Summary: The Council’s commissioned care provider (Regional Care) failed to contact the late Mrs X’s family or summon medical help in good time. The care worker acted unprofessionally and reacted hysterically to the news of Mrs X’s death which caused additional distress to Mrs X’s family. The Council has taken steps in line with its procedure and the care provider currently is suspended from taking new service users. In addition the Council will now offer Mrs X’s children, the complainants, £1500 each in recognition of the distress they suffered as a consequence of the care provider’s actions.

The complaint

1. Mrs A (as I shall call her), her two sisters - Ms B and Ms T – and her brother Mr K complain that the care provider commissioned by the Council failed to alert them to Mrs X’s deteriorating health and did not contact medical help. When they told the carer Mrs X had died, she responded inappropriately by screaming and falling into hysterics, causing additional significant distress to Mrs A and her family.

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The Ombudsman’s role and powers

2. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
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 considered the information provided by Mrs A and the Council. I spoke to Mrs A. Both Mrs A and the Council had an opportunity to comment on an earlier draft statement and I considered their comments before I reached a final decision.

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What I found

Relevant law and guidance

7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
8. Regulation 9 says the care of service uses must be appropriate, meet their needs and be person-centred.
9. Regulation 13 says service users must be safeguarded from abuse or improper treatment, including ‘significant disregard of the needs of the service user for care or treatment’.
10. Regulation 17 says care providers must maintain a contemporaneous, accurate, legible and comprehensive record of care and treatment for each service user.
11. The Council has a ‘provider of concern’ procedure which is implemented in cases of significant concern.

What happened

12. Mrs X lived on her own. She had a number of medical conditions. The Council commissioned care from Regional Care to support her. The care plan stipulated two care calls a day to assist with personal care and dressing /undressing. The care plan says, ‘When carers notice any concern they should report to the office or contact the emergency service for help.’ Ms B was named as the principal contact in case of an emergency.
13. On 6 January Ms B telephoned Mrs X. Mrs X told her the carers had been to see her as usual. She said she was in pain and Ms B told her to ring for help (Ms B could not visit as members of her family had Covid 19 at the time). Mrs A says her mother’s phone logs show Mrs X telephoned 111 and her own GP in the early hours of 7 January.
14. On 7 January Ms B rang her mother again: Mrs X now said she had been in bed with pain for two days. She said the carers had just told her to let them know if she needed anything. There was a message on Mrs X’s phone from the carer saying she hoped Mrs X felt better.
15. On 8 January carers visited Mrs X for the usual morning call. Ms B telephoned Mrs X several times but without being able to get a response. When she finally spoke to Mrs X, Mrs X said she was in a lot of pain in her stomach and back and could not get out of bed. She said she was upset because she could not contact anyone for help. Ms B persuaded her mother to call 111 again. Mrs X called 111 again and an ambulance took her to hospital that afternoon. Mrs A says there are several missed calls from the carer on Mrs X’s phone, and a voicemail message from her saying not to worry about the cat, as the other carer would feed him.
16. There were three more telephone calls from the carer to Mrs X on 10 January: Mrs A says these went unanswered as by now Mrs X was in ICU and heavily sedated.
17. Sadly Mrs X died in the early hours of 11 January.
18. Later on 11 January the carer rang Mrs X’s mobile phone again and Ms B answered it. She says when she told the carer Mrs X had died, the carer screamed and said she would be there in 5 minutes.
19. The carer arrived at Mrs X’s bungalow shortly afterwards. Mrs A says the carer ‘let herself into the property where she began banging on the wall first by the bathroom near the front door screaming and wailing, She then ran into mum's bedroom and started picking up mum's clothes hugging them and then flopped to the floor still wailing and crying. All we could do was just stand and stare at Her...This went on for about 20 minutes until we had to tell (the carer) we had to go out and sort things out. We were on our way to the funeral directors’.
20. Mrs A says the carer told them Mrs X had been unable to walk properly on 6 January and had been in a lot of pain for several days. The carer said she should have called the doctor or Ms B.
21. The carers’ notes for the period 6 January to 8 January repeated a variation on the notes for many days previously. The notes say, ‘When I arrive at (Mrs X’s) I knock on the door and I let myself in. I had a chat with her. Then I wore her (sic) clean clothes and I empty the bin. No further care needed’. In none of the entries for the period 6 to 8 January does either carer mention Mrs X was in pain. Although there were two different carers providing care, the notes are all in the same handwriting.
22. Mrs A says she understood from what the carer said that she had taken home Mrs X’s cat, and that her mother had given the carer a gift for her children at least once.

The complaint

23. Mrs A and her siblings complained to the care provider on 26 January. They said they were extremely unhappy with the care given to Mrs X and they wanted to know why the carer had not contacted Ms B or the doctor when she knew Mrs X was in considerable pain and had been in bed for some days. They said they were also extremely distressed by the ‘insensitive performance’ the carer had put on in front of them when she found out Mrs X had died.
24. The care provider replied. The quality manager said the carer did not think Mrs X was suffering a lot of pain and so had not contacted Ms B or the doctor. In response to the point that the carer had told Mrs A she knew she should have called a doctor, the quality manager said, “this was because she wished she had done more but not because she was incompetent’. He said the carer’s response when told of Mrs X’s death was because she was shocked by the news. He acknowledged it was unprofessional. He said the carer should have told the office about Mrs X’s ill health but instead had told Mrs X to contact the office herself. He said she had been disciplined.
25. Mrs A complained to the Ombudsman on behalf of herself and her siblings.
26. There was a multi-agency safeguarding investigation following Mrs X’s death. The Council says, “Following this concern, the contracts team began a full investigation, as well as investigating two complaints made against Regional Care. The investigation took place between the months of February and April 2022 and concluded at the end of April 2022. Following the investigation into the complaint the following themes were identified:

• Late, missed and short calls

• Management infrastructure to support delivery and oversight of care

• Record keeping

• Audits and assurance

• Lack of support from the nominated individual

• No registered manager in post”

27. The Council says Regional Care is currently on a full suspension and is unable to take on any new packages of care.

Analysis

28. The care provider did not act properly on seeing Mrs X’s signs of pain and failed to call medical attention promptly enough, although it is not possible to say that might have led to a different outcome.
29. The care provider failed to produce records in line with the regulations. It is clear carers were simply repeating a formula by rote.
30. The carer acted in an exceptionally unprofessional manner. Her response to the news of Mrs X’s death was personally shocking and distressing for Mrs X’s family.
31. The Council commissioned the care provider and so remains responsible for its actions.

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Agreed action

32. The Council has taken the appropriate action towards improvement of the care providers’ services so I do not have any further recommendations there;
33. It is not possible to say whether prompt medical help might have led to a different outcome but Mrs X’s family are left with that uncertainty. Within one month of my final decision the Council agrees to offer Mrs A, Ms B, Ms T and Mr K £1500 each in recognition of the distress caused to them by the actions of the care provider.

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Final decision

34. I have completed this investigation on the basis that the actions of the Council’s commissioned care provider caused injustice to Mrs X’s family.

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Investigator's decision on behalf of the Ombudsman