Decision Date: 27th May 2021
What Happened
Ms B complained on behalf of herself and her late father, Mr C.
Mr C lived in extra care housing and received some support from staff there.
Ms B had numerous concerns about the care Mr C received from the staff.
In September 2018 Ms B complained that, amongst other things, staff failed to put thickeners into his drinks which were necessary due to his risk of choking.
The Council wrote to Ms B in December after it undertook a safeguarding investigation and confirmed that there had been a failure to add the thickener.
In January 2018 Ms B complained again that staff were continuing to fail to put the thickener in Mr C’s drinks.
The Council carried out another safeguarding investigation which confirmed the failure.
The Council did not tell Ms B the outcome of the investigation.
Mr C sadly passed away in February 2019.
In March, Ms B complained to the Council again about the care he had received. She noted that she had not received replies to some of her complaints. Ms B also complained about the handling of her father’s burial arrangement.
Ms B stated that she was under the impression that her sister’s grave could accommodate another burial, so had purchased a funeral plan on that basis, as her father wished to be buried there. However, the Council told her the day before her father’s funeral that this was not possible.
Ms B chased the Council for replies in June and July, to no avail. She escalated her complaint to the LGO, who referred the complaint back to the Council. At this point the Council replied to Ms B, in January 2020, setting out how it would investigate her complaints.
The Council replied to Ms B’s complaints in October 2020:
- It accepted that its investigation into Ms B’s complaints had been delayed, partly due to the COVID-19 pandemic.
- It explained how it had investigated the incident in January where Mr Y’s drink had not been thickened for a second time, and how it had taken action to prevent recurrence of such an incident. It partially upheld her complaint because it had failed to inform Ms B of the action it took at the time.
Ms B remained unhappy and complained to the LGO.
What was found
The Council was at fault for failing to tell Ms B about the outcome of the safeguarding investigation.
During its safeguarding investigations, the Council found fault twice in the provider’s failing to administer thickener to Mr C’s drinks. The manager of the accommodation had subsequently arranged for training and guidance for staff regarding the use of thickener. All staff were also asked to review Mr C’s care plan.
The Council says it investigated the complaint and a response was prepared in February 2020 but was not sent. That was where the fault lay.
The LGO stated that the actual safeguarding plan was an appropriate response, and therefore the Council was not at fault.
In regard to the funeral plot, the LGO found that the deed purchased in the 1960’s had an error on it (it could only accommodate one burial), but the Council only realised this error the day before the funeral. The LGO said that the Council should have realised earlier. The LGO did not go so far as to say this was fault.
The LGO stated that even with COVID-19 causing delays to services, the Council’s delay in responding to Ms B’s complaints were unacceptable, and therefore fault. The Council has subsequently introduced a central tracking point for complaints.
The LGO recommended that the Council pay Ms B £250 in recognition of the distress its faults caused.
Points to note for professionals, councils, people who use services and their carers, advocacy providers, members of the public
This council DID investigate the concerns raised and drew up an action plan with the provider as the risk issue in this situation could have led to serious consequences for Mr C. It’s not possible to tell from the report though, when that plan was drawn up, and if it was on the first occasion of the failure to add the thickeners, then what should have been inferred from the same thing happening again?
Of course, it might have been that the action plan was only put in place after the SECOND investigation, but one simply cannot tell and Ms B was left in the dark.
Not telling the person who has raised the safeguarding concern of the outcome is the most obvious administrative failing in safeguarding process. They are the means by which triangulation as to whether a safeguarding plan that has been put in place is actually being followed.
The Council’s responsibility as care planner and commissioner, never mind the safeguarding responsibility, is to ensure that care and support is provided in an appropriate way, but this issue reoccurred.
Where councils respond to safeguarding concerns, the Care and Support Statutory guidance requires that they keep people who use services and their carers informed of the process. Councils need to have an understanding and appreciation that family members may have significant worry and concern for their cared for person, especially where care is of poor quality.
This emphasises the need to communicate well with families and not to expect them to wait and not know the outcome of the concern they have raised for some time as happened in this complaint.
The full Local Government Ombudsman report of Sandwell Metropolitan Borough Council’s actions can be found herehttps://www.lgo.org.uk/decisions/adult-care-services/safeguarding/20-004-873