London Borough of Croydon (19 016 048)

Category : Adult care services > Other

Decision : Upheld

Decision date : 10 Sep 2020

The Ombudsman's final decision:

Summary: The Council is at fault for failing to properly risk assess the use of a hot water tap in a community facility. Ms D was caused injury because of this failure. The Council has agreed to make a payment in recognition of the distress caused by the injury and the additional strain it placed on Ms D’s mother. It has also agreed to remind staff about the importance of completing risk assessments.

The complaint

  1. The complainant whom I refer to as Mrs C complains on behalf of her daughter, who I refer to as Ms D.
  2. Mrs C complains the Council failed to provide a cup holder for a hot water tap which resulted in Ms D suffering a severe hot water scald.

Back to top

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)

Back to top

How I considered this complaint

  1. A colleague spoke with Mrs C and considered information she sent. I made enquiries of the Council and considered its response. This includes:-
    • risk assessments for Ms D;
    • information recorded by the Council about Ms D’s needs;
    • manufacturer information about the hot water tap;
    • incident reports;
    • complaint correspondence.
  2. Mrs C and the Council have had an opportunity to comment on a draft decision. I have considered their comments before making a final decision.

Back to top

What I found

  1. Ms D attends Cherry Hub, (the “Hub”) which provides a variety of experiences and activities to support people in the community.
  2. The Council completed risk assessments for Ms D. They say Ms D can use an urn and a kettle with minimal supervision. During an inter change between two activities in different locations Ms D used a hot water tap to make a drink. She had not used the hot water tap before. A support worker was with her at the time and made a visual capability assessment that Ms D could use the hot water tap.
  3. The water tap is situated above a sink. The incident report says Ms D put the cup under the tap. It says Ms D momentarily lost her concentration, she moved her hand and was injured by the hot water. Following the incident staff followed First Aid procedures to treat the scald.
  4. The incident report says there was no surface to place the hot drink and to prevent recurrence a drip tray was needed.
  5. The Council says a cup holder was purchased so that less able people could use the hot water tap and not directly because of Ms D’s accident.
  6. Mrs C disputes this. She says staff members had been splashed with “scalding water” and asked for a drip tray before Ms D’s accident.

Is there fault causing injustice?

  1. The Council assessed Ms D as low risk for using an urn and a kettle. This suggests Ms D was aware of the dangers of hot water and that diligence was needed. Mrs C says she always supports Ms D when she uses the kettle at home.
  2. I consider the use of the hot water tap was however different. This is for the following reasons:-
    • the position of the water tap was over a sink. This is an unnatural position. To use the water tap a person needs to lean forward;
    • only a slight loss of concentration and movement of hand could lead to injury when using the hot water tap, unlike using an urn or kettle where there is usually a surface to place a cup.
  3. I therefore consider the Council was at fault for failing to carry out a risk assessment for the use of the hot water tap for Ms D as an individual, and in general for people using the service.
  4. The incident report says that to prevent reoccurrence of an accident a drip tray is needed. I therefore consider that had the Council completed a risk assessment of the hot water tap it would have identified a need for a cup holder/drip tray.
  5. I also consider that on balance had the Council installed a cup holder it is more likely than not Ms D would not have been injured.
  6. It is important that people with disabilities are not restricted by a fear to take risks. However councils and care providers should take measures to minimise any potential risks. In this case there is good general record keeping and assessments in relation to Ms D. There are also no concerns about the general support Ms D receives from the Hub.
  7. However I consider the failure to properly risk assess the hot water tap is fault.
  8. Mrs C has provided pictures of Ms D’s hand and the scalding appears significant. It has taken some time for the wound to heal and Ms D has been in some pain.
  9. Mrs C has had the time and trouble in pursuing the complaint, stress caused by the injury, and additional time and effort in caring for her daughter.

Agreed action

  1. I consider there was fault by the Council which resulted in injury to Mrs C. The Council has agreed to take the following actions to remedy the complaint:-
      1. apologise to Ms D and Mrs C for the failures I have identified in this statement, in particular the failure to properly risk assess;
      2. make a payment of £300 to Ms D in recognition of the pain and discomfort caused by the Council’s failures;
      3. make a payment of £150 to Mrs C for her time and trouble in making the complaint and for the anxiety and distress caused by having to support Ms D with her scald;
      4. ensure there are risk assessments in place for others who may be at risk from using the hot water tap;
      5. remind staff about the importance of carrying out risk assessments when installing equipment which has the potential of causing injury such as hot water taps.
  2. The Council should complete actions (a) to (c) within a month of the final decision and (d) to (e) within two months of the final decision.

Back to top

Final decision

  1. I have found fault with the actions of the Care Provider acting on behalf of the Council which has caused injustice. I have completed my investigation and closed the complaint based on the agreed actions above.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Privacy settings