Summary: There is no evidence of fault by the Council. When Mrs X fell at her care home, there was no safeguarding report made by medical staff and her daughter did not raise a complaint until 8 months after the event. There is no reason for the Council to investigate in the circumstances, where it did not know of any previous history of falls or safeguarding concerns at the time.

The complaint

1. The complainant, whom I shall refer to as Ms B, complains on behalf of her mother Mrs X that the Council’s investigation of her mother’s fall at a care home was inadequate.

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The Ombudsman’s role and powers

2. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. 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)
3. 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

4. I read the papers put in by Ms B and discussed the complaint with her.
5. I considered the Council’s comments about the complaint and any supporting documents it provided.
6. I gave the Council and Ms B the opportunity to comment on my draft decision.

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What I found

Key facts

7. Mrs X moved into her care home in August 2017.
8. The care home said that Mrs X ‘slipped’ in June 2018. This was not recorded as a ‘fall’ but the paramedics were called.
9. The care home records show that it carried out a monthly risk assessment which did not put her at an increased risk of falling. The care home carried out the last assessment on 19 September 2018.
10. Ms B says the care homes risk assessment was wrong. She says that as her mother had a fall in June 2018, the risk assessment should have noted she had had a previous fall. The care says Mrs X had a slip, not a fall in June and so it did not tick the box that indicated previous falls.
11. Ms B also said that risk assessment did not include her mother’s incontinence. The care home accepts this was wrong and the assessment should have ticked the box to say Mrs X was incontinent.
12. Ms B also disagrees with the care homes assessment that her mother was steady on her feet. She says that her mother would only walk if someone was holding her arm. The care home says that care assistants found that ‘Mrs X would mobilise with the occasional support of one arm, solely for gaining emotional confidence, while walking alongside health care assistants’. The home says Mrs X did not need the support of two healthcare assistants.
13. Both the care home and Ms B agreed that Mrs X could be initially dizzy when standing due to medication. There was no box on the falls risk assessment ticked for this point.
14. Mrs X had a fall at her care home on 23 October 2018. The homes care record says ‘see accident report’. The ambulance took Mrs X to hospital and the care home phoned her daughter.
15. Ms B says that when the care home first called them the care worker said their mother fell in the lounge. Then they were told she fell in the bathroom.
16. The report from the care home says that ‘at 11:45 Mrs X was assisted to the toilet. On standing from the toilet she lost her footing and fell to the floor. A staff member witnessed the fall and assisted her gently to the floor. Paramedics saw Mrs X in the bathroom and took her to hospital.’
17. Ms B says a member of hospital radiography staff told her that ‘there was no way the fractures could have been caused from Mrs X being lowered to the floor’. The hospital staff did not raise a safeguarding report with the Council.
18. Ms B made a complaint to the Council in June 2019. The safeguarding team said that as the complaint was historic (it happened over 8 months ago) a safeguarding investigation was not appropriate and the Council would deal with it as a formal complaint.
19. There was some confusion over which complaints process Ms B should follow. Then Ms B asked the Council to contact the care home with her complaint on her behalf. The care home responded in October 2019. The care home said that it was sorry it happened and for any distress caused. However, falls do happen and are sometimes unavoidable, and that staff followed the correct procedure by calling an ambulance and then Mrs X’s family.

My analysis

20. Ms B first told the Council of Mrs X’s fall 8 months after it happened. No medical professionals made a safeguarding report at the time so there is no evidence to support Ms B’s view that the details given by the care home are not correct. Given there were no previous safeguarding reports or reports to the Council of Mrs X falling I can see no reason for the Council to investigate further at the time. The care home had carried out a risk assessment and got Mrs X medical care quickly.
21. Ms B has raised concerns about the falls risk assessment during my investigation of the complaint, but did not raise this at the time in June or October 2018 to either the care home or the Council. I do consider this complaint should have been raised at the time, as it is not possible now, for the Council to visit to check if the assessment had been carried out properly.
22. The risk assessment gave Mrs X a score of 16, with a score below 13 indicating a resident was at risk of falls and a score of below 8 indicating a high risk. If the care home had recorded the June incident as a fall and the assessment had correctly included her mother’s incontinence, this would have given a score of 13. This would not have showed that Ms B’s mother was at risk of falls. From the evidence I have seen, there is not enough evidence for me to say for certain that Mrs X was unsteady on her feet or had a problem with her balance, other than dizziness she had been treated for. But, for the sake of argument, if this was the case her score would have been 11. So, she would not have been at high risk of falls. A score of 11, would have required healthcare workers to closely monitor Mrs X, which does seem to have been the case anyway as according to the reports a carer accompanied Mrs X in the bathroom.
23. I can see no evidence that the care home did not properly monitor Mrs X according to her risk of falling and so it does seem this was an accident. I do understand Ms B’s concerns that her sister was initially told her mum fell in the lounge on the phone, but there is no way now, to discover what was said in a private telephone call. If the medical professional (or Ms B) had concerns about Mrs X’s injuries then she raising a safeguarding report at the time would have been the correct thing to do.
24. Mrs X was been unable to mobilise since the accident and has now passed away, so the effects of the fall had a significant impact. However, I cannot see any evidence of fault by the Council in its decision not to investigate the complaint further. This is especially because no complaint was made about the incident or falls risk assessment at the time the falls occurred.

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Final decision

25. I have completed my investigation of the complaint. This complaint is not upheld as I find no evidence of fault.

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Investigator's decision on behalf of the Ombudsman