Council rebuked over failure in care for woman with dementia

A care provider at Sheffield Council “failed to look after” a woman when it did not take account of her needs, the support provided was not in line with her needs, and it could not provide her medication record, the ombudsman has found.

The case of a dementia sufferer identified only as Mrs Y was raised with the Local Government and Social Care Ombudsman by her daughter, Mrs X.

A report concluded that it was “no longer possible to remedy the injustice to Mrs Y as she has died” after a fall at a care home, but the council should apologise to her daughter, make a symbolic payment of £250 and work with the care home to improve its practices.

According to a report, Mrs Y had lived at home with her husband. Sheffield Council first gave her ‘reablement support’ in December 2022 when she went home from hospital to help her independence and then it agreed to long-term support in the form of four calls a day.

In February 2023, the report said, the council agreed Mrs Y should access day services to prevent social isolation and it then agreed to respite care because “Mr Y was struggling to cope because Mrs Y was wandering around at night”.

The same assessment said Mrs Y needed help maintaining her nutrition and hydration as she needed prompting to take three prescribed fortified drinks a day and had a dietician monitoring her.

Following this, the council made a care and support plan and sent a copy of it to its care provider, Valley Wood.

The respite care plan included, among other things, that she was not a falls risk, she would wander around the unit at night and she needed hourly checking.

On March 26, she had an “unwitnessed fall” at 6.45am where she cut her head and broke her collarbone. The staff, who called for an ambulance after 7am, said they had been helping another patient when they had heard a bang.

Following an investigation by the company that runs the care home, a staff member was suspended. It also admitted that “it had been distressing for Mrs Y to be on the floor for an hour after her fall”.

The care provider had accepted that “a lack of care and compassion had been shown to Mrs Y and her family, and apologised”.

The ambulance service said that Mrs Y had been covered in bruises and they were told she had been up all night banging her head and shoulders on doors.

The council had also made safeguarding enquiries into a number of concerns raised. It found that Mrs Y had been covered in bruises due to her fall but she had not been banging her head on door frames.

The report said Mrs Y had left the hospital on April 28 and relocated to another care home where she died on May 7. The ombudsman found that a number of faults had been made. This included the fact that neither the council nor the care home had assessed Mrs Y as being at risk of falls.

Another one is while the care home assessed Mrs Y as needing hourly checks at night, records showed that it did not provide hourly checks.