Date of decision: 23 June 2025
Summary
The complaint concerned failure by Buckland Care Ltd to implement appropriate safeguarding to protect a resident with a known very high risk of falls, resulting in physical harm, a likely premature death and significant distress to her and her family.
What happened
The resident, Mrs Y, was repeatedly assessed as being at very high risk of falls after a series of incidents in late 2023, within the care home setting.
Her mobility worsened, and she became dependent on staff, but the provider did not undertake the required bed rail risk assessments following changes to her condition or after new medication was introduced.
In early 2024, as Mrs Y started on an end-of-life care pathway, Mrs X visited and told staff that she was close to the edge of the bed and the staff moved her to her left side, noting that she was not settled. She was medicated with a new medicine to ease her agitation, but the medicine could cause restlessness. That night, she fell out of bed and was hospitalised.
Paramedics formally reported the lack of safety rails. A bed rail assessment did not occur until after her hospital discharge the next day – by which point, rails were recommended because she was now acknowledged to be bedbound – but she died later that day, three days after starting end-of-life care.
What was found
The Ombudsman found the Care Provider failed to meet statutory duties under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 regarding safe care provision and proper response to significant changes in circumstances. Multiple potential breaches of the provider’s own policy and regulatory standards were identified. Mrs Y’s injury was on the balance of probabilities, avoidable, and she needed hospital treatment, so her last days were spent in hospital, rather than remaining in the familiar care home setting. The failure to assess and act led to preventable harm, distress, and unnecessary uncertainty for the resident’s family.
The Care Provider was required to apologise and to ensure improved staff training and policy compliance.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The report makes clear the legal obligations on care providers under the Health and Social Care Act 2008 and associated Regulations to ensure safe care through proper assessment and timely adaptation of care plans. The CQC can prosecute for this sort of regulatory issue. The estate of the person who has been negligently cared for can choose to sue, if it sees any point, but this lady was on end-of-life care. The Ombudsman can fill the gap with a recommended payment for distress and injustice.
The Care Provider’s bed rails policy stated that risk assessments should be:
- Reviewed and documented after any significant change in the Resident’s condition or needs, which include a reduction or improvement in weight, and/or a reduction or improvement in mobility
- Reviewed and documented after any change of equipment for the Resident
- Reviewed as a minimum, monthly. Frequency will vary depending on the Resident and their circumstances.
The Care Provider’s bed rails policy stated that its own risk assessments should consider:
- How likely is it that the Resident would fall from their bed;
- If likely, are bed rails an appropriate solution or could the risk of falling from the bed be reduced by means other than bed rails;
- Could the use of a bed rail increase risks to the Resident’s physical or clinical condition;
- How likely is it that the Resident may attempt to climb over the bed rails;
- Has the Resident used bed rails before? Do they have a history of falling from bed, or conversely of climbing over bed rails;
- What are the Resident’s views on using bed rails;
- What configuration of bed, mattress and rail system is being used;
- Are other devices being used, which could increase risk, such as lateral turning devices.
Not following its own policy obviously led the care home into a disastrous sequence of oversights and omissions. Delay in revisiting care plans or risk assessments, especially when a resident is increasingly vulnerable, is a potential breach of regulatory standards. Relevant case law also stresses that failure to reassess and adapt care where there is evidence of new risk or a significant incident can amount to negligence in civil law terms.
The complaint also raises Mental Capacity Act 2005 issues, as sudden changes in risk or cognition demand prompt best interests consultation and proportionate risk-related decisions.
Practical consequences for non-compliance include not only distress and risk to individuals, but systemic risk for all residents and reputational damage for providers.
Streamlined care plan reviews, clear escalation protocols, and robust council oversight are critical to prevent a recurrence.
These obligations apply whether care is funded privately or publicly, and providers should ensure record-keeping, communication with families, and service improvement actions are prioritised.
The complaint was shared with the CQC in the normal way, where a breach of the regulations could be identified, ultimately, by that organisation.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Buckland Care Limited (24 014 761) 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.
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