Summary: Ms B complained about the actions taken by the Council’s alarm call service when responding to her mother (Mrs D) after she had fallen. We have not found fault with the Council.

The complaint

1. Ms B complained that Milton Keynes Council (the Council) failed to acknowledge fault in the way its alarm call service (the Service) dealt with her mother, Mrs D, in December 2020. Specifically, it:
• left Mrs D unattended in an unsafe position which led to another fall;
• failed to identify she had signs of dementia;
• failed to update its records following a review of Mrs D’s alarm call needs in September 2020, to include the possible dementia and Ms B as a contact in the event of a fall; and
• moved her after the first fall which may have exacerbated her injury.
2. Ms B has been caused distress and uncertainty as to whether different actions may have prevented the injury occurring. Mrs D died a short time after going to hospital and Ms B was unable to visit her due to COVID restrictions.

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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. 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

5. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. Ms B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

6. Ms B’s mother, Mrs D was elderly and had a number of health conditions. She lived in her own flat and paid for the Service. She had a pendant alarm which she could press when she needed assistance. The Service sends out a first responder to assess the situation, resolve the problem or request help from another service, such as an ambulance. The responder will stay with the person until the ambulance arrives if possible. If they have to attend to another emergency call, they will only leave the person if they can be left safely, and another person is on the way.
7. The Service holds details of users on its central database, including any medical conditions. Mrs D’s details had been reviewed in January 2020 and the record included four conditions but not dementia or memory problems. The Council says that it held Mrs D’s details as the location contact and then Ms B as the first emergency contact.
8. In September 2020 Ms B discovered that Mrs D had made or triggered over 50 alerts to the Service in the previous three months. She contacted the Service by telephone and had a long conversation about the situation. The Council listened to the call. It said that Ms B confirmed the previous four conditions and also said Mrs D’s short term memory was poor but her long-term memory was good. The Council said Ms B asked to be called if the Service sent a responder or an ambulance out to Mrs D.

2 December 2020

9. Mrs D pressed her pendant alarm at 19:47. She said she had fallen while going to bed and could not get up. The Service sent a responder who arrived at 20.05. They spoke to Mrs D and established she was not in pain, could move her arms and legs, was lucid and chatty. They proceeded to lift her to sitting with an inflatable cushion seat and intended to help her get to bed once she was upright. The responder said Mrs D assisted with the process with no sign of pain. It was only when she tried to stand up with the help of her walker that the responder noticed Mrs D’s leg was shaking and she was wincing.
10. At this point the responder could not leave Mrs D unattended on the inflatable seat as it was unstable. She reached for a stool which she placed against a bookcase and assisted Mrs D to transfer onto it. Mrs D was seated with her back against the bookcase. The responder placed a cushion between her back and the bookcase, and another between her leg and the walker and covered her legs with a blanket. Mrs D was anxious to get to bed.
11. The responder then, with Mrs D’s consent, called an ambulance. At that time waits for an ambulance for non-emergency calls were often between four to six hours. The ambulance service carried out some basic checks over the telephone and spoke to Mrs D. She said she had not hurt herself and wanted to go to bed.
12. The responder said Mrs D was adamant that she did not want the responder to call Ms B. She said Ms B might not be at home because she often went to Spain. The responder sat with Mrs D and said they chatted about her family.
13. At 20:50 she rang the Service to inform it they were still waiting for an ambulance. The Service said there was another user who had been waiting for an ambulance since 16:40. The Service also said there was another call waiting from a person who had fallen.
14. The responder asked the Service to call Ms B as Mrs D had requested that the responder did not call her. The Service called Ms B at 20.52. Initially she rang Mrs D’s care agency to see if a carer could attend as Ms B felt this would be the quickest option. She rang back at 21:00 to say no carer was available and she would get a taxi, so would be about 45 minutes. The responder said Mrs D was unhappy that Ms B had been called.
15. By this point the user who was waiting had not responded to two further calls and the Service was concerned that they were unresponsive.
16. The responder called the ambulance service again and there was still no estimated arrival time. They spoke to Mrs D again over the telephone and she said she just wanted to get to bed. The responder said she needed to leave and told the ambulance service how and where Mrs D was sitting. They advised putting cushions around her and not to give Mrs D anything to eat or drink.
17. The responder placed cushions around her and her walker in front of her with her alarm pendant and phone within her reach. She left at 21:25.
18. Ms B arrived at 21:45. She said Mrs D was in distress, cold and thirsty. Ms B telephoned the ambulance service for an update. After she had finished the call Mrs D fell from the stool.
19. She was admitted to hospital who confirmed Mrs D had broken her hip. Ms B said staff also commented she was unable to give a history and presented with severe cognitive impairment.
20. Mrs D died 15 days later. An inquest was held. The Coroner said the main cause of death was a COVID-19 infection followed by the hip fracture. Frailty and dementia were secondary factors. They said she had two falls (one unwitnessed accident and one accompanied as a result of her frailty) on 2 December 2020, but it was not possible to say which fall led to the fracture.
21. Ms B made a safeguarding referral to the Council. The Council made enquiries and spoke to the Service including the responder. It concluded that the referral was not substantiated.
22. Ms B complained to the Council about the actions of the Service, which she felt had contributed to Mrs D’s death. The Council responded at stage one of its procedure and answered the questions Ms B had raised. The Council explained why it had not called Ms B sooner, why the responder had moved Mrs D, why she was left on a stool and why the responder’s assessment of Mrs D’s mental state so inaccurate.
23. Ms B escalated her complaint to stage two of the procedure. The Council responded in May 2021. It clarified several queries, including confirming that Ms B was the first emergency contact, the calls to the Service are charged at a local rate, there was no information on Mrs D’s records to say she had impaired cognitive ability, and that the responder was satisfied on a number of levels that Mrs D had capacity to make decisions about her care. It said it was carrying out a review across social care of evening and night support to maximise available resources.
24. Ms B then complained to us.

