The Ombudsman's final decision:
Summary: Mr C complains the Care Provider failed to keep his late mother safe causing a harmful impact on her health and distress to her family. We have found fault by the Care Provider in failing to ensure a protocol put in place was both adequate and robustly followed but consider the agreed action of an apology and payment provides a suitable remedy.
- The complainant, whom I shall refer to as Mr C, complains the Care Provider failed to keep his late mother (Mrs X) safe as another resident attacked Mrs X in her room and failed to put in place adequate measures to protect her after the incident.
- Mr C says because of the Care Provider’s fault, his mother suffered a harmful impact on her welfare and mental health which also caused her family distress.
The Ombudsman’s role and powers
- We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
- If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
- We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
- their personal representative (if they have one), or
- someone we consider to be suitable.
(Local Government Act 1974, section 26A(2), as amended)
- If we are satisfied with a care provider’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)
How I considered this complaint
- I read the papers provided by Mr C and discussed the complaint with him. I have considered the Care Provider’s response and information it provided.
- I have explained my draft decision to Mr C and the Care Provider and provided an opportunity for comment.
What I found
- On 4 July 2021, another care home resident entered Mrs X’s room. The detailed daily care notes recorded that a care worker heard Mrs X shouting and on entering the room found her on the floor with another resident standing over her holding on to her right wrist. It was noted that Mrs X was very distressed and said the other resident had pulled her from the bed. The care worker saw a raised bruise on Mrs X’s right wrist and sought medical advice. Care workers checked on Mrs X throughout the night and contacted the family about the incident. A family member took Mrs X to hospital the following morning for an x-ray which found no broken bones.
- The Care Provider notified the Council’s Safeguarding team and the Care Quality Commission about the incident and put in place a protocol to prevent further contact between Mrs X and the other resident. This protocol is dated 7 July and set out that Mrs X and the other resident were to be separated at all times and not to be in the same lounge or communal area. The other resident was to be checked every 15 minutes by a designated care assistant and was to have his behaviour monitored by the senior on duty. Mrs X’s bedroom door was to be locked at all times when she was in the room to maintain her safety.
- Mrs X’s family wrote to the Care Provider on 9 July to complain about the incident and that the other resident had since been allowed access to their mother and was not being properly supervised.
- The Care Provider wrote to Mrs X’s family on 9 July to confirm it had made a safeguarding referral and would also complete its own investigation into what had happened and explained the above protocol. The Care Provider confirmed Mrs X would use the garden lounge which had an allocated carer to provide reassurance and the other resident would be removed from the area for family visits to reduce stress and anxiety. The Care Provider confirmed Mrs X’s room would be locked at night but all carers carried a pass key and Mrs X had been given a personal pendant alarm.
- Mrs X’s family moved her to another care home on 15 July.
- The Care Provider completed its investigation and produced a report dated 1 August. This noted the other resident was an emergency respite admission but at the time of the incident was in the process of becoming a permanent resident. The investigation considered information from Mrs X, relevant staff, statements provided to the police and the care notes.
- The Council’s safeguarding outcome is dated 16 September. This found that another resident did enter Mrs X’s room on 4 July and pulled her from her bed and across the room by the wrist. The bedroom door was not locked as this was Mrs X’s preference and there was no evidence of any earlier risk discussions with Mrs X about the possible risks to her if the room was not locked at night. However, it was also found that there was no previous history of assault by the other resident who did not appear to require one-to-one care or extensive observation when the care home accepted him. It was noted there had been a verbal disagreement with another resident on 1 July but this was very different to the incident with Mrs X. It also found that a care worker had assured Mrs X’s family the other resident would be kept away from her. However, the following day Mrs X told her daughter that the resident had stood by her door without a staff member. The care worker initially denied this was the case but it later became apparent that the resident had been allowed to go to the toilet unaccompanied and Mrs X could have seen him near her door. Although it was noted the delay was due to busy staff dealing with other residents this was found to be a concerning oversight given the distress and immediate risk presented to Mrs X. It was also found that on 6 July the resident was sitting in the same room as Mrs X and stood up and exposed himself. There was a care worker with the resident who took quick action to deal with the situation. The care manager advised the resident’s social worker that they were unable to safely meet his needs due to his behaviour.
- The Council noted the action taken by the Care Provider to minimise the risk of a similar incident reoccurring. This included agreeing with Mrs X to lock her door at night to give her added security as only staff who all held a master key could enter her room. There was also a door alarm so Mrs X did not have to put the catch down. The home provided Mrs X a personal assistance alarm to allow her to call for help if needed. The Care Provider updated the care plans for both Mrs X and the other resident. The Care Provider liaised with the other resident’s social worker to find an alternative placement as it had become clear he required an environment where his needs could be met and the risks to himself and others could be managed. Staff were told of the need to monitor any potential triggers for any resident and inform the senior carer and document in the care plan which may lead to an unexpected reaction and behaviour. The Council decided no further action was necessary.
- The Care Provider wrote to Mrs X’s family on 21 September following the outcome of the Safeguarding investigation. The Care Provider expressed regret for the incident causing Mrs X harm and distress.
- I have seen no evidence that the original incident could reasonably have been prevented based on the information available to the Care Provider at the time. The Care Provider took action to try and prevent any future incidents and made the required notifications. I see no fault here.
- However, it is regrettable that there were two further incidents shortly afterwards when the same resident was allowed in close proximity to Mrs C. Although it is accepted that a busy care environment cannot guarantee such incidents could never happen, I would expect particular care and attention to have been paid in the days immediately after the original incident given the potential risk to Mrs X. On balance, I consider this constitutes fault.
- Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a token payment to them as a remedy for their own distress.
- While the Care Provider’s fault above has left Mrs X’s family feeling let down and distressed about the protection their mother received, I cannot say if this contributed to the deterioration in her health or untimely death. As Mr C’s mother has died, it is not possible to remedy the injustice caused to her. However, it is possible to remedy the injustice to Mr C for the avoidable distress and uncertainty he has been caused by the Care Provider’s failure to ensure the protocol was adequate to prevent contact between Mrs X and the other resident or that it was robustly followed.
- I am satisfied Mr C has experienced distress and uncertainty from these failures, including for the time and trouble he has been put through in pursuing the complaint.
- The Care Provider will within one month of my final decision:
- apologise to Mr C for its failure to ensure the protocol put in place to prevent contact between Mrs X and the other resident was both adequate and robustly followed; and
- pay Mr C £250 in recognition of his avoidable distress and time and trouble.
- I have completed my investigation as I have found fault but consider the agreed actions above provide a suitable remedy for the injustice.
Investigator's decision on behalf of the Ombudsman