Council pays £7,500 over failures to investigate care home injury

The Local Government Ombudsman has criticised Kent County Council for failing three times to investigate an incident which resulted in the serious injury of an elderly resident in a care home.

In a report on the matter, Ombudsman Anne Seex said that “the Council’s three failures to investigate the incident caused the man’s daughter significant injustice. She had to wait for more than a year for an answer to whether her father’s death could have been prevented. This has caused her significant distress.”

Mr B lived in a residential care home, where his care was arranged and paid for by the Council. One day he had an altercation with another resident, Mr K. Both men fell to the floor. Mr K suffered a minor head injury and Mr B a broken hip. They went into hospital by ambulance. Mr B underwent surgery but failed to regain full consciousness. He died 11 days later of pneumonia.

Mr B’s daughter, Mrs B, complained that the Council did not properly investigate how the incident came about, failed to keep her father safe, and gave her wrong information.

It took a safeguarding investigation, a complaints investigation, an internal Council investigation, and a complaint to the Ombudsman, before a second internal Council investigation properly looked at whether the incident involving Mrs B’s father could have been avoided.

The Ombudsman commended the Council’s second internal investigation, which found serious cause for concern, notably that the previous investigations had not uncovered relevant evidence or identified the home’s failure to assess the risk or manage the situation. Also, the home had not raised a safeguarding alert when it should have done, and had inadequate risk assessment and management.

The Ombudsman recommends that the Council should:

•         pay Mrs B £5,000 to recognise the injustice of her justified feeling that her father’s death could have been avoided, and distress caused during the year she waited for a credible investigation

•         pay her a further £1,000 to recognise that it was her efforts that enabled it to identify systemic weaknesses in parts of its adult care service, and

•         provide up to £1,500 for Mrs B to choose a memorial to her father.

KCC Cabinet member for Adult Social Care Graham Gibbens said: "We take our safeguarding responsibilities very seriously and always seek to deliver a high standard of service. This incident involved an altercation between two residents in a private care home and as a result of the Ombudsman report, the care home has improved its practices. We, as the local authority have taken management action, improved staff training and local safeguarding arrangements and we have learnt lessons from this case and will continue to do so." 

Neasa MacErlean