Summary: The Council’s commissioned care provider failed to take precautions to protect the late Mrs Y’s skin integrity in accordance with her risk assessments. It also failed to seek the correct medical help promptly. The Council’s safeguarding investigation was at fault in finding the home had acted appropriately when it had gathered evidence to the contrary. The Council will now offer Mr X an apology and a sum in recognition of the distress its actions caused.

The complaint

1. Mr X (as I shall call the complainant) complains about the way the Council’s commissioned care provider failed to seek proper medical attention when his late mother Mrs Y suffered a deep laceration to her leg, despite the knowledge she was taking anti-coagulant medication. He also complains about the Council’s safeguarding investigation.

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The Ombudsman’s role and powers

2. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
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 spoke to Mr X. I considered the information provided by the Council and by Mr X. Both Mr X and the Council had the opportunity to comment on a draft of this statement and I considered their comments before I reached a final decision.

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What I found

Relevant law and guidance

6. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
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. The guidance says care providers should “use risk assessments about the health, safety and welfare of people using their service to make required adjustments. These adjustments may be to premises, equipment, staff training, processes, and practices and can affect any aspect of care and treatment.” (Regulation 12)
9. The guidance also says “the provider must actively work with others, both internally and externally, to make sure that care and treatment remains safe for people using services.” (Regulation 12)
10. The care provider’s accident policy says, “Assess the situation - does the injury require medical intervention?

Could this be in house 1st Aid, District Nurse, 111 or GP, Emergency 999. If in doubt ask advice of Senior staff on duty”

What happened

11. Mrs Y was a resident in the Hylands care home. She had dementia and many physical health problems. She was discharged from hospital back to the Hylands on 8 February after an operation. She was unable to walk or get up from a chair without assistance. She had a gangrenous foot and was prescribed anti-coagulant medication.
12. Mrs Y’s risk assessments dated 8 February note “(Mrs Y) is at risk of bleeding heavily if she was to cut or knock herself…. Staff must contact a medical professional immediately if (Mrs Y) was to knock or cut herself, even if (Mrs Y) does not appear to be bleeding heavily.”
13. On 11 February a care worker noticed Mrs Y’s leg was bleeding heavily. Mrs Y had not moved from the chair where she had sat since returning to the lounge after lunch. The care worker noted, “it was bleeding loads so we dressed it and called District Nurse out to sort it”. The District Nurse attended within the hour but was unable to stem the bleeding and called an ambulance. The ambulance arrived an hour later and took Mrs Y to hospital where the wound was dressed and she was discharged.
14. The care provider notified the adult safeguarding team about the incident and a safeguarding alert was raised.
15. A social worker visited the home on 14 February to investigate the incident. She spoke to Mrs Y who said she thought she had scratched herself on something. She noted, ‘Staff state she told them she was scratching herself when she started bleeding and think it could either be a large diamante ring she was wearing on her left hand that she was using to scratch or long finger nails’.
16. The social worker recorded that the body map and incident report were accurately completed by the care provider. She noted the ring had been removed to the home’s safe and Mrs Y’s fingernails had been filed short. She concluded the home had dealt with the incident appropriately. The safeguarding case was closed.
17. On 20 February Mr X telephoned the social worker and asked to meet. He had concerns about the care home and said he had lost trust since the incident. He said the care home had described the cut to him as a ‘skin tear’ when it was a major laceration.
18. Mrs Y died on 6 March and Mr X postponed the meeting.
19. Mr X contacted the Council again at the end of April. He wanted to know how to make a complaint. He said the home was withholding information about his mother. He said the doctor who attended his mother in hospital on 11 February told him the injury was ‘reportable’ and he wanted to know if it had been reported.
20. The Council investigated the matter further. A social care coordinator visited the care home and met senior staff. She noted they said ‘the ambulance was not initially called as they felt if the district nurse could see to it then this would be better for (Mrs Y) as they state going to hospital had always been a distressing experience for her.’
21. The care coordinator also spoke to the District Nurse who had attended Mrs Y. The District Nurse said the care home staff told her Mrs Y had suffered a skin tear. She said when she arrived at the home, she ‘found it to be a long deep wound having discussed with the staff at the time they thought the only explanation for this was that she had done with her ring but couldn't be sure. (The District Nurse) called an ambulance she struggled to stem the bleeding as she was on two lots of coagulants she recalls the lady to have poor circulation in her legs. (The District Nurse) feels they should have called an ambulance rather than the district nursing team.’
22. The care coordinator emailed Mr X in June to say she was waiting for more information and would write to him again when she could. In January 2020 Mr X emailed to ask for an update.
23. The care coordinator responded on 22 January. She reiterated that the cause of the injury was unclear. She said the care provider had called the District Nurse rather than the ambulance in the first place as they believed it would be less distressing for Mrs Y. She said the Council did not believe there was a safeguarding concern to investigate. She suggested he make a complaint to the care home as a response may give him ‘closure’ on his concerns.
24. Mr X complained to the Ombudsman. He said the idea that a frail elderly woman could inflict a 10cm-long deep laceration to her own calf was ‘nonsense’.
25. The Council says “nobody saw how (Mrs Y) injured herself, she was however, wearing a very chunky piece of costume jewellery and the staff wondered if she could have done it with this. It should be noted that (Mrs Y) was receiving treatment from the District Nurse for gangrene in her toes and she had been subject to a Dolpa [sic] test, which confirmed that she had little or no pulse in her legs and was therefore at risk of skin damage. This was also noted in both her care and risk assessments documents”. Mr X says the ring which his mother wore had no jagged edges of the sort which could inflict such a deep cut.
26. The Council says the home did not report the incident to the CQC as it was not deemed a notifiable incident. It says normally the attention of the District Nurse would have been sufficient but the medication which Mrs Y was taking “changed the usual procedure”.
27. The social worker who investigated the safeguarding alert says the care home notes showed “District Nurse came promptly and when she could not stop the bleeding an ambulance was called for immediately, therefore the home had called for medical assistance promptly.”
28. The Council says there is no evidence to suggest that Mrs Y would have been distressed by the home calling the ambulance. Mr X says she had been admitted to hospital many times before without showing signs of distress.

