Royal Borough of Windsor and Maidenhead at fault for failing to properly consider the risks when separating a married couple of 59 years, failing to provide adequate care and failing to provide appropriate complaint responses

Decision Date: 25/08/2020

What Happened

Mr X complained on behalf of his late parents, Mr and Mrs Y. 

Mr and Mrs Y had been married for 59 years. In recent years their health had deteriorated, which led to Mrs Y receiving a care package from Bespoke, assessed by Optalis in January 2017 (from the report is seems as though this was Council commissioned, but did not explain any details, and specifically states they were assessed by Optails, rather than the Council).  

Mr Y was not assessed until August 2017, which identified that he provided some care for Mrs Y, and identified a need for ‘social inclusion’.

Mr X and his sister Ms Z, had previously provided some level of care, and continued to check in on them periodically. 

In January 2018 Mr and Mrs Y were both admitted to hospital. 

Mrs Y

Mrs Y was admitted into hospital with severe dehydration. Ms Z raised concerns with the Council about the level of care being provided by Bespoke. She said Mrs Y’s mood had deteriorated and she was refusing to drink. Ms Z did not believe care workers were prompting Mrs Y with fluids, did not stay the full time and may have fed her food which was too hot (she thought Mrs Y had a burn on her tongue).

The Council completed a safeguarding enquiry which concluded: 

  • calls were between 5 and 40 minutes. On one occasion Mr and Mrs Y missed out on a total of one and a half hours of care in one day, which the Council noted was significant
  • care logs did not record care workers prompting Mrs Y with fluids
  • care workers had not identified Mrs Y’s burnt tongue. 

As a result, Bespoke implemented a food and fluid chart to monitor intake, and agreed to complete full care time. The issue of the burnt tongue was not solved. 

The Council noted, presumably through the safeguarding enquiry assessments, that the current amount of 4 care calls a day, were not sufficient to provide care to Mrs Y, and that she needed 24 hour care. 

Mrs Y’s family highlighted to the Council that they were very interested in a live-in care worker, because a long-term care placement could have a huge negative impact on Mr and Mrs Y’s mental health, as they had been married so long. To this, the Council stated it may not be able to meet the cost of a live-in carer, and ‘discussed the possibility of combining Mr and Mrs Y’s budgets’ (the report did not go into specifics of what their budgets provided for). There were notes to show that there was a proposal to use a direct payment for both Mr and Mrs Y and fund a live-in care worker and that the family mentioned the possibility of topping up the Council funding if it was not enough.

On 12 March, a social worker emailed the operations manager giving an outline of Mr and Mrs Y’s case. She stated that “[Mrs Y] and her husband have been married for over 50 years and the importance of remaining together appears important to both [Mr and Mrs Y]. [Mrs Y] will noticeably react to her husband’s visits to her in hospital placing his face in both her hands. [Mr Y] has also noticeably declined since [Mrs Y] has not been at home, becoming withdrawn and less able to manage his personal care and nutritional needs”. 

The social worker said she had completed a care needs assessment, mental capacity assessment, and a best interests decision but said “these have not been recorded yet”. The LGO found no evidence that any of these were completed. 

The social worker said it was hoping to be able to arrange DPs for both Mr and Mrs Y, but that it would take a while to arrange, so in the meantime she asked the manager to agree to a nursing home placement for Mrs Y. 

The manager agreed, so Mrs Y was admitted to the care home. There was no evidence of a complete needs assessment. 

Late in the month, the social worker phoned Ms Z to advise that Mrs Y had settled into the care home and was eating and drinking well. They discussed a possible return home, but Ms Z was undecided, she could see that Mrs Y was benefitting from the care, but was unsure how Mr Y would cope. They agreed to wait until the family had discussed options to make a best interests decision about Mrs Y’s long term care. That same day, the Council recorded Mrs Y’s placement as permanent.

Mr Y

Three days after Mrs Y was admitted to hospital in January 2018, Mr Y was also taken to hospital, suffering from dehydration. 

When he was due to be discharged, Mr X complained to Optalis that home would not be a suitable place for Mr Y. It transpired through the LGO’s investigation that Mr Y was not assessed when discharged from hospital. 

Mr Y was discharged to his home with a care package from Bespoke, but later readmitted to hospital, and again discharged. 

In March, Mrs Y’s social worker requested a review of Mr Y’s care package, because she was aware that separating Mr and Mrs Y could have a detrimental impact on their mental and physical health. 

The review was conducted by a student social worker, who noted that there were no changes needed to his support plan, despite Ms Z highlighting that Mr Y was ‘very low’ and had not been eating or drinking since Mrs Y had been in hospital. 

In mid-March, Mrs Y moved into a care home while Mr Y remained at home. At the end of March, Mr Y was admitted to hospital with sepsis and acute kidney infection.

Mr Y was discharged home after around three weeks, following an Occupational Therapist (OT) assessment. The Council increased his package of care to four calls daily.

