Lancashire County Council (21 004 975)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 10 Nov 2022

The Ombudsman's final decision:

Summary: We have found fault with the Council for the actions of the care provider it commissioned. The care provider mis-medicated Mr X’s father on three occasions. This caused Mr X and his family avoidable distress. The Council has agreed to remedy this injustice.

The complaint

  1. Mr X complained on behalf of his late father, Mr Y.
  2. Mr X complained the Council did not do enough to prevent the care home staff mis-medicating his father on three occasions.

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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. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
  3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
  1. If we are satisfied with an organisation’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

  1. I have considered Mr X’s complaint and have spoken to him about it.
  2. I have also considered the Council’s response to Mr X and to my enquiries.
  3. Mr X 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

The law

The Care Act 2014

  1. The Care Act 2014 is the overarching legislation relating to council’s obligations in respect of people who have an assessed need for residential accommodation.
  2. The duty is usually discharged by a council making arrangements for the provision of accommodation in (by and large, private sector) care homes regulated by the Care Quality Commission, and in practice most complaints received by LGSCO about residential accommodation will be about elderly people in care homes, with or without nursing care.

Medication policy and procedures

  1. The Council’s medication policy and procedure regulation 12: safe care and treatment (version 3) was in place from October 2020 until January 2022. This set out the responsibilities for managers and care staff working in residential care homes in administrating and dispensing of medication.
  2. The policy states that staff administrating medicine should be Safe Handling of Medication in Health and Social Care (SHOM) trained. It also set out the processes that staff should follow when administrating medicine. This included keeping record of medication, labelling, the dosage, the times, and two members of staff signing the chart.
  3. There was specific polices for the administration of controlled drugs. It said it must be witnessed by a second member of staff and the chart must include the signatures of the two people.
  4. The policy also required the staff to inform the person and/or the person acting on their behalf if an error occurs. It also stated that if the medication that was given in error was someone else’s, then this must be recorded on their notes.
  5. In January 2022, the Council reviewed the policy and procedures and published version 4. It included an update under ‘record keeping’ which requires a ‘medication profile’ to be on the front of all Medication Administration Charts. This should include a photograph and other details specific to the residents.
  6. Under ‘administration (of medication) by staff’, text is added to state that staff must check the medication profile.
  7. The policy for the administration of controlled drugs has been amended to state that a controlled drug must be administrated by a medication trained member of the management team and witnessed by a medication trained second member of staff, and the chart must be signed by both.

What happened

  1. Mr X’s father, Mr Y was a resident at Thornton House care home.

First incident

  1. In March 2021, a care assistant accidently gave Mr Y a second dose of his daily medication within 30 minutes of his first. This caused his heart rate to lower, and he was taken to hospital for monitoring.
  2. The Council received a safeguard alert on the same day. The Council carried out a safeguarding investigation. It concluded that the staff member did not follow the care home’s risk assessment or medication policy. The carer was told she would no longer administrate medication to residents and was to retake her Safe Handling of Medication in Health and Social Care (SHOM) training and undergo competency checks.
  3. The Council closed the case as it considered the care provider had taken appropriate measures in reducing the risk of recurrence.

Further incidents

  1. In June 2021, a carer administrated another resident’s medication to Mr Y. The care manager contacted 111 and was advised to monitor Mr Y for adverse effects. The care notes stated that Mr Y appeared drowsy but otherwise unaffected.
  2. The Council received a safeguarding alert the next day. During the Council’s investigation, 3 days after the first medication error, Mr Y was given the wrong medication again.
  3. Sadly, Mr Y passed away later that day. The coroner advised Mr Y’s death had been determined as being from natural causes.
  4. The Council’s investigation concluded that two staff members had not followed the home’s medication policy and procedures and had falsified medication records.


  1. The Council confirmed that disciplinary investigations were undertaken following the maladministration of medication to Mr Y. The staff members were investigated on the grounds they circumvented the medication policy and administered medication singlehandedly rather than with a second staff member. It was also alleged they signed for a counter signatory who wasn't present at administration.
  2. The investigations found there was evidence to substantiate the allegations. Disciplinary hearings were carried out where all allegations were upheld and both staff were dismissed with immediate effect.
  3. At Thornton House:
    • all staff have been retrained in Safe Handling of Medication,
    • all charts reviewed,
    • senior managers, not carers are now responsible for administrating all controlled drugs,
    • learning points from the enquiry/investigation have been shared with staff and the management team, and
    • hand over arrangements have been reviewed and strengthened.

My findings

  1. I have found the Council commissioned care provider at fault for failing to administer medication to Mr Y in accordance with the Council’s medication policy and procedure. This resulted in Mr Y receiving a double dose of his medication in March 2021, and someone else’s medication on two occasions in June 2021.
  2. Although the coroner concluded the mis-medication did not cause Mr Y’s death, the uncertainty and distress caused Mr Y’s family an injustice. They believed Mr Y was in a safe place at Thornton House. The discovery of the care staff’s failure to follow procedure and the falsification of records caused additional avoidable distress during a time when the family was grieving Mr Y’s passing.
  3. The Council commissioned Mr Y’s care services from Thornton House, therefore, I have treated the care staff’s actions as if they were the Council actions. My recommendation reflects this.
  4. From the evidence I have seen, the Council has updated its medication policy and has put other measures in place to prevent medication errors happening in the future. I have recommended the Council monitor Thornton House over the next 3 months and provide us with records showing any medication errors during this time.

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Agreed action

  1. Within 4 weeks of my decision, the Council has agreed to:
      1. Apologise to Mr X and his family for the care home’s failure to follow medication policy and the distress this caused.
      2. Pay Mr X £500 for the avoidable distress caused to Mr Y’s family as a result of the Council commissioned care provider’s actions.
  2. Within 12 weeks of my decision, the Council should:
      1. Provide a record of any medication errors that have occurred at Thornton House during this time.

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Final decision

  1. I have completed my investigation. The Council commissioned care provider was at fault for not following medication policy and falsifying records.

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Investigator's decision on behalf of the Ombudsman

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