Summary: Mrs X complains the Care Provider failed to properly care for her mother, resulting in her suffering a fall which contributed to her death. We find fault by the Care Provider causing distress. We recommend it provides an apology and payment to Mrs X and that it takes further action to prevent recurrence.

The complaint

1. Mrs X complains the Care Provider failed to properly care for her mother, Mrs Y, resulting in her suffering a fall which contributed to her death. Mrs X says her mother lost confidence after the fall and became less active, remaining in bed all day.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
5. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

6. I spoke to Mrs X and I reviewed documents provided by Mrs X and the Care Provider.
7. I gave Mrs X and the Care Provider the chance to comment on a draft of this decision. I considered any comments before finalising my decision.

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What I found

Care Quality Commission

8. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.

Fundamental Standards of Care

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.

Regulation 12 safe care and treatment

10. Care and treatment must be provided in a safe way for service users. This includes:
• doing all that is reasonably practicable to mitigate any such risks;
• ensuring persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
11. CQC Guidance on Regulation 12 says providers must report incidents that affect the health, safety and welfare of service users both internally and to relevant external authorities/bodies. Competent staff must review and thoroughly investigate incidents. Staff should ensure action is taken to remedy the situation and prevent further occurrences. Staff who were involved in incidents should receive information about them and this should be shared with others to promote learning. Incidents include those that have potential for harm.

Role of a Coroner

12. The Ombudsman cannot make a finding on the cause of a person’s death. The appropriate body to investigate the cause of death if this is unclear is a Coroner. Usually doctors or police refer a case to the Coroner as and when appropriate.

What happened

13. Mrs Y lived at home and received carer visits from the Care Provider.
14. On 31 October 2020 during a carer visit, Mrs Y suffered a fall. She hurt her wrist during the fall but she did not need hospital treatment. The carer called 111 and her daughter, Mrs X, who attended.
15. On 15 November Mrs X complained to the Care Provider. She said during the visit of 31 October Carer A had forgotten to put the brake on her mother’s wheelchair. When her mother tried to transfer into the wheelchair it moved and she fell. Mrs X said Carer A was new and suggested she was overtired and not properly trained. Since the fall her mother was unable to bear weight on her wrist, limiting her independence.
16. In response, on 10 December, the Care Provider apologised for the distress the incident caused to Mrs Y. It confirmed Carer A had completed a training programme, shadowed a colleague on an earlier shift and provided care in line with Mrs Y’s care plan. Further, that Carer A had worked 5.5 hours that day with appropriate rest breaks. However, the Care Provider confirmed it would review its service, provide further training to Carer A, review care plans and risk assessments for all clients using wheelchairs and, share lessons learned with staff. It would also monitor Mrs Y’s progress over the coming weeks.
17. Mrs Y passed away on 7 January 2021.
18. Mrs X has told the Ombudsman Mrs Y’s death certificate said the main cause of death was old age and second was hypertension.
19. When I spoke to Mrs X she wanted the Care Provider to provide better training to its staff and to ensure it did not overburden new staff members.
20. In response to enquiries the Care Provider provided:
• Mrs Y’s care plans
• Carer A’s training records
• Carer A’s timesheet for the week prior to 31 October 2020
• Carer visit records dating from October 2020 to January 2021
• Records of investigation meetings held with staff in November and December 2020
• An Incident report form completed in November 2020
• Investigation summary report and outcomes
• Action plan and supporting documents
21. I have reviewed the documents provided and refer to relevant information below.
22. A care plan dated 9 June 2020 shows Mrs Y was in her 90s. She had three carer visits per day to help her with personal care, cleaning, shopping and meal preparation. The care plan says Mrs Y had recently started spending more time in bed but wanted help from a carer to use the bathroom. She could transfer herself to and from her wheelchair. However, she would like her carer to offer guidance and stay close.
23. Records of training show Carer A completed relevant training before 31 October 2020, including moving and handling training. It is not clear if the training included incident reporting or use of a wheelchair.
24. Carer visit records show Carer A visited Mrs Y at lunchtime and during the evening on 31 October. The record says during the evening visit Carer A helped Mrs Y to the bathroom and then left to tidy the kitchen until she was needed.
25. A carer visit record completed for the morning of 1 November says Mrs X was present and told the carer Mrs Y had fallen the previous evening and hurt her arm. Mrs Y said she fell while moving onto the wheelchair as the brakes were not on. The carer reported that Mrs Y was in good spirits and she helped her with tasks that day, including a bathroom visit.
26. Carer visit records from 2 November onwards show Mrs Y was feeling more fragile, needed more support and did not want to visit the bathroom. She used a commode near her bed instead.
27. On 19 November 2020 Mrs X complained to the Care Provider about the incident on 31 October. On the same date the Care Provider started an investigation and informed social services and the CQC. In its response to enquiries the Care Provider said the incident was not reported clearly when it happened and a manager first became aware on receiving Mrs X’s complaint.
28. On 19 November the Care Provider spoke to a carer to find out how Mrs Y was after the fall. They asked the carer what Mrs Y had said. The carer gave details similar to Mrs Y’s previous account. The carer told the Care Provider that Mrs Y was getting better but she was scared to go to the bathroom as that is where she fell and she no longer wanted to get up unless another person was with her.
29. On 23 November the Care Provider asked Carer A for her account of what happened on 31 October. Carer A explained she had shadowed another carer the evening before who said she should leave Mrs Y alone while she was in the bathroom. She was not told about the wheelchair brakes. She was told Mrs Y would usually call out from the bathroom when she was ready to transfer back to the wheelchair. That evening she took Mrs Y to the bathroom and asked her to call her when she needed help, then left to wash up. Carer A said she knew about the handle brakes on the wheelchair but did not leave them on. She did not think Mrs Y could get to the wheelchair alone. Carer A said she did not know about the other wheelchair brakes. Carer A said she spoke to staff at the office after the fall.
30. Carer A completed an incident report form on 23 November 2020, regarding the fall on 31 October. This says she took Mrs Y to the bathroom and was not present when she fell. It says she reported the fall to the office at the time.
31. On 4 December the Care Provider spoke to Carer B. This was because Carer A had shadowed Carer B on 30 October. Carer B explained Carer A watched her complete all tasks. Carer A watched as she took Mrs Y through to the bathroom in her wheelchair. Carer B put the brakes on the wheelchair as she always did. Mrs Y transferred to a perching stool and they left her to use the bathroom. Mrs Y called when she was finished, having transferred back into the wheelchair herself. Carer B said Mrs Y was now lacking in confidence. Although she was able to transfer to a commode herself she wanted staff to be next to her for reassurance.
32. On 4 December the Care Provider spoke to office staff. They did not recall hearing from Carer A on 31 October. Call records showed they did receive a call from Carer A that evening but they could not remember the detail of the call. They did recall speaking to another carer on 1 November who told them Mrs Y had had a fall but not that any carer was present at the time.
33. On 9 December the Care Provider visited Mrs Y and asked what happened on 31 October. Its records show Mrs Y said the brakes were not on her wheelchair. She was in the bathroom and went to sit down on her wheelchair but it rolled backwards and she fell. The Care Provider tested the wheelchair during this visit and found it moved even when the brakes were set. They told Mrs Y she would need to replace it.
34. On 10 December the Care Provider spoke to other carers. They all confirmed they checked the brakes worked on the wheelchair before use. And that they would take Mrs Y to the bathroom, set the brakes on the wheelchair, and then return when she was ready, with her having already transferred into the wheelchair.
35. On 10 December the Care Provider spoke to Carer A again about what happened on 31 October. Carer A said she had never used a wheelchair before but tried the handle brakes while shadowing Carer B on 30 October. She explained she would hold the brakes to keep the wheelchair still while Mrs Y transferred and when she let go the brakes released. She expected Mrs Y to call her when she needed to transfer. Immediately after the fall Mrs Y said she had been trying to get to her wheelchair when she fell and was unhappy with herself for not waiting for Carer A. Carer A said she saw the wheelchair was in the same position as when she left.
36. The Care Provider reviewed Mrs Y’s care plan on 10 December 2020. The updated plan says Mrs Y spends all her time in bed except for getting up to use a commode. It provides further details as to where the carer should position the wheelchair for transfers, says the carer should ensure the brakes are on, and guide Mrs Y to ensure she transfers safely. The carer should always be present during transfers. When Mrs Y uses the bathroom the carer should take her to the bathroom on the wheelchair, assist her to transfer to the commode, then leave and Mrs Y will call when she is finished and needs assistance to transfer again. However, during the review on 10 December Mrs Y said she did not currently want to use her wheelchair.
37. The carer visit records show that towards the end of December Mrs Y stopped getting out of bed, even to use the commode, as she was worried about falling.
38. The carer visit records report the Care Providers visited Mrs Y again on 23 and 29 December to check her care plan and how she was.
39. Timesheets for Carer A show she worked regular hours with breaks in the week before the incident.
40. The Care Provider completed an investigation summary and outcomes. They found the accounts of what happened on 31 October were not consistent. It was not clear if Mrs Y fell because the brakes were not applied on the wheelchair or if she fell while walking towards the wheelchair. Although call logs showed Carer A called the office on 31 October there were no written call records and the office did not remember details of the call.
41. The action plan and supporting documents show:
• Carer A completed refresher moving and handling training on 9 December.
• The Care Provider held a professional discussion with Carer A on 9 December where they discussed reporting procedures and the need to complete an incident report form immediately after an incident. They also discussed the importance of checking equipment and speaking to the office if unsure.
• The Care Provider has since carried out further spot checks and competency checks on Carer A.
• On 10 December the Care Provider reviewed and updated Mrs Y’s care plan.
• On 10 December the Care Provider carried out a risk assessment of Mrs Y’s wheelchair and advised she should get a new one as the brake was faulty.
• Carer visit records show carers were monitoring Mrs Y’s progress after the fall.
• On 23 and 29 December the Care Provider visited Mrs Y to check on her progress.
• The Care Provider checked whether it met regulatory requirements on wheelchair services. It already risk assessed equipment every six months. And carers risk assessed during each visit. No further action was required.
• Since the incident the Care Provider had added more detail to the care plans of all new clients regarding equipment use. It had also since reviewed all existing client care plans to ensure it records best practice moving and handling details.
• The Care Provider shared lessons learned with those who prepare care plans to ensure they have sufficient detail to allow carers to use the equipment safely.
• The Care Provider provided additional wheelchair training to new carers to ensure they know how to safely use a wheelchair. And it provided further moving and handling training other staff.
• The Care Provider had updated its daily on-call documents to prompt the recording of any incidents. And it updated its management meeting agenda to prompt sharing and discussion of incidents.
• The Care Provider has also engaged an external consultant to review all processes and suggest any improvements.
42. In response to a draft of this decision the Care Provider provided further evidence of its training programme. This shows Carer A’s training, prior to 31 October 2020, included incident reporting.

