Ombudsman finds Dudley Council at fault for failing to protect

The Social Inspectorate published its findings following an investigation into the protection complaints of the daughter, identified in the report as Mrs X.

The patient, Mrs Y, was suffering from dementia when she was admitted to hospital in October 2022 and transferred to a care home outside Dudley borough the following month.

In mid-December 2022, Ms. Y returned to hospital where it was discovered that she had developed a significant pressure ulcer.

Her condition worsened and she was discharged to another nursing home, where she died a few days later.

A report by the Social Care Ombudsman states: “Records show that when the protective measures were first collected in November 2022, the name and address of the referrer were not provided.

“However, the notes show that when the social worker spoke to Ms X, she confirmed that she had raised the safeguarding issues.”

The Ombudsman concluded that the authority should have informed Ms X following confirmation from the social worker, although the local council claimed that it could not provide Ms X with information because the referrer’s details were not recorded.

The Ombudsman concluded that the Council’s failure to do so “delayed her opportunity to raise her concerns about the outcome in a timely manner, thereby prolonging her distress and uncertainty”.

It was also found that the local council had not adequately addressed Mrs X’s concerns about her mother’s discharge from hospital to a care home outside the area.

Mrs X informed the city council that her mother did not eat or drink anything in hospital, was bedridden for weeks and was subsequently unable to walk.

The council was also informed that Mrs Y would be sent against her will to a care home in an area she did not know.

Andrea Goddard, Dudley Council councillor and cabinet member for adult social care, said: “We note and agree with the findings of the Ombudsman’s report and have apologised to the complainant.

“The lessons learned from this case have been shared with local practitioners to ensure they are considered and followed in future dismissals. We have provided evidence of the actions we have taken to the Ombudsman.”

The Ombudsman concluded that the council had been at fault for causing injustice, stating: “The council was at fault for failing to inform Ms X of the outcome of the investigation and for failing to adequately address her concerns about Ms Y’s discharge to a care home.”

The hospital concerned was not named in the report, but the Ombudsman noted that he had investigated a complaint made by Ms X, which had been partially upheld.

The Ombudsman’s report concluded that the hospital’s investigation “concluded that overall the care provided to Ms Y and communication with Ms X could have been better. The Hospital Trust has identified a need for further training of its staff.”

Councillor Goddard added that anyone with concerns about abuse or safeguarding can report them via the ‘Tell us’ pages in the Safeguarding Portal on the Council’s website.