Analysis

25. These events leading to Mrs D’s death must have been very upsetting for Ms B and I understand why she has pursued her complaint. However, my role is to consider whether there was any fault in the way the Council dealt with Mrs D’s call to the Service which has caused Ms B an injustice. I cannot reach any view on the cause of, or circumstances which led to, Mrs D’s death: that was the role of the Coroner.
26. Looking at each part of Ms B’s complaint in turn:

The Service left Mrs D unattended in an unsafe position which led to another fall

27. I have not identified any fault in the way the Service acted in respect of Mrs D’s fall. The responder undertook basic initial checks of Mrs D and did not identify any injuries, confusion, pain or distress. At this stage they considered this was a routine call to assist Mrs D to get up so she could get to bed. It was only halfway through this process that the responder noticed a problem when Mrs D tried to weight-bear on her leg. This was not ideal as the responder was unable to leave Mrs D unattended on the inflatable cushion, so had to use whatever was in reach: a stool. They created a back-rest, made Mrs D as comfortable as possible and sat with her while waiting for an ambulance. They chatted with Mrs D throughout this time and the ambulance service also spoke to her twice. Mrs D only said she wished to go to bed.
28. The wait for an ambulance was not within the Council’s control and the Service had to balance a difficult situation given the urgent nature of the waiting call. The best scenario would have been for the responder to have waited with Mrs D until Ms B arrived, but this was not possible.
29. Again, I consider the Service took reasonable steps to ensure Mrs D was as safe as possible. Once an ambulance was called the Service contacted Ms B, even though it was against the wishes of Mrs D. It also made calls to the ambulance service for advice and to check when an ambulance might arrive. It obtained advice on leaving Mrs D and minimised the time Mrs D would have to wait before Ms B arrived. The ambulance service advised against moving her again and giving her any food or drink. Unfortunately, Mrs D fell again in spite of these steps, a short time after Ms B had arrived. This must have been distressing for Ms B to witness but I have not concluded this was due to fault by the Service. I have also noted that the Council did not uphold the safeguarding referral.

failed to identify Mrs D had signs of dementia

30. The responder has given a detailed account of her interactions with Mrs D and explained why she was satisfied she had capacity to make decisions about her care, including whether or not to call Mrs D. Despite Mrs D’s instruction, the Service did call Ms B once it was apparent Mrs D needed an ambulance. I have not found fault with the conclusions the responder reached on the basis of the observations she made.
31. I accept that by the time Ms B arrived and once she arrived at the hospital, Mrs D’s mental condition had deteriorated. But I have not concluded from the information provided that the responder’s initial view was wrong.

failed to update its records following a review of Mrs D’s alarm call needs in September 2020, to include the possible dementia and Ms B as a contact in the event of a fall

32. Ms B believes the Service should have updated its records after her call in October 2020 when she mentioned Mrs D’s memory problems. The Council denied Ms B mentioned dementia and so had no reason to update the notes.
33. The Council could have updated its records to include the memory problems, but I do not consider this would have led to a different outcome as the responder explained how and why they reached a view of Mrs D’s mental state when they arrived. Even if they had known Mrs D’s short-term memory was poor it is unlikely to have altered their assessment which was based on how Mrs D interacted with them and Mrs D’s reactions to the situation.
34. Ms B was listed as the first emergency contact, after Mrs D as the location contact on site. This was substantiated by the fact the Service called Ms B when an ambulance was called.

moved her after the first fall which may have exacerbated her injury

35. The responder did not identify any obvious signs of injury, Mrs D could move her arms and legs, said she was not hurt and had no pain. So, it was reasonable for the responder to treat it as a routine lift at that point. The ambulance service advised against moving her again once the injury was apparent. As explained above I have not found fault with the actions taken here.

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Final decision

36. I have completed my investigation into this complaint as I am unable to find fault causing injustice in the actions of the Council towards Ms B.

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Investigator's decision on behalf of the Ombudsman