Analysis

29. The care provider’s risk assessment for Mrs Y shows staff were aware Mrs Y would bleed heavily if she cut herself. However, her large ring (with which staff thought she had cut herself) was not removed until after the incident, nor were her long nails filed short until then. That was a failure to act in accordance with the risk assessment.
30. The Council says there is no evidence Mrs Y would be distressed if an ambulance was called. The District Nurse says the care provider should have called an ambulance rather than for her. It was a failing on the part of the care provider not to seek appropriate medical assistance promptly for an elderly lady with a deep skin laceration who was bleeding profusely as a result of the medication she was taking.
31. The safeguarding investigator read the care home files including the risk assessment. She concluded the home had acted promptly and the safeguarding investigation was closed on her recommendation. The Council subsequently interviewed the District Nurse, after Mr X’s complaint, and heard her view that the care provider should have called an ambulance not the District Nurse team. In the light of those pieces of information it was contradictory for the Council still to conclude the care provider had acted appropriately. In my view that was fault on the part of the Council.

Agreed action

32. Within one month of my final decision the Council will discuss with the care provider how it ensures the knowledge in risk assessments is disseminated to its staff, and the way it responds to emergency incidents;
33. Within one month of my final decision the Council will review the way in which it reached its own conclusions about this incident and what other measures it should put in place as a result;
34. Within one month of my final decision the Council will apologise to Mr X for the actions of the care provider which led to a delay in Mrs Y receiving appropriate treatment;
35. Within one month of my final decision the Council will offer £500 to Mr X in recognition of the distress caused by the poor treatment of Mrs Y; it should also offer £250 in recognition of the time and trouble he was put to in making a complaint to the Ombudsman which the Council should have resolved.

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Final decision

36. There was fault on the part of the Council which caused injustice to both Mrs Y and Mr X.

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Investigator's decision on behalf of the Ombudsman