Summary: Home care staff commissioned by the Council failed to follow the correct procedure when Mrs Y was unwell. The Council then failed to deal with Mrs X’s complaint about this properly.

The complaint

1. Mrs X complains home carers commissioned by the Council failed to follow the correct procedure when her mother, Mrs Y was unwell, resulting in a delay in Mrs Y being admitted to hospital.
2. Mrs X complains about how the Council dealt with her complaint about the above

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What I have investigated

3. I have only investigated point 2 of the complaint. I explain the reasons for this at the end of this statement.

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The Ombudsman’s role and powers

4. 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)
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)

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How I considered this complaint

6. I have:

• considered the written complaint and discussed it with Mrs X;
• considered the Council’s response to the complaint;
• considered relevant legislation;
• offered Mrs X and the Council the opportunity to comment on a draft of this document, and considered the comments made.

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What I found

Relevant legislation

7. 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.
8. Regulation 9 Person Centred Care says Care Provider must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate and meets their needs.
9. Regulation 12 Safe Care & Treatment says people must not be given unsafe care or treatment or be put at risk of harm that could be avoided. Care Providers must assess the risks to a person’s health and safety during any care or treatment and make sure care staff have the qualifications, competence, skills and experience to keep people safe.

Key facts

10. Mrs Y was receiving home care services after being discharged from hospital in July 2021, following a fall.
11. Mrs X says Mrs Y appeared unwell on 10 July 2021. She had not eaten all day and did not have her teeth in, which was out of character.
12. Later the following day a carer telephoned Mrs X to say Mrs Y appeared unwell.
13. Mrs X visited Mrs Y the following day (12 July 2021) at lunchtime. When she arrived, a carer was already there, Mrs X was surprised by this as Mrs Y did not have a lunchtime visit. The carer was on the telephone to the team office, Mrs X believes the carer was reporting that Mrs Y was unwell. The carer told Mrs X she was dropping off dietary sheets.
14. Mrs X says Mrs Y was slumped in a chair and unable to communicate. She discussed her concern with the carer. The records document Mrs X’s concern, and that Mrs Y was unable to pick up a drink and had still not eaten her breakfast. Mrs X says as the carer was leaving she suggested Mrs X call the NHS 111 service, which she did.
15. Mrs Y was admitted to hospital where she was diagnosed with a severe urine/kidney infection. Mrs X informed the Council.
16. Mrs Y sadly passed away the following day,13 July 2021.
17. Mrs X believes medical help should have been sought sooner, and that Mrs Y should have been admitted to hospital on 11 July 2021 because it was clear she was unwell. She believes if Mrs Y had received treatment sooner it would have increased her chance of survival.
18. Mrs X complained to the Council on 21 July 2021. She expected a response, or a holding letter within 20 days. She received a response on 22 September 2021, two months later. Mrs X says this added to her frustration. The author of the letter acknowledged the delay in completing the investigation and providing Mrs X with a written response. I have had sight of the letter. It addresses the material facts and acknowledges fault, saying care staff had not responded appropriately at the time, “that in the event of a person deteriorating and concerns are expressed for their health, contact to be made to GP / 111 or 999 in emergency situations”.
19. The author concluded that carers that “…visited your mother between 11th and 12th July 2021 did not undertake the appropriate process for escalation of deteriorating health which was observed to impact significant on your mothers’ function and safety at home”. Mrs X’s complaint was upheld.
20. The author set out the lessons learnt and that the procedure for escalating concerns about a service user who is unwell would be reiterated to the care staff involved, both verbally and in writing, and this would be monitored through individual supervision and team meeting briefings. They concluded by saying “Please accept our apologies that the level of customer care did not reach the standards that Hull City Council expects”.
21. Mrs X is dissatisfied with the response. She says it fails to take account of Mrs Y’s suffering and of her own distress. She believes carers need better training and that the Council should show greater care, compassion, and accountability. She believes she should be compensated for her loss and distress.

Analysis

22. People have a right to expect safe, effective, and appropriate care that meets their needs. This is not what happened here.
23. The Council acknowledged that care staff failed to follow the correct procedure when Mrs Y was unwell. Whilst it is not possible to say this directly caused Mrs Y’s death, it is clear she was in distress for longer than was necessary.
24. Sadly, Mrs Y has died, so it is not possible to provide a remedy. Where a person has died we will not normally seek a substantive remedy in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment that would enrich a person’s estate.
25. However, Mrs X has also suffered an injustice. She has been left with the uncertainty and distress about what may have happened had Mrs Y been admitted to hospital sooner.
26. The Council acknowledges it failed to deal with Mrs X’s complaint in a timely manner. Its final complaint response was inadequate and poorly presented. It simply reiterated the material facts and failed to offer a sincere apology or acknowledge Mrs X’s distress. It also failed to offer a remedy for her distress and for the delay in dealing with her complaint. This compounded Mrs X’s grief and sense of injustice.

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Agreed action

27. The Council will within four weeks of the final decision:

• provide Mrs X with a sincere written apology for the failings highlighted above;
• pay her £250 to acknowledge her time and trouble pursuing the complaint with the Council and the Ombudsman;
• pay her £250 for her distress;
• provide evidence of policy/service improvements/staff training to this office.

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Final decision

28. The Council acknowledged that home care staff failed to follow the correct procedure when Mrs Y was unwell. The Council then failed to deal with Mrs X’s complaint about this properly.
29. The above recommendations are a suitable way to remedy the injustice to Mrs X.
30. It is on this basis; the complaint will be closed.
31. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share a copy of the final decision with CQC.

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Parts of the complaint that I did not investigate

32. I have not investigated the events leading to the complaint. The facts are established, and the Council upheld the complaint.

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Investigator's decision on behalf of the Ombudsman