Oxfordshire Council apologises after ‘chaotic’ safeguarding investigation - it's failings really are pandemic

Oxfordshire council and a local care home both failed to conduct adequate investigations into the care of a woman with dementia, Ombudsman finds 

Oxfordshire council has apologised after coming under heavy criticism for a ‘chaotic’ safeguarding inquiry into the care of a woman with dementia.

The Local Government Ombudsman found the council took 14 weeks to chase up a safeguarding report from the woman’s care home and failed to properly challenge the care provider’s version of events.

The local authority also failed to involve the woman’s husband in its investigation and did not notify agencies that it had concluded the claims of neglect were partially substantiated.

The council has apologised to the woman’s husband and paid him £750 for his distress.

The care provider was also investigated and found to have provided inadequate care to the woman. It is yet to accept the ombudsman’s recommendations.

‘No action’

The woman had advanced dementia and was unable to say she was hungry or thirsty. She was admitted to hospital with severe dehydration after a week-long respite stay at Huntercombe Hall in Henley-on-Thames. She died a week after being discharged.

Hospital staff made a safeguarding referral to the council during the three weeks the woman was in their care. Her husband also complained to the provider about his wife’s care. He said she was less responsive, limp, dehydrated and had oral thrush after her stay at the home.

The ombudsman found that despite responding promptly to the safeguarding alert, the council’s actions and decisions later became ‘contradictory and somewhat chaotic’.

The council asked the care home to investigate the matter and provide a report by 16 April 2014. The care home failed to meet the deadline or respond to a reminder.

The ombudsman criticised the council for taking no action to chase this up. Fourteen weeks after receiving the initial alert, the council emailed the home to say it would close and uphold the complaint if the report was not received.

This was inappropriate and contrary to government guidance on safeguarding and the council’s own policy, the ombudsman found.

‘Incomplete paperwork’

After receiving the report, the council then appeared to take “no action whatsoever”.

“It appears the matter never progressed beyond the initial investigation stage. Much of the paperwork is incomplete,” the ombudsman’s report said.

The care home’s report stated there was no deterioration in the woman’s condition during her stay, but the ombudsman found she was clearly unwell within a few hours of leaving the home.

The council appeared to accept the care home’s version of events and told the husband that the safeguarding alert would be closed because charts from the care home showed his wife had been offered fluids but staff found it difficult to encourage her to drink. The charts did not support this finding, the ombudsman found.

The council closed its assessment and recorded a finding of ‘neglect – partially substantiated’, but there are no records to show this information was shared with the care home, the woman’s husband or the council’s monitoring department.

The ombudsman said the council had merely repeated the version of events given by the care home and did not “recognise the inconsistency in the care provider’s records for the woman and an account given by the GP who saw her on the day she left the home”.

The report added that the council had failed to involve the husband throughout its investigation and had denied him a truthful outcome to his complaint. “He has also suffered the stress and anxiety of pursuing this complaint, which has impacted on his grief at losing his wife,” it said.

John Jackson, director of adult social services at Oxfordshire council, said: “The way we handled this case was very disappointing. We have not hesitated to apologise.

“As the ombudsman has acknowledged, we have implemented robust and extensive improvements to procedures, even though at the time this was an isolated case of poor practice and in no way systemic or representative of the general standards to which we operated in 2014 or now.”

Care provider investigation

An investigation by the ombudsman into the care home provider found:

• The home did not provide the woman’s husband with a written response to his complaint until nine months after it was made.
• The food and fluid records at the home were incomplete and did not support the claims made by the provider that the woman had been offered this and declined.
• The care home failed to provide the woman with adequate care during her stay and this amounted to partial neglect.

The care home has yet to accept the recommendations of the ombudsman to provide a full written apology to the husband and waive the full fee for his wife’s stay at the care home.

Jane Martin, the Local Government Ombudsman, said: “While nothing can make up for the loss of a loved one, I hope my investigation will give this woman’s family some reassurance that lessons have been learnt and other vulnerable adults will not have the same experience.

“Neither the care provider nor the council’s investigations were up to the standard I expect, and failed to give the family proper answers as to what went wrong. Organisations can only learn from events like these if they conduct thorough and searching investigations.

“I welcome the significant steps Oxfordshire council has already taken to improve its policies, procedures and staff training in this area and am pleased it has agreed to my further recommendations. I now call on the care provider to reflect on my report and implement the remedies I have recommended.”