Findings

43. We reach findings based on the balance of probabilities. This means I do not need to be certain of what happened on 31 October, rather I must consider whether it is more likely than not that x happened rather than y. I will attach more weight to evidence recorded at the time of the incident or soon after, rather than many weeks later. This is because memories may fade with time. I will attach more weight where an account remains consistent. This is because a changing account of events means there is some uncertainty about which is accurate. And I will consider if there is any evidence that supports an account.
44. The relevant care plan said Mrs Y could manage transfers herself but a carer should offer guidance. I would therefore expect a carer to ensure Mrs Y set her wheelchair brakes during transfers or else set the brakes themselves. The evidence shows it was the carer who would usually set the brakes on the wheelchair for Mrs Y, though this level of detail was not recorded in the care plan at the time.
45. The accounts of Carer A and Mrs Y are corresponding in that on 31 October Carer A took Mrs Y to the bathroom in her wheelchair but did not ensure Mrs Y then set the brakes on the wheelchair or set them herself. The wheelchair brakes were not on. Carer A then left Mrs Y in the bathroom on a perching stool or commode. As to what happened next, Mrs Y gave an account the following day and this account has remained consistent. I have not seen any conflicting evidence and, I have no other reason to question the accuracy of Mrs Y’s account. I therefore accept, on balance, that Mrs Y fell when trying to transfer back onto the wheelchair. This happened because Carer A did not ensure the wheelchair brakes were on and so the wheelchair rolled backwards.
46. Given Carer A’s account and the evidence that she called the office on 31 October, I accept on balance that Carer A reported the incident to the office at the time. However, there is nothing to suggest the office gave Carer A any advice, such as to complete an incident reporting form. Further, no other steps were taken to investigate the incident or mitigate any further risk to Mrs Y, until Mrs X complained.
47. On the evidence seen I find the Care Provider:
• did not train Carer A how to use a wheelchair safely,
• did not ensure Mrs Y’s care plan had sufficient detail to ensure carers safely used the wheelchair,
• did not take reasonable steps to ensure Mrs Y was kept safe on 31 October,
• did not effectively train Carer A or its office staff on incident reporting,
• did not promptly carry out an investigation or take action to ensure Mrs Y’s safety and to mitigate risks.
48. I find this is a failure to meet the fundamental standards of care and is fault.
49. Mrs Y suffered a physical injury as a result. She also suffered emotionally, becoming more anxious and fearful to move around her home herself. However, I cannot say this contributed to her death. Given Mrs Y has since passed it is not possible to provide any remedy to her. However, I can consider a remedy for any injustice to Mrs Y and to prevent injustice to others in future.
50. In its complaint response the Care Provider did not acknowledge that Carer A had not set the brakes on the wheelchair or that Mrs Y had reported this as the cause of her fall. It therefore has not yet acknowledged or apologised for its failings. I will make a recommendation in this regard.
51. I consider Mrs X has suffered distress, having witnessed the impact the fall had on her mother.
52. I have taken account of the comprehensive actions already taken by the Care Provider and have made some further recommendations. However, I have not seen any evidence to suggest Carer A was overworked or overburdened and so I have not made any recommendations in this regard.

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Agreed action

53. To remedy the injustice set out above I recommend the Care Provider carry out the following actions:
54. Within one month:
• Provide Mrs X with a written apology for the fault identified at paragraph 47;
• Pay Mrs X £300 in recognition of the distress she has suffered.
55. Within three months:
• Take action to ensure carers are routinely shown or can otherwise confirm they know how to use a client’s equipment before providing any care to that client, and keep a written record of this confirmation.
• Provide all staff with further training on recording and reporting incidents.
56. The Care Provider has accepted my recommendations.

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Final decision

57. I find fault by the Care Provider causing injustice. The Care Provider has accepted my recommendations and I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman