02:14PM, Wednesday 05 May 2021
‘Injustice’ was caused to a man found in his ‘soiled bed’ after the Royal Borough made safeguarding failings, an investigation concluded.
The Local Government Ombudsman found ‘inadequate care’ was provided by an agency commissioned by the council to a resident, known as Mr C, and the provider failed to raise his repeated pressure sores he suffered following discharges from hospital to the local authority.
They also found the council was at fault for not properly completing two safeguarding enquiries into the issue.
The council’s care plan for Mr C was deemed ‘unsafe’ and ‘did not meet his needs’ as it commissioned the agency to provide four care calls a day, each involving two care staff.
Mr C, who passed away in January 2019 from sepsis, was ‘entirely reliant’ on care workers for all his needs as he was an elderly man who was bedbound and unable to move his lower part of his body.
His ex-wife, Ms B, said two years before his death, he had several hospital admissions because of pressure sores, which would then heal when he was in hospital but deteriorate again when he was at home.
Following a hospital admission in July 2018, the district nursing team, hospital, and ambulance all separately made safeguarding referrals to the council due to the pressure sores, there not being enough food in the house, and findings that the agency weren’t providing the appropriate care.
While a safeguarding enquiry meeting was held in September 2018, the Ombudsman found this wasn’t completed.
In terms of Mr C’s care plan, the council proposed a care plan with six calls a days to check on him, but later changed it to five when it was implemented.
The Ombudsman couldn’t find an explanation as to why it was changed to five.
This was later changed to four calls by Mr C as he declined the fifth call of the day, saying he had never had a fifth call, he refused to pay for it, and it was not needed due to him having a mattress that minimised pressure sore risk.
After Mr C was admitted again in December 2018, another safeguarding referral was submitted after the tissue viability nurse found him in a wet soiled pad with build-up of thick filth in the groin’.
The ambulance crew also found Mr C in bed with soiled bedsheets. Mr C said the carers came to his house ‘very late’ in the morning, spent four minutes within the house, and did not leave him with basics such as water.
Ms B added he was left without care for 15 hours over Christmas as one of the carers didn’t show up.
The Ombudsman found the Royal Borough at fault and said it caused ‘injustice’ to the elderly man.
The council has apologised to Mr C’s family in acknowledgment of its fault and pay £1,000 for the distress caused.
It pledged to strengthen its quality assurance process and panel procedure for approving care packages, while also introducing a framework for managing people with complex needs, including those who refuse care.
A spokesperson said: “We recognise the findings in this report and have apologised to the family involved. We are pleased that the Ombudsman stated we had already implemented a number of service improvements as a result of the complaint and did not recommend any other service improvements.”
Billy Presbury, 21, of Moray Drive, and Kai Warwick, 19, of Whiteford Road, targeted a trio of teenage boys in Farnham Park on June 1, 2019.