Care workers in Reading did not follow emergency procedures to ensure a vulnerable woman received the correct medical attention, the Local Government and Social Care Ombudsman has found.
The woman, who was being cared for by Reading Borough Council’s care provider, the Radis Group, was elderly and had health conditions including lung disease.
She lived alone, and received three calls a day from care workers. However, when she fell ill in July 2017, care workers failed to follow the provider’s procedures and alert her GP in a timely manner.
The woman was eventually admitted to hospital but died the next day.
Michael King, Local Government and Social Care Ombudsman, said:
“The woman in this case was clearly unwell when care workers made their visits. We cannot say whether earlier medical intervention might have resulted in a better outcome for her, but the family has been left not knowing whether their mother and grandmother might have survived had care workers acted differently.
“Councils can outsource care but they cannot outsource responsibility for that care, which is why we are finding the council at fault for the actions of the care provider.
“I’m pleased the council has accepted its responsibilities, and welcome its readiness to make the procedural changes we have recommended to try to avoid the issue reoccurring.”
The woman’s son complained to the Ombudsman when they were unhappy with the council’s investigation into his complaint.
The Ombudsman’s investigation found faults with the care provider’s actions, including that it did not follow its own emergency procedures, that workers missed a lunchtime visit, that care logs were incomplete or there were questions about their accuracy, and information was not passed on between workers.
The investigation also found the council’s safeguarding investigation was not robust enough in identifying the faults.
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 apologise to the man and discuss with him whether he wishes the council to provide a lasting tribute in memory of his mother.
The council will also pay him £100 to acknowledge the time and trouble he has had in bringing his complaint.
The Ombudsman has the power to make recommendations to improve a council or care provider’s processes for the wider public. In this case the council has agreed to ensure the care provider has trained all staff on its emergency procedures, and the procedures to follow when a service user is ill. They will also be trained on accurate and complete record keeping.
The council will also review its adult social care complaints procedure to clarify how it deals with complaints against commissioned care providers, and how it will ensure serious complaints are independently investigated.
It will also remind staff involved in adult safeguarding enquiries the importance of ensuring enquiry reports are factual and accurate.
Article date: 21 February 2019