Council apologise to family after beloved sister’s ‘avoidable’ death at Sheffield care home
A Council has been heavily criticised for not putting ‘proper safeguarding measures’ in place for a woman in one of its care homes in Sheffield before she fell and died.
Derbyshire County Council’s initial investigation into the dementia-sufferer’s death decided she had received a ‘good overall standard of care’, despite her experiencing ‘numerous falls’ while living in the The Grange Care Home in Eckington.
During one last incident at the home in March 2016, the woman fell and broke her ribs and received serious chest injuries. She died in hospital the following month. A coroner’s inquest found she died of her injuries and failings by the council ‘contributed to that’.
The Ombudsman investigated the council’s response to the woman’s death, following a complaint by her brother.
He complained the council’s probe into her death had been inadequate, including a safeguarding investigation which found it had ‘no concerns’ about that care, even though care home staff failed to complete care planning for her or record those falls properly.
In a report to the Care Quality Commission, produced some months later, the council acknowledged it had not implemented its safeguarding procedure correctly following the woman’s admission to hospital, and it had not followed the correct risk assessment and referral procedures during her stay at the home.
Derbyshire County Council Leader Councillor Barry Lewis said the Council ‘fully accepted’ the Local Government and Social Care Ombudsman’s findings and ‘apologised wholeheartedly’ for the failings that led to Miss Allen’s death.
“In this case, our actions fell below the high standards that we expect of ourselves and we are truly sorry for what happened,” Mr Lewis added.
“We would like to offer our sincere condolences to Miss Allen’s family and we’d once again like to apologise unreservedly.
“The safety and wellbeing of our residents is our number one priority and we have worked extremely hard to address the issues involved in this tragic case.
“We have implemented a number of changes to do our best to ensure this can’t happen again including: reviewing and revising our falls policy, establishing a Quality and Improvement Board to oversee the delivery of a quality improvement plan, increasing staffing in the service, implementing changes to our pre-admission assessments and compulsory falls prevention training for staff.
“Three years on we continue to build on the progress we’ve made and the Ombudsman’s report recognises the steps we’ve taken to improve the quality of care at the home and apply good practice across our care homes.
“A recent independent inspection of the home found evidence of improvements in the recording of falls and the admission process and we have already undertaken a further comprehensive learning review which is driving our work to ensure we provide the best possible care for the people of Derbyshire.
“We continue to work to improve our processes to ensure that we meet the high standards that people rightly expect of us and that residents are safe in our care.”
Michael King, Local Government and Social Care Ombudsman, said: “Our findings reinforce what the coroner’s investigation found – that this woman’s death was avoidable.
“These failings were compounded when the council did not respond appropriately when it was alerted to her injuries by the hospital.
“The council conducted the most cursory of investigations, despite it being evident the woman had experienced frequent falls while in its care. The council had a duty not just to this woman, but to others living in the home, to investigate her injuries to ensure nobody else was at risk. It was only because of the brother’s persistence and the involvement of the Care Quality Commission that the council carried out a further investigation into her care.
“Since these events took place in 2016, the council has made changes to the way it manages its care of vulnerable people and put in place measures to monitor their effectiveness. However, I am publishing this report to ensure the council learns lessons about openness and transparency when mistakes happen.”