Summary: Mrs C complains about a serious fall suffered by her late mother at a temporary care home placement (Granby Reablement Hub) arranged by the Council for rehabilitation. Mrs C says her late mother suffered a serious injury from the fall which meant she could not return home as expected and had to move to a nursing home where she later passed away. The Ombudsman has found fault in the record keeping and reporting about the fall. The Ombudsman considers the agreed actions of an apology and payment with improvements to procedures the Council has already made provide a suitable remedy.

The complaint

1. The complainant, whom I shall refer to as Mrs C, complains about a serious fall suffered by her late mother at a temporary care home placement (Granby Reablement Hub) arranged by the Council for rehabilitation. I shall refer to Mrs C’s late mother as Mrs B. Mrs C says she received contradictory information about the circumstances of the fall and the Council failed to make a report to the Health and Safety Executive under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013.
2. Mrs C says her late mother suffered a serious injury from the fall which meant she could not return home as expected and had to move to a nursing home where she later passed away incurring residential fees that she otherwise would not have incurred.

Back to top

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)

Back to top

How I considered this complaint

5. I read the papers provided by Mrs C and discussed the complaint with both her and her husband together at the outset of my investigation.
6. I have considered some information from the Council and provided a copy of this to Mrs C. I have explained my draft decision to Mrs C and the Council and considered the comments received before reaching my final decision.

