Sheffield City Council at fault for poor care in administering medications

Decision Date: 29th October 2019

What Happened

Mr and Mrs X were an elderly couple. Mr X had significant care needs and Mrs X had dementia. Their daughter Ms A supported them with daily tasks but they were also received 4 care calls a day.

Mr X’s care plan included a stipulation for carers to administer medication. The administration of one of his drugs was time-critical.

In January 2018 the Council allocated the provision of care services to a care agency called Inspire. As well as a copy of each of their care plans, the Council sent a service amendment form setting out that the service must order and collect medication from the GP monthly. It had to be ordered at least 48 hours before the medication ran out.

Ms A said she had to order the medication herself as she discovered the carer had not, and it was close to running out. She

She raised concerns about the carers’ ability to look after Mr X properly

  • The carers were supposed to check the weekly Warfarin dose with the hospital and administer appropriately but Ms A had concerns they did not do so.
  • Carers did not always sign the Warfarin chart
  • On occasions medication was left out where either Mr and Mrs X could have taken it
  • On other occasions the previous day’s tablets were unused, although Ms A said the carers wrote in the logbook the medication had been taken.
  • Mr X was supposed to take Warfarin at 6pm but sometimes the care calls were later than 7.30pm.
  • Ms A also said her father was sometimes left soiled and wet. Urine bottles were left unemptied; soiled pads were left on the floor, and the dishes were left unwashed.
  • Ms A said on 4 February she went to their home to find excrement all over the bathroom and bedroom.

Ms A says she raised concerns first of all with the Council on the second day the carers were in post (22nd Jan). She raised concerns in writing on 27 January.

On 12 February Ms A raised a safeguarding alert about the poor care.

She sent photographic evidence to the Council of the poor conditions in the flat and the medication left out. She said there were many different carers who attended; they did not know on their first call what medication was supposed to be administered; they wrote “all well” in their notes when they left even if the flat was not clean, Mr X was left soiled or no medications had been administered. Carers had failed to check and monitor the pressure sores on Mr X’s legs. Carers did not assist Mrs X to wash or dress. The Council agreed the matter warranted a safeguarding enquiry.

Council notes showed a discussion on 21st February where a manager from Inspire said to Ms A that the situation had been difficult because she created a ‘hostile environment’ and told her that staff found her intimidating.

On 23 February Mr X’s GP raised a further safeguarding concern. Mr X was admitted to A&E with severe heart failure and cardiac arrest, as care staff failed to give him his medication.

In March a new care agency took over the care contract, but shortly after, Mr X died.

At a safeguarding meeting in June, the Inspire manager stated in regard to the failure to administer medicine, he had put an action plan in place to withdraw the two carers, carry out spot checks and put a new MAR chart in place. Ms A disputed that this had actually happened, as the two carers had returned to Mr X’s house after that incident. Again, the Inspire manager accused Ms A of intimidating carers.

A social worker carried out a detailed investigation of Ms A’s concerns.

  • Inspire said they never received the service amendment form. The Social Worker found this to be incorrect.
  • She found evidence that carers had not been consistent with completion of the MAR charts or the Warfarin record.
  • The care agency had not contacted the hospital as stipulated to find out the dosage for the week.
  • On one occasion Ms A had to stop a carer giving her father medication he should not have had.
  • The social worker noted the agency’s acknowledgement that the wrong dosage of Warfarin had been given and another tablet had been wrongly administered.
  • There were concerns about the standards of personal care and Inspire acknowledged staff had not liaised properly with District Nurses about Mr X’s skin integrity.
  • There had been a breakdown of communication between Inspire and Ms A.

Overall the social worker found that neglect had occurred.

Mrs X then also died.

Ms A complained to the Council in September 2018. She complained about Inspire and said their contract should be terminated. She complained about the Council’s monitoring of the agency. She expressed concerns about the training provided to carers. She said the Council should ask service users about their experience of care. She complained about the delay in sending her the minutes of the safeguarding meetings.

The Council’s head of commissioning responded in October. She upheld the complaint about the poor-quality service given to Mr and Mrs X. She apologised for the length of time it had taken to conclude the safeguarding process. She explained the Council’s risk escalation process and said that Inspire had been given an ‘amber’ status in July 2018 because of the concerns raised. She said the contracts monitoring officer was currently visiting on a fortnightly basis to ensure the agency complied with its action plan for improvement.

Ms A remained dissatisfied and complained to the Ombudsman.

What was found

The LGO found that the care agency (acting on behalf of the Council) failed to provide safe care for Mr and Mrs X. Carers’ failure to administer medication properly and abide by the stipulated dosage caused actual harm to Mr X. That was fault which caused significant injustice to Mr X as well as to Ms A.

Carers also failed to provide proper care and treatment to Mrs X, leaving medication within reach and failing to ensure she was always washed and dressed.

The carers failed to report sores on Mr X’s legs and a sore in his groin which Ms A said was clearly visible to anyone who carried out personal care. That failure also caused injustice.

The Council operates a risk management/escalation process for service provision jointly with the local health body. “Low or no risk” is categorised green; “low/moderate risk” is categorised amber; “high risk/concern” is classed as a serious incident and categorised red. A provider in the amber category is visited every 4-6 weeks to monitor its action plan for improvement. A provider in the red category is visited every 2-4 weeks to monitor its improvement plan. The contracts monitoring officer was visiting the care agency on a two-weekly basis; there had been a serious incident with medication, but the Council did not escalate the status of the care provider to “red”. The LGO stated that Council should clarify the way in which it complied with its own procedure here.

Ms A was told numerous times that she was creating a hostile work environment, and that she intimidated staff. The LGO also said it was unfair for the Council in its investigation to criticize Ms A for the breakdown in communication, when it was the actions of the care provider which caused harm to Mr X.

The LGO recommended that the Council pay £2000 to Ms A in recognition of the considerable anxiety and distress caused by its actions.

Points for the public, service users, risk managers, families and providers

This is a classic example of the legal principle that councils cannot escape responsibility merely by ceasing to provide directly, and contracting ‘OUT’ or delegating their own meeting needs functions to outside businesses. The public law function of meeting needs, cannot be laid off merely through contract.

The provider owed a duty of care and should be contacting its insurer because this kind of evidence could be used in an action by the estate for damages for breach of that common law duty in negligence, even though it is not suggested it is in anyone’s interest to pursue that sort of a remedy.

It is public money that has been used to commission the service. The regulator’s functions are not the same as contract monitoring for value for money and for the council’s assurance that its own statutory duties are being met.

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The full Local Government Ombudsman report of Sheffield City Council’s actions can be found here

https://www.lgo.org.uk/decisions/adult-care-services/safeguarding/18-016-372