Summary: There is no fault by the Council in the way it dealt with a safeguarding referral made by Mr X about carers incorrectly placing his leg in a wheelchair. There is also no fault in the way the Council responded to Mr X’s complaint about the above.

The complaint

1. Mr X complains about the way the Council dealt with a safeguarding investigation into the circumstances of an injury he sustained, which he says happened after carers incorrectly placed his leg in a wheelchair.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:

• we could not add to any previous investigation by the organisation; or
• further investigation would not lead to a different outcome. (Local Government Act 1974, section 24A(6), as amended, section 34(B)).

Back to top

What I found

Relevant legislation

3. 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.
4. Section 42 of the Care Act 2014 says a safeguarding duty applies where an adult:

• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect; and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

5. If the section 42 threshold is met, then the Council must make enquiries or cause others to do so. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by whom.

Key facts

6. Mr X is paralysed and has no feeling in his legs. He lives in his own home within an extra care housing facility. He receives care from carers based at the facility, and a different care agency. The care is arranged and funded by the Council.
7. On 16 October 2024 carers attended Mr X to undertake planned care in accordance with his care plan. As part of the care, two carers hoisted Mr X into a wheelchair. Mr X says he assumed his legs and feet were correctly positioned and secured.
8. Later the same day, Mr X caught his foot on a doorframe whilst mobilising himself in the wheelchair into another property at the facility. He heard the footplate scrape the doorframe but was not initially concerned. That evening carers attended Mr X and placed him in bed, they nor Mr X noted any issue with his leg.
9. The following day the carers noticed Mr X’s leg was swollen and suggested he go to A&E. Mr X refused. The carers recorded what they had seen and the dialogue with Mr X. The following day, Mr X contacted the care team based at the extra care facility to say he did not wish to be transferred into his chair as he had hurt his leg.
10. A district nurse arrived the following day and advised Mr X to go to hospital. She also took a photograph of the affected leg. Mr X refused to go to hospital. The district nurse and left a message for a senior carer from the extra care living facility informing her (carer) of her concerns.
11. Mr X decided to go to A&E on 20 October 2024, and his leg was found to be broken. A cast was applied, and he was discharged the following morning.
12. On 23 October 2023, one of the carers who had assisted Mr X into his wheelchair on the day in question, attended him after receiving a call from him saying a light had been left on in his bathroom and the window left open. Mr X says he pointed out his leg cast in a lightheaded friendly manner. He says the carer said she would not take responsibility for the leg and went on to be abusive. Mr X says he felt threatened by her tone.
13. A senior carer from the extra care facility took a statement from Mr X on 23 & 24th October 2024. Mr X commented he believed no-one was to blame, and that he thought his leg had been secured appropriately.
14. Mr X said it was only afterwards that he began to think this must have been the reason his foot caught on the doorframe.
15. A nurse visited Mr X on 26 October 2024 and Mr X said he believed his leg had not been secured correctly on the day of the accident. The nurse advised Mr X to report the incident. Mr X contacted the carers team leader the same morning to report the matter and report the carers response to him on 23 October 2024. A care manager and a team leader visited Mr X and took a statement. Following which, the carer in question was interviewed and denied the allegation.
16. Mr X made a referral to the Council’s safeguarding team. The team screened the complaint and made initial enquiries. I have sight of the safeguarding response document. This sets out the events and the measures/actions identified. The author of the document confirmed a referral had been made to the Council’s contracts and quality team, and that the risk to Mr X had been mitigated as the care provider had taken appropriate action in dealing with the allegations, which had been dealt with in line with HR policy. The author also noted Mr X had declined further support from safeguarding and the safeguarding investigation was subsequently closed and Mr X informed.
17. Mr X believed the investigation to be flawed, and he submitted a formal complaint to the Council. The investigating officer contacted Mr X to discuss the complaint. Notes of the meeting were recorded. The officer provided Mr X with a written complaint response on 12 November 2024. I have had sight of a copy of the letter. The officer sets out a summary of the complaint and the information she had relied on during the investigation. The officer then goes on to respond in detail to each aspect of the complaint.
18. Three aspects of the complaint were not upheld, three were found to be inconclusive and one aspect upheld. Two aspects of the complaint were upheld. The first related to Mr X’s wish that the care company take learning from the incident, and that he wanted the care team to understand his feelings/emotions when being transferred, and the importance of good communication. The second aspect upheld, related to an incorrect discharge summary from the hospital, which Mr X had contacted the hospital directly to have amended.
19. The officer concluded it was not possible to determine if Mr X’s foot had been secured appropriately, and reiterated Mr X’s expressed view, that no-one was to blame. The officer said concluded it was not possible to determine the content of any conversation Mr X had with a carer when there was no-one else present.
20. The officer confirmed she had informed the on-site care team that Mr X wished to discuss his disability and its affect, and good communication during transfers.
21. The officer confirmed the management team had identified training in paralysis for the carers who attend Mr X to increase their knowledge about paralysis and the effects this can have on the body.
22. Mr X was dissatisfied with the response. He believes the Council’s investigation to be flawed and incomplete.

Analysis

23. It is not my role to determine whether the allegations Mr X makes have any substance. My role is to determine if, following the concerns raised, the Council acted properly.
24. I have considered the process the Council followed and found no fault in its actions. It responded promptly to the safeguarding alert raised by Mr X and conducted appropriate initial enquiries. It sought the views of Mr X, and after consideration of the information available, ceased the investigation. As there was no fault in the process, I cannot criticise this decision.
25. Usually, we would expect a care provider to raise a safeguarding alert following any report of injury, but in this case, Mr X initially made no complaint, delayed seeking medical advice and, on more than one occasion said he believed no-one was to blame. Any investigation by this office now could not establish if Mr X’s leg had been appropriately secured.
26. I concur with the Council, that it is not possible to establish conversation between two people when there is no independent witness. Each person will have their own interpretation of the events and neither we, nor the Council can determine the facts.
27. Having reviewed the Council’s complaint response, I am satisfied it undertook a thorough investigation into Mr X’s complaint. It set out and responded to each aspect of the complaint and cross-referenced relevant records to support its findings.
28. Any further investigation by this office would not add to that of the Council. On that basis, I propose to discontinue the investigation.
29. Both Mr X and the Council had an opportunity to comment on a draft of this document.

Back to top

Final decision

30. There is no fault by the Council in the way it dealt with a safeguarding referral made by Mr X about carers incorrectly placing his leg in a wheelchair. There is also no fault in the way the Council responded to Mr X’s complaint about the above.
31. It is on this basis; the complaint will be closed.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman