Date of decision: 18 November 2025
Summary
Staff in a Doncaster Council commissioned care home failed to monitor symptoms, seek prompt medical advice, or record concerns from a daughter about the worry that her mother had a serious UTI, leaving the family with lasting uncertainty about whether earlier action could have prevented the woman’s hospitalisation and death.
What happened
The Council had commissioned Woodlea Residential Care Home, owned by Trust Care Ltd, to provide care for Mrs C, who moved into the Care Home in 2023 with a catheter in place to manage her toileting needs.
Woodlea had a catheter policy requiring daily monitoring for infection, immediate notification of a nurse or GP if infection was suspected, and clear recording of observations, symptoms and actions in care notes.
In February 2025, Ms X visited her mother, Mrs C, at the Care Home in the early afternoon. During the visit, Mrs C told Ms X she was in pain and suspected she had a urinary tract infection and complained that staff had not acted on her concerns. Ms X then told Care Home staff that Mrs C suspected she had a urinary tract infection; she reported this to three separate staff members within about half an hour before leaving the Care Home later that day.
Despite these reports, Mrs C’s care notes contained no record that any concern about a possible infection had been reported to staff that day.
That evening, staff recorded in Mrs C’s care notes that she said she was in pain, then noted that she ate some food, chatted with a staff member and went to sleep. The notes recorded no further concerns for the rest of that day and did not show that staff took any observations such as temperature or blood pressure, or that they sought medical advice.
The next morning, Ms X returned to the Care Home and overheard staff at the morning handover describing Mrs C as being “okay”. Ms X challenged this, saying Mrs C could not be okay if she had been in pain the previous day, but staff had not shared any concern at handover because it had not been recorded in the notes. Ms X then checked on Mrs C herself and found she was showing signs of being in pain, so she went back to staff to report this.
At that point, Mrs C’s care notes finally recorded that she was in pain and was not responding appropriately such that staff took observations including temperature and blood pressure, and then phoned a medical professional for advice. That professional was concerned that Mrs C may be in sepsis based on her symptoms, so called an ambulance. Mrs C was taken to hospital by ambulance and died there a month later.
After Mrs C’s death, Ms X’s representative, Miss G – also a relative of Mrs C – made a complaint to the Care Provider about the care commissioned by the Council. Miss G said staff had failed to act on Ms X’s concerns about Mrs C’s condition the night before she was admitted to hospital, and argued that Mrs C had been fit and well beforehand and might not have died if the Care Home had contacted a doctor promptly when Ms X first raised concerns.
The Care Provider responded, accepting several failings. It acknowledged that staff did not take Mrs C’s temperature on the day Ms X reported her concerns, even though that would have been expected under policy, and accepted that, although Ms X did tell staff about her concerns, these were not recorded in the care notes. It also accepted that, although Mrs C’s signs of discomfort were not continuous, staff should have contacted a doctor or community nurse for advice once they became aware that she was in pain, and that the failure to record Ms X’s concerns meant staff at the morning handover were unaware of this information and did not raise it.
The Care Provider said it would reflect on lessons learned and created an action plan. This included providing relevant training for staff, reminding staff about procedures when infection is suspected, reinforcing the importance of accurate record‑keeping, and carrying out reflective discussions with senior staff on how to prevent similar incidents.
What was found
The Ombudsman found the Care Home’s failures in assessment, escalation and record‑keeping caused significant distress and uncertainty to the daughter, and the Council must apologise and make a symbolic payment.
The Ombudsman also identified City of Doncaster Council as responsible for the remedy because it had commissioned the care, so the Care Provider’s actions were treated as the Council’s actions in law, because the duty to meet need appropriately had not been formally delegated to a provider, simply because it was commissioned to provide the placement.
The Ombudsman found that the Care Home breached the Care Provider’s own catheter policy; this was fault in safe care and risk management. The report cites Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which requires care providers to provide care and treatment in a safe way, by assessing and mitigating risks to the health and safety of residents and working with health professionals to ensure the health and welfare of residents. The Care Provider’s policy for residents with catheters required staff to monitor residents daily for signs of infection, to notify a nurse or GP if they identify any symptoms of infection, and to record all observations, symptoms and actions taken in the resident’s care notes.
That omission meant Mrs C was possibly put at risk of avoidable harm and left Ms X with ongoing uncertainty about whether earlier identification and treatment of the infection might have changed the outcome.
The potential breach of Regulation 17, because records were not accurate, complete or contemporaneous, which had led to those concerns not being communicated at the morning handover, possibly putting Mrs C at risk of avoidable harm and prolonging her distress. It increased Ms X’s distress when she heard staff describe Mrs C as “okay” despite her pain. This upset her because she felt staff were not acting on her concerns or providing Mrs C with the treatment she needed.
The failure to seek medical advice also contributed to Mrs C being put at risk of avoidable harm, and possibly delayed medical treatment. It also meant Ms X was left with uncertainty about whether Mrs C’s death was preventable. This uncertainty was a significant injustice.
The Ombudsman accepted that the Council could not be found, on the balance of probabilities, to have caused Mrs C’s death because there was no clinical evidence to prove causation, but concluded that Ms X suffered serious distress from witnessing the poor care and from her uncertainty about preventability. In line with the Ombudsman’s remedies guidance, the Ombudsman considered a symbolic financial payment appropriate to acknowledge this personal injustice to Ms X, rather than to Mrs C’s estate.
No further service‑improvement recommendations were required from the Home because it could evidence having taken improvement initiatives. However, as the commissioning authority, the Council was required to work with the Care Home to send Ms X an apology that met with the Ombudsman’s guidance on effective apologies and to pay her £500 to recognise the avoidable distress and uncertainty caused.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The Ombudsman’s analysis focuses mainly on breaches of provider policies and likely breaches of CQC regulations.
Public law and community care law show that a commissioning council also has responsibilities under the Care Act to ensure the duty to meet need is met appropriately, even when it has commissioned the care and a private law duty of care has arisen as between the care home and the client.
A commissioning council must still ensure that the service is adequate and safe, not merely assume that it can close the file. The report treats the provider’s action plan as sufficient remediation and does not explore whether the council’s commissioning, contract monitoring and quality assurance arrangements were themselves deficient in public law terms, for example, by failing to pick up systemic risks around catheter care, escalation and record‑keeping that could affect other residents.
The events covered by this report appear to have taken place over a relatively short period of time, but the report could have considered whether Mrs C’s Care Act care plan and risk assessments were robust enough, given a known catheter and infection risk, rather than treating the problem purely as an in‑the‑moment failure of individual staff.
The report arguably underplays the Council’s own legal duties and the possibility that delay in reassessment or in triggering an urgent review could itself be a breach of the Care Act framework.
The Ombudsman does not examine whether safeguarding duties were engaged or whether the absence of timely escalation should have been criticised as a failure of the council’s safeguarding system, not just of individual staff judgment. The remedies discussion focuses on actions improvements actions taken by the provider and on symbolic redress for Ms X rather than considering whether a more searching recommendation about safeguarding practice, clinical liaison and sepsis pathways across the Council was warranted.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s City of Doncaster Council (25 001 159) 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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