The Local Government and Social Care Ombudsman has heavily criticised Derbyshire County Council for not putting the proper safeguarding measures in place for a woman in one of its care homes before she fell and died.

The council’s initial safeguarding investigation into the dementia-sufferer’s death decided she had received a “good overall standard of care”, despite her experiencing numerous falls while living in the council-run The Grange Care Home.

During one last incident at the home in March 2016, the woman fell and broke her ribs and received serious chest injuries. She died in hospital the following month. A coroner’s inquest found she died of her injuries and failings by the council contributed to that.

The Ombudsman investigated the council’s response to the woman’s death, following a complaint by her brother. He complained the council’s investigation into her death had been inadequate, including a safeguarding investigation which found it had “no concerns” about that care, even though care home staff failed to complete care planning for her or record those falls properly.

In a report to the Care Quality Commission, produced some months later, the council acknowledged it had not implemented its safeguarding procedure correctly following the woman’s admission to hospital, and it had not followed the correct risk assessment and referral procedures during her stay at the home.

The Ombudsman’s investigation found the council missed numerous opportunities to assess and try to prevent the woman’s pattern of falls. It also criticised the council for not doing enough to monitor the woman’s nutrition, hydration and low weight – which the inquest found was a factor in her death.

The Ombudsman also found the council at fault for not keeping accurate and up-to-date records of other allegations the woman and her family made about incidents in the home.

Michael King, Local Government and Social Care Ombudsman, said:

“Our findings reinforce what the Coroner’s investigation found – that this woman’s death was avoidable. These failings were compounded when the council did not respond appropriately when it was alerted to her injuries by the hospital.

“The council conducted the most cursory of investigations, despite it being evident the woman had experienced frequent falls while in its care. The council had a duty not just to this woman, but to others living in the home, to investigate her injuries to ensure nobody else was at risk. It was only because of the brother’s persistence and the involvement of the Care Quality Commission that the council carried out a further investigation into her care.

“Since these events took place in 2016, the council has made changes to the way it manages its care of vulnerable people and put in place measures to monitor their effectiveness. However, I am publishing this report to ensure the council learns lessons about openness and transparency when mistakes happen.”

The Local Government and Social Care Ombudsman’s role is to remedy injustice and share learning from investigations to help improve public, and adult social care, services. In this case the council has agreed to give an unreserved apology to the brother and make a payment of £1,000 to a registered charity of his choice. It will also offer to pay for a memorial for the woman – such as a park bench or tree.

The Ombudsman has the power to make recommendations to improve processes for the wider public. In this case the council has agreed to make a number of changes to its record keeping and safeguarding procedures.

Article date: 16 December 2019