Summary: Ms X complained the Council failed to arrange a follow up safeguarding meeting as agreed, in relation to concerns a care home failed to call an ambulance in response to her mother’s seizures. The Council’s failure to communicate clearly with Ms X amounts to fault. This fault has caused Ms X distress and uncertainty and put her to unnecessary time and trouble.

The complaint

1. The complainant, whom I shall refer to as Ms X complained the Council failed to arrange a follow up safeguarding meeting as agreed, in relation to concerns a care home failed to call an ambulance in response to her mother’s seizures.

Back to top

The Ombudsman’s role and powers

2. 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)
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)

Back to top

How I considered this complaint

4. As part of the investigation, I have:
• considered the complaint and the documents provided by Ms X;
• made enquiries of the Council and considered the comments and documents the Council provided;
• discussed the issues with Ms X;
• Ms X and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

Back to top

What I found

5. Ms X’s mother, Mrs Y had been a self-funding resident at Care Home 1 since 2018. Ms X states she was independently mobile and independent with her personal care until she had two falls in February 2021.
6. Care Home 1’s records show that staff called Mrs Y’s GP on 17 February 2021 as she was complaining of pain in her back going down to her leg. Mrs Y was seen by an advanced paramedic the following day, and the GP arranged for an X-ray. A GP examined Mrs Y on 23 February 2021 and referred her for physiotherapy. The GP confirmed the X-ray had not reveal any abnormalities.
7. On 24 February 2021 staff at Care Home 1 found Mrs X sitting on the floor. Staff assessed Mrs Y and carried out post fall monitoring for 72 hours. Mrs X saw a GP at the home on 2 March 2021. The GP then reviewed Mrs Y’s condition on 9 March 2021 and increased her medication.
8. Ms X was unable to visit her mother at this time due to COVID-19 restrictions. She did not see her face to face until 11 March 2021. During the visit Ms X states Mrs Y was complaining of pain and she observed her having complex partial seizures. Ms X asked Care Home 1 to contact Mrs Y’s GP. She also provided videos of Mrs Y’s seizures.
9. Care Home 1’s records show they called the surgery and spoke to a GP the following day. The GP confirmed they would call back but did not. When the care home staff called the out of hours service the following day, a GP said they would not visit and the home should call 999 and send Mrs Y to hospital if necessary.
10. Mrs Y’s GP visited on 15 March 2021 and changed her medication. The surgery arranged for an X-ray on 17 March 2021. Mrs Y was then admitted to hospital with a fractured hip and had a hip replacement operation. Ms X states that Mrs Y’s seizures stopped after the operation and that she was told by hospital that the increased seizure activity was likely to be a response to the acute pain she was in. The hospital made a safeguarding referral in relation to Mrs Y’s fractured hip.
11. Mrs Y was discharged from hospital back to Care Home 1 in early April 2021. Ms X states the family were not involved in Mrs Y’s discharge planning.
12. As part of the safeguarding investigation the Council held a case conference on 9 April 2021. Ms X questioned why the care home had not called 999 after she had sent videos of Mrs Y having seizures over a 30 minute period, having been told to by the GP. She raised concerns that staff did not act professionally in not identifying the pain Mrs Y was in and failing to seek medical support in time.
13. Care home staff explained they had determined that sending Mrs Y to hospital presented a high risk of her contracting COVID-19. They would admit a resident to hospital if they had bleeding or a fracture but after consultation with the doctors and physiotherapist there was no suggestion Mrs Y met this criteria.
14. The Care home staff also confirmed they had a seizure protocol in place, which was to call an ambulance if the seizures are more than five minutes long.
15. On returning to Care Home 1 Mrs Y was not able to weight bear or mobilise in a wheelchair. She had a recliner chair with a lap belt as she was still at high risk of falls because she could now stand up. There was a Deprivation of Liberty Safeguards (DoLS) authorisation in place for this. Ms X understood the need for the lap belt but was concerned it would not work if Mrs Y could take it off. She suggested that if Mrs Y needed one to one supervision the care home should request this and suggested making an application for Continuing Healthcare (CHC) funding.
16. Care Home 1 agreed to apply for funding and Ms X and her sister agreed to pay for one to one supervision in the interim. The family also asked for a personalised seizure plan for Mrs Y as they felt the blanket procedure from the NHS was not sufficient.
17. The Chair of the meeting, Officer 1 agreed to arrange a follow up meeting in two weeks’ time.
18. Following the meeting Care Home 1 contacted the neurology epilepsy service to request an individualised focal seizure plan and made a CHC referral. At a multidisciplinary meeting on 13 April 2021 Mrs Y’s GP agreed that, pending clear guidance from the neurology service, Mrs Y would be sent to hospital if she had two episodes of seizure in a day.
19. On 23 April 2021 care home staff spoke with an epilepsy specialist nurse and the care home manager then updated Ms X. They stated the epilepsy nurse had confirmed the home had made the correct clinical assessment and decision in not sending Mrs Y to the hospital. The nurse advised the care home to continue to follow NICE guidelines and the home’s policy and procedure for seizures.
20. In late April 2021 Ms X asked for an urgent Best Interests meeting for Mrs Y as the family wanted to move her to another care home. A meeting was arranged for 4 May 2021, but the social worker advised shorty before the meeting they were unable to attend. Ms X states the social worker advised her it would be illegal for the family to move Mrs Y to a new care home without a best interest meeting.
21. Ms X contacted Officer 1 to raise concerns about the social worker and delays in the safeguarding investigation. She also noted that it was now five weeks since the safeguarding meeting and the follow up meeting had still not taken place.
22. Officer 1 apologised for the social worker’s non-attendance at the meeting, and for the social worker’s delay in sending out the safeguarding report. Officer 1 stated that as a follow up meeting had not been put in their diary, they wrongly assumed the situation had settled. Officer 1 apologised for this and explained they relied on social worker’s organising meetings for them to attend and chair. In addition, Officer 1 offered to attend the best interest meeting in the social worker’s place. They suggested the best interest meeting would be a formality as Ms X’s reasons for wanting to move Mrs Y were valid and understandable, Mrs Y was a self-funder and there was no reason not to move Mrs Y closer to her family.
23. Officer 1 also asked whether Ms X felt there was any benefit in holding a further safeguarding meeting given that she was now requesting to move Mrs Y to another home.
24. Ms X confirmed she felt a further meeting was necessary as the family had not had an adequate response to the questions they asked at the meeting regarding calling an ambulance. She asserted Care Home 1 should be able to show it had learnt from this experience and would act differently in the future but had instead simply said it had acted in line with its policy. Ms X considered there was a public interest issue as there were other vulnerable residents at Care Home 1.
25. As the Council considered the reasons for moving Mrs Y were acceptable, Ms X questioned whether a best interest meeting was necessary. Officer 1 confirmed that as the Council was not objecting to the move there was no need for a formal meeting.
26. Ms X states the new care home declined to accept Mrs Y based on a disingenuous account of Mrs Y’s presentation and needs given by Care Home 1. She then chased the NHS to complete the CHC assessment so that she could present this to the new home as a true representation of Mrs Y’s needs. The assessment was completed in June 2021.
27. In late June 2021 Ms X contacted the Care Quality Commission who forwarded her complaint regarding the safeguarding investigation to the Council. The Council’s response apologised for any misunderstanding regarding moving Mrs Y to a new care home. It confirmed it was not illegal to move Mrs Y without a formal Best Interests meeting as there was a documented and agreed decision.
28. The Council apologised for Officer 1’s comment about the follow up meeting not being put in his diary and his reliance on social workers organising meetings. It considered Officer 1 was trying to assist and support Ms X’s wish to move Mrs Y but acknowledged the explanation for the delay in arranging the meeting was clumsy and ill considered. The Council also apologised for the delay in arranging a follow up safeguarding meeting and stated this would take place in the next two weeks.
29. In relation to Ms X’s wider concerns about safeguarding a senior officer, Officer 2 had carried out an independent review and highlighted the following findings that required further follow up to ensure lessons were learnt:
• Care Home 1 failed to call 999 in relation to Mrs Y’s seizures despite advice from the out of hours doctor as it assumed there was a high risk of Mrs Y contracting COVID-19 from a hospital admission. However there was no evidence that the risks were fully weighed up, discussed or agreed with an appropriate medical practitioner before arriving at this conclusion.
• Care Home 1’s seizure protocol was not presented to the safeguarding enquiry for scrutiny. The protocol not to call an ambulance for a seizure lasting less than five minutes may not be effective in responding to certain types of seizures that are shorter than five minutes in duration but nonetheless require medical attention/ intervention.
• A lack of clarity around the discharge planning and Mrs Y’s behavioural presentation during her stay in hospital.
30. Officer 2 recommended a representative from the hospital attend the follow up safeguarding meeting and scrutiny of Care Home 1’s seizure protocol. As Care Home 1 identified a need for staff training, it should be asked to provide training in these areas and confirm this has been completed.
31. Ms X was not satisfied by the Council’s response and has asked the Ombudsman to investigate her concerns. The follow up meeting has still not taken place and Ms X is concerned that nothing has been done to address the concerns identified in the safeguarding process. Although Mrs Y moved to a new care home in August 2021, Ms X maintains there is a public interest issue in relation to the other residents.

