved, and apologised for the distress caused.
22. In November, Ms X complained to the Council.
23. The Council responded. The Council said it dealt with the incident as a safeguarding incident. It said it could not address her concerns further because they were addressed appropriately through the safeguarding process.
24. Ms X then complained to the Ombudsman.

Analysis

The incident

25. Ms X complains that carers dropped her while lifting her using a hoist. She says the hoist strap was not correctly secured.
26. As I have said above, it is not for the Ombudsman to reinvestigate the safeguarding referral but to consider whether the Council conducted a suitable investigation in line with its safeguarding procedures.
27. The Council’s informal enquiries say it did not speak to Ms X. It says it tried to call her once but there was no answer. There is no evidence that the Council attempted to call Ms X again.
28. After its enquiries, the Council decided not to do a section 42 safeguarding enquiry. This is a decision the Council is entitled to make. However, the Ombudsman would expect a council to make this decision after speaking to the person who was the subject of the referral.
29. I find the Council could have made more effort to speak to Ms X as part of its enquiries. This is fault. I find that the fault caused Ms X injustice in that she was denied an opportunity to be involved in the process and give her version of events.
30. The Council accepts it could have done more to facilitate contact with Ms X. It acknowledges it should have included Ms X as part of the Council’s enquiries.
31. The Council also accepts that it did not feed back to Ms X the outcome of its enquiry. This is fault. It says it did not do this because Ms X did not make the safeguarding referral herself. It accepts it may have helped Ms X to have some understanding of what action the Council had taken.
32. I find this fault caused Ms X injustice because it caused uncertainty: Ms X did not know what the Council was doing about the incident.
33. It is positive that the Council has reflected on this incident and accepts it can learn from it.

Failure to log to incident

34. Ms X says carers did not record the incident at the time, did not complete an incident form, and did not notify head office or the Council.
35. I agree with Ms X. The carers involved in the incident did not report the incident or log it anywhere.
36. As I have said above, Regulation 12 says incidents that affect the health, safety and welfare of people using services must be reported internally and to relevant external authorities/bodies.
37. While the carers did not report the incident initially, I find that the care agency rectified this within a very short period of time (a few days). The care agency made sure the carers completed the incident form, made a note in Ms X’s care records, and notified external authorities as it should have.
38. I do not find this significant enough to constitute fault. For this reason, I do not find fault.

The Council’s complaint response

39. Ms X complains about the way the Council responded to her complaint about the incident. She says the Council did not contact her to see what happened.
40. As I have said above, I find the Council at fault for failing to speak to Ms X as part of its informal enquiries. However, I do not find the Council at fault for its complaint response. The safeguarding process was the appropriate way to address the incident.

Council follow-up after the incident

41. Ms X complains that the Council and care agency did not check on her for five weeks after she was injured.
42. I do not agree. I have seen records which show the Council spoke twice to Ms X two days after the incident, when it first became aware of it. The Council then spoke to Ms X again four days later. Ms X acknowledges that someone called her the day after the incident and the day after that.
43. Records also show that Council Officer A spoke to Ms X 11 times during the course of the following six weeks. Ms X says the Council did not speak to her about the incident during those 11 calls. I cannot say what was discussed during those calls, but I have already found the Council at fault for failing to involve Ms X in its investigation into what happened.
44. I cannot say when or if the care agency spoke to Ms X after its initial call following the incident. However, the care agency was providing care to Ms X on behalf of the Council. I find that the Council was responsible for Ms X’s care. It was therefore the Council’s responsibility to contact Ms X, which it did.
45. I find that Council did check on Ms X after the incident. For this reason, I do not agree with Ms X. I therefore do not find the Council at fault.

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Agreed action

46. Within four weeks of this decision, the Council has agreed to apologise to Ms X in writing for not speaking to her as part of its enquiry and for not telling her the outcome.
47. Within three months of this decision, the Council has agreed to remind staff (including management) to speak to the person who is the subject of a safeguarding referral or enquiry.
48. Also within three months of this decision, the Council has agreed to remind staff (including management) to make sure they tell the person who is the subject of a safeguarding referral or enquiry the outcome, regardless of whether they are the person who made the referral.
49. The Ombudsman will need to see evidence that these actions have been completed.

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Final decision

50. I have completed my investigation. I uphold Ms X’s complaint because I find fault with the way the Council made its enquiries. I find this fault caused Ms X injustice. The Council has agreed to take action to remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman