Decision Date: 27 August 2024
Summary
Ms D submitted a complaint, arguing that there were faults in the Council’s safeguarding investigation into the bruising her mother, Mrs X, sustained whilst in a care home. She believed the Council’s oversights in Mrs X’s case may have left her in an unsafe environment and this caused the family distress and frustration.
What happened
In 2022, Mrs X, was living in a care home and with a diagnosis of dementia. In September she went into hospital for a short time and returned to the facility. Three days after her discharge, the home raised a report to the Council that it found bruising in three places on Mrs X’s body.
The home stated that it had checked Mrs. X after her return from the hospital and noticed bruising and provided photos. However, the home claimed the hospital had not disclosed any information about the bruising. The hospital discharge letter had no record of any bruising, leading to initial confusion over whether the injuries occurred at the hospital or in the care home.
The Council began a safeguarding inquiry, reaching out to both the hospital and the care home to gather further records and body maps. However, Ms D, Mrs X’s daughter and representative, felt the Council failed to keep her informed or involve her sufficiently in the investigation.
In October, Ms D said she saw another bruise on Mrs X’s knee which was causing her pain, but when she mentioned it to the care home, no one had noticed it or knew how it occurred. In late October, Ms D removed Mrs X from the care home due to concerns for her safety.
In late November, the safeguarding officer noted that the care home couldn’t prove the photos were taken on the day Mrs X was discharged, suggesting they were taken three days later. He also observed that the body map provided by the care home was delayed. The Council then decided to convene a meeting of relevant professionals and representatives.
In January 2023, Ms D still had not heard from the Council and emailed expressing concerns about the delay in the proposed meeting. It appears the Council did not respond to her email or follow up these concerns.
In March, the safeguarding meeting chair contacted Ms D, which was the first time she was informed of the three-day delay between Mrs X’s discharge from the hospital and the care home, reporting the injury even though they had found the bruising on the day she was discharged.
On 30 March, the Council held a safeguarding conference, which Ms D attended. The Council concluded the bruising likely occurred in the care home. The concern of neglect or omission was substantiated, but allegations of physical or sexual abuse were unsubstantiated.
The Council identified actions for the home, including reviewing its bruising policy, improving record-keeping, and enhancing communication between staff and family.
The Council concluded its safeguarding investigation in March 2023, but did not send Ms D the conference minutes until May 2023. In July 2023, Ms D complained about delays and the Council’s failure to follow its own policy. She also claimed the Council did not involve her as Mrs X’s representative or fully assess whether Mrs X remained at risk.
In August 2023, the Council partly upheld Ms D’s complaint. It said it initially focused on the injury occurring in the hospital, but later found it happened in the home after Mrs X had moved out to live with Ms D.
The Council did not believe the injury was caused by assault. It acknowledged a delay in contacting Ms D and agreed it should have communicated better about the strategy meeting, which it typically handles through individual meetings rather than one formal session. The Council accepted there were delays in identifying the cause of the injuries and liaising with the family, hospital, and care home. It also agreed there was an unacceptable delay in arranging the conference, which Ms D had requested for early February but which only took place on 30 March.
Ms D complained that the Council’s own response did not address how the injuries occurred or consult medical experts.
She also believed the Council prematurely accepted the care home’s inconsistent information and failed to properly assess the risk. Ms D felt the delays left Mrs X potentially unsafe and that she wasn’t given full information until just before the conference, which hindered her in representing her mother.
In response, the Council said it consulted medical professionals but did not receive specific opinions. It agreed it could have asked more targeted questions about the bruising and would instruct the safeguarding team to do so in the future. The Council acknowledged delays in changing its view on where the injury occurred, due in part to workload pressures, and apologised for not following up with the care home or contacting Ms D more promptly.
The Council noted the hospital’s recent information suggesting the bruising was caused by medication but explained that without clarity on how the bruising occurred, it was hard to assess risk or take preventive action.
What was found
Hertfordshire County Council was found at fault for delays and inadequate family communication during a safeguarding inquiry regarding Mrs X’s care home injuries. The investigation highlighted the distress and uncertainty Ms D experienced due to procedural lapses and poor engagement with the family.
As a remedy, the Council agreed to formally apologise to Ms D in line with its apology guidelines and pay her £200 to acknowledge the impact.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The report centres on a vulnerable adult who was left at risk of harm due to the local authority’s failure to respond to safeguarding concerns in a timely and effective manner. Despite evidence of neglect and potential harm to the individual, the Council’s actions were slow and lacked sufficient follow-through.
The Ombudsman made a series of findings which were effectively criticisms of the investigative and forensic instincts and pace and questioning acumen of the social work staff – essential aspects of a good safeguarding system.
Local authorities should act quickly when safeguarding concerns are raised, especially in situations where a person is vulnerable and at immediate risk of harm. Professionals should be trained to recognise early signs of risk and follow statutory procedures to assess and intervene promptly, in line with the Care Act 2014.
The LGSCO found that the Council’s risk assessment and care planning processes were inadequate. The individual’s care needs were not properly assessed, and risks were not mitigated in a person-centred manner. There was also a failure to review the care plan considering new safeguarding concerns that emerged during the investigation.
Risk assessments must be comprehensive and updated regularly. The failure to consider a person’s evolving needs or consider emerging safeguarding concerns was a major shortcoming in this case. Councils should ensure care plans are reviewed regularly and whenever new safeguarding risks arise.
Another significant issue was the delay in the Council’s response. After concerns were raised about the individual’s care, the local authority took months to follow through on safeguarding actions and failed to maintain clear communication with the individual’s family and care providers. Timeliness and communication are crucial when addressing safeguarding concerns. The Council’s failure to inform the family or involve them in discussions about the care plan further exacerbated the situation.
The ruling highlights the importance of service users and their families or carers being actively involved in care planning and safeguarding processes. Moreover, the failure to engage the individual’s family in the decision-making process contributed to the breakdown in safeguarding due process, as their insights were crucial to understanding the person’s needs and vulnerabilities.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Hertfordshire County Council (23 013 598) report.
If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
Did you enjoy this analysis? Want to stay informed with our weekly Alert Service?
Then do click here to find out how you can receive the latest insights from experts and commentators and stay updated on key judicial decisions, ombudsmen’s reports, and critical law and policy changes, all for just £50 per YEAR and sent straight to your inbox or WhatsApp!