In response to my enquiries the Council states two actions were agreed at the safeguarding meeting in April 2021:

• To address the family’s request for a personalised seizure plan and to clarify the position regarding calling an ambulance as part of a seizure response; and
• To follow up CHC funding on behalf of the family.
1. It states there was a pro-active follow up in relation to both matters. A multidisciplinary team meeting was held to agree when, pending clear guidance from the neuroscience department at the hospital, Mrs Y should be sent to hospital if she had further seizures. The neurology service subsequently confirmed Care Home 1 was correct not to call an ambulance.
2. A new social worker was allocated with the focus of progressing the CHC application. This was successful and payments were backdated.
3. The Council states that when Officer 2 scrutinised the safeguarding enquiry and made recommendations they did not have sight of the work already undertaken by Care Home 1. Officer 2 was not aware that Care Home 1 was in communication with the department for neuroscience regarding the seizure protocol and a personalised plan. Or that Care Home 1 had carried already carried out staff training. The Council states the documentation showing the issues had been addressed had not been uploaded onto its system, so they were not available to other users.
4. It states that the enquiry officer was keeping abreast of matters with Care Home 1 but was not communicating this to Ms X as the relationship between the enquiry officer and the family had broken down. The Council states that in retrospect it should not have agreed to a change in social worker as this muddied the waters and changed the focus of the work being carried out. It also prevented clear communication between Care Home 1, the Council and Mrs Y’s family.
5. The Council also acknowledges it failed to communicate with the family its assumption that all matters had been resolved so there was no purpose to a further meeting. It states that following Ms X’s complaint, Officer 1 suggested a different officer chair the follow up meeting but that due to a miscommunication the meeting did not take place. By the time this was picked up the family had moved Mrs Y to another home.
6. Officer 1 apologises that the family did not feel matters were followed up appropriately but maintains there was no evidence of intentional neglect or abuse on the part of the home’s management or care team.

Analysis

38. The Council’s failure to communicate clearly with Ms X amounts to fault. Ms X raised concerns at the safeguarding meeting on 9 April 2021 which she expected would be addressed in the follow up meeting. While the Council and Care Home 1 may have taken action to address these issues, there is no evidence the Council updated Ms X or confirmed the action taken. Ms X was clear in May 2021 that although she intended to move Mrs Y to another home, she still considered a follow up meeting was necessary. The Council responded to her query regarding the need for a Best Interests meeting but did not respond regarding the safeguarding meeting or provider any additional information.
39. This fault is compounded by the failure to ensure that all documentation was correctly uploaded and accessible to all officers. There cannot be effective scrutiny of the safeguarding enquiries unless all the relevant documentation is available. This failing meant the Council’s response to Ms X’s complaint did not accurately reflect the situation and again raised Ms X’s expectations there would be a follow up meeting.
40. There is no record of any communication between the Council and Ms X following the response to her complaint on 29 July 2021, or any explanation as to why the Council would not hold a follow up meeting before closing the safeguarding case.
41. These failings have caused Ms X distress and uncertainty and have put her to unnecessary time and trouble.

Back to top

Agreed action

42. The Council has agreed to apologise and pay Ms X £150 in recognition of the distress and uncertainty caused by the failings in the Council’s communication with Ms X in relation to the safeguarding investigation.
43. The Council should take this action within one month of the final decision on this complaint.

Back to top

Final decision

44. The Council’s failure to communicate clearly with Ms X amounts to fault. This fault has caused Ms X an injustice.

Back to top

Investigator's decision on behalf of the Ombudsman