Mr Y was readmitted to hospital the following day. The ambulance service raised a safeguarding alert citing concerns of neglect and acts of omission. A care worker had visited and was not able to help Mr Y to mobilise as he was too weak and unstable and there were no mobility aids available. 

Mr X was unaware of this safeguarding concern, and the Council had no evidence he or the family were ever alerted. 

The social worker told Mr X that they would need to meet in the hospital and plan Mr Y’s discharge once all reports were completed and he was medically fit.

The hospital would not discharge Mr Y until an OT had visited his home to assess it and he had support in place. The OT discussed plans with the family and they said they would like Mr Y to be at home with Mrs Y because of his depression due to being away from her. They said Mr Y would end up back in hospital if discharged home without 24-hour care. The OT said she felt Mr Y’s needs could be met at home with care workers. She said she would order a hospital bed for him and do a home assessment.

Mr X wrote to the Council and said it had given no consideration to Mr and Mrs Y being married for nearly 60 years. Mr Y would spend his days sitting in the same chair all day except when care workers visited and helped him to the toilet. He asked when Mr Y would have support to visit Mrs Y.

The Council replied stating that it said it would not be appropriate for Mr Y to move into a care home, as was established through assessments. It said if the family could no longer support Mr Y there were “voluntary organisations that could help with shopping and he could pay privately for cleaning and ironing. Voluntary organisations could also provide a befriending service if Mr Y wanted company at home.”

On the 10th of May, Mr Y was discharged from hospital. The Council arranged for Carewatch to take over from Bespoke as it could not restart at the required time.

The next day, Mr X emailed the social worker to complain. He said that

  • He had visited Mr Y the night before and found him in urine-soaked clothes and pad from that morning. He had helped him to bed. 
  • A care worker from Carewatch had visited and left before Mr Y returned from hospital. 
  • Family provided him with an evening meal as he had none, and when a carer turned up at 8:20pm (40 minutes early), Mr Y had said it was too early to go to bed so was left fully clothed in his chair. 
  • The care worker stayed 10 minutes, not the required 30, and did not toilet Mr Y, left all the lights on and left Mr Y’s walking stick far from his chair. 
  • Mr Y tried to get this unaided as he had been sent home without a walking frame. 
  • Mr X said there were no food and fluid charts in place. 

The Council followed up with Carewatch about the failed visits and lack of food and fluid charts, and with the hospital to get the walking frame delivered. A social worker visited and noted Mr Y was happy to be at home. She explained to Mr Y what the care workers should do during each call and spoke to Carewatch to stress that Mr Y should be helped to bed on the last call. She asked Carewatch to arrange for the quality officer to visit Mr Y and this also took place the same day.

On 16 May, the Council completed a risk assessment for Mr Y to go and visit Mrs Y twice a week with a care worker. It agreed a total of three hours weekly for the two visits to Mrs Y

Sadly, towards the end of May, Mr Y collapsed and died in his home with a care worker present. 

The care worker called an ambulance, and called again a second time when he realised Mr Y was not breathing. When the crew arrived, they asked the care worker if he had performed CPR, but the care worker had not, as he had been told by Carewatch not to perform CPR at all. The ambulance service raised a safeguarding alert with the Council. This safeguarding investigation concluded that the allegation was not substantiated, and the LGO was satisfied that the enquiry was carried out properly. 

When the LGO enquired about the lack of Care Act assessments for Mr Y, the Council said that it had experienced high staff and management turnover. It acknowledged that it failed to assess the impact of separating Mr and Mrs Y. The Council said it had since implemented various quality measures and was working to achieve a consistent level of best practice.

What was found


The Council took seven months, from January to August 2017, to assess Mr Y’s needs in his own right. This was too long. The Council was at fault. Mr Y’s needs were not adequately met for many months putting him at an avoidable, increased risk of harm.

The LGO found no adequate assessment which properly considered Mr Y’s needs in line with the Care Act after he was admitted to hospital in January 2018. This was fault. As a result, there was no consideration of the risk to Mr Y, despite numerous concerns raised by his family. 

There was no evidence that the Council gave due consideration either to a live-in care arrangement, or a placement with Mrs Y, despite having said it would. This meant the Council could not be clear about the support Mr Y needed or that it met his needs adequately. The LGO stated that this caused Mr Y significant and undue distress and risk of harm. It also caused him actual harm, as everyone involved accepted that this contributed to his worsening condition.

There was also no evidence of the decision for Mrs Y’s residential placement to become permanent. This was fault. This caused her to be at an increased, and undue, risk of harm. Mrs Y did not have capacity to decide about her own care so a best interests decision was needed for this (although the report does not mention a capacity assessment having taken place). There was no record of a best interest decision. This was also fault.

Finally, the LGO highlighted that Mr Y’s separation from Mrs Y due to her move to the care home and the expressed concerns about this, engaged article 8 of the Human Rights Act. Again, there was no evidence that the Council considered whether it was appropriate to limit this right in the circumstances, or any consideration of their human rights at all. Failure to regard its responsibilities was fault. This fault caused significant and undue stress, frustration and outrage to Mr X and Ms Z as they repeatedly raised their concerns, as well as Mr Y because he was unable to see his wife. 

Quality of care

The care provided before January 2018 was inadequate, as it resulted in the hospitalisation of both Mr and Mrs Y. The LGO stated that the failure to provide the care as planned put Mr and Mrs Y at an increased and undue risk of harm.

Mr Y was also left without the care he needed from Carewatch. This was also fault and caused Mr Y to be at an increased and undue risk of harm.

Complaint handling 

The Council was at fault for the way it communicated with Mr X about the arrangement with Optalis and Carewatch. They failed to fully involve him in the process and keep him actively informed. Failure to do so was fault and caused Mr X significant and undue time and trouble, stress and outrage.


Unfortunately, Mrs Y had also passed away by the time this complaint was brought. 

The LGO recommended that the Council:

  • apologise to Mr X and Ms Z 
  • pay Mr X and Ms Z £750 each to recognise the distress it caused in failing to properly consider the risks of separating Mr and Mrs Y
  • pay Mr X a further £500 for the time and trouble and distress he was caused in bringing his complaint
  • review any cases where couples are separated by their care needs, to ensure the risks and human rights were fully considered for both parties. Also, that adequate contact is included on the care and support plans
  • review assessment practice across the Council to ensure it is consistent and Care Act compliant
  • ensure it has an effective mechanism for following up where complaints about poor practice have been received and to check that improvements are made and sustained
  • put in measures to ensure complaints about several agencies receive a coordinated response
  • review its commissioning practice when services are rated “Requires improvement” to ensure it considers any increased risk to people.

Points to note for the public, service users, hospital leavers, family and peer supporters, advocates, and councils etc

This complaint highlights the impact that councils can have through their failures to know their legal responsibilities and to act upon them.Mr and Mrs Y both had care needs, with Mrs Y’s needs identified and planned for initially with care at home. The quality of that care was clearly not good enough which led to safeguarding processes that also recognised the needs of Mr and Mrs Y. 

The couple had a series of hospital admissions, therefore the council knew that they had needs, yet took seven months to assess Mr Y in his own right. Here we have seen poor recording, but more importantly poor practice on the whole. This man was discharged from hospital without proper assessment of his needs and the risks of him returning home and upon readmission, the hospital helpfully refused to allow him to be discharged without an OT assessment and without an appropriate care package in place. 

Mrs Y on the other hand had hospital admissions, and was then admitted to a care home on a temporary basis. The council did engage with their family to seek a view about how they could both best be supported, however ignored the request for live-in care despite suggesting that their budgets could be combined to fund such care. The issue that many councils neglect to consider is that a person’s budget is not a couple’s budget – each person has their own budget identified through the assessment process. A person’s budget has to be sufficient to meet their outcomes, and had this council assessed Mr Y sooner, it may have been viable for their budgets to be used flexibly enough to provide them with live-in care and keep them together at home. 

The council failed in several ways including in recordings of the assessment and mental capacity assessment process. It had no records of actions claimed to be undertaken by a social worker. What it did have were the student social worker’s comments that there were no changes needed to Mr Y’s support plan despite it being evident that Mr Y had been feeling very low since he and his wife were separated by her health needs and that he had not been eating and drinking since her admission to hospital. We hope that the council will learn from this experience and ensure that both student and qualified social workers understand that such a change in presentation and activity for a person does amount to a need to revise a support plan. 

Councils are obliged to consider the person’s wishes and feelings as part of the assessment process. This situation also engaged Article 8 ECHR as the care arrangements for this couple created a separation that clearly had an impact for their right to a private family life. This couple had been married for 59 years and spent the end of their lives separated. They had been provided with two inadequate care agencies, despite the council being obliged to commission sufficient quality services for people to access care from under s.5 Care Act 2014. 

The decision-making in relation to Mrs Y’s care home placement highlights the impact that each individual decision along the way has had. The decisions pertaining to Mrs Y were as follows: 

  • that her needs were significant enough for her to require 24 hour care in a care home;
  • that the council would set up direct payments to enable Mr and Mrs Y to remain at home together with live-in care. 
  • that until these were set up it was in Mrs Y’s best interests to remain in the care home despite the separation from Mr Y and 
  • finally, that a best interests meeting was needed to determine where her needs would best be met in the long-term. 

So why, we ask, did the council record her placement as permanent on the same day it agreed a best-interests meeting was needed? It appears that this council had no real intention of enabling a person-centred approach for Mr and Mrs Y despite being very clear about the duration of their marriage and potential impact of separation.  

The involvement of the LGSCO in this complaint flags the danger of councils not being aware of or merely disregarding their legal responsibilities. Helpfully the LGSCO has suggested financial remedies, however, since Mr Y has passed away, there can be no remedy that will address the distress and anguish this couple will have experienced at the hands of the council. 

The full Local Government Ombudsman report of Windsor and Maidenhead County Council’s actions can be found here

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