An investigation into a complaint at an Oxfordshire care home, which resulted in a dementia patient’s death, has shown substandard investigations by the care home and council are to blame.
The investigation was prompted by a complaint from a man who said his wife was left severely dehydrated and suffering from oral thrush after a week-long respite stay at the Huntercombe Hall Care Home, operated by Caring Homes Healthcare Group Ltd.
The woman, who suffered with advanced dementia, required full assistance in all areas of daily living, and could not say when she was hungry or thirsty. She struggled to swallow and needed a thickening agent added to her drinks.
The woman’s husband had privately arranged and funded the stay at the Henley-on-Thames home and spoke to the carers there about her special circumstances.
Upon returning to pick her up she was ‘less responsive and limp’ and her mouth had a coating of white spots, her husband reported.
The woman was taken to hospital, with paramedics administering intravenous fluids through a drip, and stayed here for three weeks; her records showing dehydration and problems with her kidneys.
The woman passed away just a week after being discharged from hospital.
During her stay in hospital, hospital staff made a safeguarding referral to Oxfordshire County Council. The man also complained to the provider about his wife’s care.
The care home responded to the man’s complaint but found no shortfalls in its treatment of the woman.
Meanwhile the council conducted its own investigation, but at no point involved the husband.
The council did not conduct a strategy meeting, but asked for a report from the provider.
The Ombudsman report found that the council did not chase the provider report swiftly when they were slow to respond – potentially putting other vulnerable residents at risk.
Other findings showed that the council’s report accepted the provider’s version of events, as well as recording a finding of ‘neglect – partially substantiated’.
The council did not recognise 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 council closed the initial assessment, taking no further action and it was unclear if they told the provider it had come to a finding of partial neglect, or told the CQC and its own contract department about the findings.
The LGO’s investigation stated the council did not act in accordance with the law and relevant government guidance, ignoring Department of Health guidance on safeguarding adults and failing to follow its own policy and procedure relating to safeguarding investigation.
The investigation upheld the man’s complaint against the care provider about the quality of care his wife received, and found issues with the way it completed records about the woman’s care. It also found fault in the way the provider dealt with the man’s subsequent complaint.
Dr Jane Martin, 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 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 upon my report and implement the remedies I have recommended.”
Oxfordshire council has apologised to the man and has been ordered to pay him a total cost of £750, as well as provide a full written apology and waive the full fee for her stay in the home.
