A pensioner suffered four falls in eight days - the last of which resulted in a broken hip - before council bosses took action and ordered a safeguarding review. The man, in his late eighties, initially recovered from surgery on his hip but died just over two weeks later.
Neither the fall or fracture were recorded as a cause of death. He had been placed at Bradwell Court, in Congleton, having previously been detained under the mental health act.
During his brief time at the home, ‘Mr Y’ also sustained a head injury that needed hospital treatment, an investigation by the ombudsman has found. His family reported concerns over his ‘agitation and mental health’, as well as the ‘poor attitude’ of one care worker.
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Stockport council - which arranged the care - has been rapped by the Local Government and Social Care Ombudsman (LGO) for failing to respond appropriately to the complaints. It has since apologised and took 'immediate action' in line with the ombudsman's recommendations.
An LGO report reads: “The council failed to complete a care plan prior to Mr Y’s admission to a care home and failed to respond appropriately to concerns about his wellbeing and the alleged behaviour of a carer.” It adds that the council also failed to keep in touch with Mr Y’s son - ‘Mr X’ - during and after a safeguarding investigation ,and failed to provide an adequate response to his complaints.
Mr Y was admitted to hospital on January 26, 2020, with an officer from Cheshire East social services visiting him on February 1 to discuss his discharge. At the time Mr Y’s mental health was said to be his ‘main issue’.
And while the hospital reported he had been ‘more settled’ over recent days, this still required ‘close monitoring’. A report also noted that Mr Y was ‘independently mobile for approximately 30 metres, steady pace, good balance’.
This officer took information from the ward about Mr Y’s health and care needs and completed an initial assessment. While Mr Y owned a property in Cheshire East, in recent years he had lived with his partner in Stockport, meaning Stockport council assumed responsibility for his care.
His family requested a short-term residential placement with a view to sheltered accommodation in the longer term. On February 17 he moved into Bradwell Court, which is registered to care for the ‘elderly mentally ill’ (EMI). However, during his eight days at the care home, Mr Y suffered four falls.
His son said he was not told about the first fall, and only discovered this when his daughter visited the care home. Mr Y suffered a head injury after his third fall, and was taken by ambulance to hospital where he had a brain scan, before being discharged back to Bradley Court.
However, within 24 hours of returning, Mr Y fell again. He had summoned carers to help him use the toilet but when they did not arrive soon enough, he attempted to manage alone.
After falling, he was readmitted to hospital and found to have a broken hip. Although he initially recovered from surgery to repair the fracture, sadly his health deteriorated, and he died on March 11.
Mr Y’s death certificate did not record the fall/fracture, or subsequent surgery as a cause of death. However, the ombudsman found that it was only after his final fall that Stockport council acted, and a safeguarding referral was made.
To complicate matters, this was undertaken by Cheshire East council - to the dissatisfaction of Mr X, who felt Stockport was ‘passing the buck’. An investigation found that the safeguarding concern was ‘partly substantiated’ on grounds including that the arms on the dining room chair were known to be loose and the falls risk assessment did not take into consideration Mr Y’s prescribed medication.
Aids required in Mr Y’s toilet were also not in place.The LGO said that the council had acted properly by completing an initial assessment of Mr Y’s needs before he was discharged from hospital, but failed to follow this up with an interim assessment, and was therefore ‘at fault’.
Mr X’s daughter visited Mr Y on 20 February, when she was told by another resident that her grandfather had fallen in the dining room because the arm of a chair had collapsed. During this visit she witnessed a male carer ‘huffing and puffing’ when Mr Y asked to go to the toilet.
A few days later, during a telephone conversation with Mr Y, he told her he had pressed his buzzer four times in the toilet the previous evening and when the same male carer attended, he was made to feel like a ‘nuisance’. Mr X contacted Stockport council to express his concern about Mr Y’s mental health, and that a carer had treated his father badly.
He was advised to speak to the care home and request that the carer in question no longer attended to his father and told to address his mental health issues through his psychiatrist. The ombudsman said this response was ‘wholly inadequate’.
The report reads: "Any reports about carers treating residents badly should be investigated promptly and robustly. It was wholly inadequate to suggest Mr X contact the care home to request that the carer in question did not attend to Mr Y. This could have left Mr Y and other residents exposed to unacceptable treatment.”
Mr X submitted a formal complaint to Stockport Council in July 2020 over the quality of care provided to Mr Y, and about the way his earlier complaint had been handled. He did not receive a response until nearly a year later, which upheld the complaint and confirmed the cost of Mr Y’s placement would be cancelled.
This read: “The council agrees that the service fell short of what a reasonable person would expect and accepts that this resulted in a very stressful period for you and your family. For which the council apologises to you. The council also apologises for the delay in responding to you in a timely manner.”
However Mr X was dissatisfied with the response, feeling there was a ‘lack of accountability’ for what happened to Mr Y. The ombudsman agreed the response was not good enough.
The report reads: “Mr X’s distress and frustration is understandable. The council’s complaint response letter compounded this. Although the council upheld the complaint and apologised, its letter lacked any detail or gravitas.” The council has been ordered to apologise for its failings, as well as pay Mr X £250 for his ‘time and trouble pursuing the complaint’ and a further £500 to acknowledge Mr X’s distress and frustration caused by the council’s failure to respond appropriately to his concerns’.
A Stockport council spokesperson said: “Stockport council accepts the judgement of the Local Government Ombudsman and can confirm that we are taking immediate action on the recommendations provided so that we can improve our support for people in this area. We have apologised to the family.”
Sanctuary Care, which runs Bradwell Court, has been contaced for comment.
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