Back to top

What I found

7. Mrs B was 92 years old and living independently at home. Mrs B was admitted to hospital after a fall at her home in early July 2018. Mrs B was not seriously injured and was transferred to a rehabilitation centre once a place was available. Mrs B fell a few days into her stay at the rehabilitation centre and was admitted to hospital. Mrs B had fractured her right hip which required an operation and hospital stay. After several assessments it was decided Mrs B could not return home and she moved to a nursing home.
8. Mrs C wrote to the centre in January 2019 to say her mother was unable to return home due to the injury she had sustained during her fall and sought the incident report.
9. The centre responded with a copy of the accident form. This was an emailed acknowledgement of a report dated 26 July 2018. This document says Mrs B walked to the corridor outside the lounge area as she had been asked by staff to go to her room to see someone but was then told she did not need to be seen. Mrs B had walked a few steps and lost her footing and fell hard although she did not hit her head. Staff made Mrs B comfortable on the floor and called an ambulance. This report says it was not a Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) reportable incident.
10. Mrs C contacted the centre to say her mother’s account differed from the above report. Mrs B said she was called by a staff member and helped from her chair and when told she was not required she turned back to the chair still being helped when she lost her balance and fell. Mrs C explained her mother had received little physiotherapy during her hospital stay and been unsure on her feet before her admission and used a zimmer and stairlift at home.
11. The centre responded and referred to Mrs B’s assessment and treatment plan and stated staff were assisting her with her mobility and she was using a walking frame when she fell and this happened in the corridor.
12. Mrs C contacted the centre to point out a discrepancy as the accident report made no mention of using a walking frame or staff support at the time of the fall. Mrs C also disputed the incident was not RIDDOR reportable. Mrs C stated she had not seen her mother using a walking frame at the centre and she had used a wheelchair during visits.
13. The centre referred Mrs C to the Council’s complaint procedure in March but did not respond to the highlighted discrepancies. Mrs C raised these again. The centre responded to say it was an error that there was no mention of a zimmer in the accident report and apologised. The centre also stated the failure to make a RIDDOR report was an oversight and this should have been made to the Health and Safety Executive (HSE) at the time or within 3 days of the outcome of any hospital treatment. The centre confirmed it did make a report to the CQC on the day of the incident.
14. Mrs C responded to the centre in April to ask if a report had now been made to the HSE and seeking the outcome of any investigation. Mrs C also stated her mother was unable to use a zimmer without carer support and repeated she had only ever seen her using a wheelchair at the centre. Mrs C suggested her mother was either not supported or supported inadequately leading to the fall. Mrs C asked if there had been a risk assessment for using a zimmer unaided. Mrs C subsequently sought the relevant care plans, assessments and records for her mother. The centre referred Mrs C to the Council.
15. Mrs C complained to the Council in May. The Council arranged to meet with Mrs C to discuss the complaint. Following this meeting, the Council provided a response to Mrs C in August. The Council confirmed it had considered all the correspondence with the centre and spoken to the Unit Manager and the person who had completed the accident form as well as a carer witness to the fall and Mrs B’s records. The Council accepted a RIDDOR report should have been made as soon as the severity of the fall was known. This had now been completed. The carer had confirmed they were assisting Mrs B when she fell. There is no reference to the use of a zimmer frame.
16. Mrs C contacted the Council in August to seek the date of the HSE report and noted there was no reference to using a zimmer frame at the time of the incident or in the ambulance records or accident report.
17. The Council responded to Mrs C in September with a copy of the HSE report dated 26 April 2019. The Council had not received any contact from HSE following the report. The author of the Council’s letter says they had reviewed their notes of the interview with a member of centre staff in July 2019 and these did include a reference to Mrs B being accompanied from the chair with her zimmer frame. The Council apologised for any misunderstanding. The attached HSE report timed the accident as 10.30am and says Mrs B was mobilising with a walking frame and fell when she turned. There is no reference to being assisted or accompanied by a carer at the time.
18. I have reviewed the relevant records for Mrs B. The risk assessment/falls management plan identified there was a risk of falls while getting in or out of a chair. Mrs B was assessed as transferring with the assistance of a wheeled zimmer frame and one carer in and out of a chair and should only do so with assistance either by verbal call or pendant use. It also identified other risks of falls including when mobilising. It is noted that Mrs B’s balance varied and she should not be left alone in the lounge, toilet or bedroom and one staff should transfer her between these areas. The risk level is noted as low.
19. The manual handling risk assessment form says Mrs B had a history of falls and a zimmer was needed with assistance of one staff member. The Personal Evacuation Plan (PEP) also refers to a wheeled zimmer frame plus one staff member. The pressure relief chart records refer to transferring Mrs B using a wheeled zimmer frame with two staff and use of a wheelchair on various dates. The daily notes for Mrs B also refer to the use of both a wheeled zimmer frame and wheelchair on various dates with Mrs B also being assisted. The note for the day of the fall is difficult to read but appears to refer to a fall while she was walking with one staff member and was taken to hospital by ambulance.
20. 
    The Council’s undated ‘Accident Investigation Form’ states the accident happened at 10.30am on 26 July 2018. This states the service user “fell in the corridor on the Green Unit Checked over by staff and 999 called and S/U taken to Royal Liverpool Hospital.” It also states, “Suspected fracture to Right Side.” Under the heading ‘Equipment in use at the time of the accident’ the following is recorded “Mobile on corridor.” Under the heading ‘How the Task was being undertaken’ it is recorded that “Mobile walking along corridor to bedroom. Under ‘Immediate cause of the accident’ it says, “Fall whilst walking lost footing whilst turning.”
21. There are two undated witness statements attached to the above form. These both say Mrs B was using a walking frame and being assisted by one member of staff to leave her armchair to go to her room to see the District Nurse. They both say it was realised the wrong service user had been called and Mrs B fell when she got to the corridor at the point of turning around whilst still using the frame and being assisted.
22. The report to the Care Quality Commission (CQC) is dated 26 July 2018 and says Mrs B suffered a fracture to her right hip in a fall in a corridor when she was with others and the matter had been reported to the HSE. The centre says in its complaint correspondence with Mrs C that it made the report to CQC on the day of the fall. At this time there had not been a report to the HSE. The CQC report states Mrs B was walking along the corridor to her bedroom when she tuned and stumbled. There is no reference to the use of a zimmer frame or being assisted.
23. The Council has also provided notes from an Occupational Therapist (OT) who witnessed the fall from a distance. These are dated the day of the fall and say Mrs B was mobilising with a staff member and wheeled zimmer frame. The notes also say a staff member reported Mrs B had lost her footing when turning around and fallen forward towards her right side and collided with the door frame. The OT noted the lower left limb was seen to be externally rotated and shortened. I understand the fracture was to Mrs B’s right hip.
24. There are clear discrepancies and an absence of detail in the recorded information about the circumstances surrounding Mrs B’s fall. I consider this to be a failure of proper record keeping by the Granby Hub and constitutes fault. There was also a failure to make a RIDDOR report to the HSE at the correct time which is further fault.
25. In its response to the Ombudsman the Council has accepted the formal reports around the fall lack detail about the specific circumstances. The Council has confirmed that following Mrs C’s complaint it has briefed all relevant managers about the quality of accident reporting both procedurally in terms of RIDDOR and around the quality of the information being included in accident reports.
26. I sought a copy of the Council’s notes from its interviews with the Unit Manager, the person who completed the accident form and the carer witness to the fall referred to in its complaint correspondence. The Council says it met the Unit Manager and carer in July 2019 to gain background information on the circumstances around the fall and to clarify gaps in information required for the response to Mrs C. The Council says there are no written notes of the meeting but the information was used to inform the Council’s response to Mrs C’s complaint.
27. 
    I am concerned as this contradicts the Council’s complaint response to Mrs C in September 2019 which refers directly to the author’s notes during her interview with the carer that witnessed the fall. This was a key meeting and I consider the Council should have ensured there was a proper record particularly given the discrepancies identified by Mrs C in her complaint. I consider this is fault by the Council.
28. I cannot say even on the balance of probabilities what happened when Mrs B fell given the contradictory nature of the records. I consider this has caused Mrs C a significant degree of uncertainty about whether the fall and its consequences were avoidable. Mrs C also had to spend a significant amount of time and trouble in trying to establish to correct course of events.

Agreed action

29. In addition to the action it has already taken, the Council will:
1. write to Mrs C to apologise and pay her £200 to recognise her uncertainty and time and trouble within one month of my final decision;
2. provide a copy of the briefing provided to all relevant staff about the quality of accident reporting both in terms of RIDDOR and around the quality of the information being included in accident reports within one month of my final decision; and
3. review its own record keeping procedures to ensure an adequate record of key meetings and interviews completed during complaint investigations is maintained within two months of my final decision.

Back to top

Final decision

30. I have completed my investigation as I have found fault by the Council but consider the agreed actions above with the actions the Council has already taken are enough to provide a suitable remedy.

Back to top

Investigator's decision on behalf of the Ombudsman