Dudley Council safeguarding failures contributed to a daughter’s distress after the death of her mother according to an ombudsman.
The social care watchdog published its findings after an investigation into safeguarding complaints from the daughter, identified as Mrs X in the report.
The patient, referred to as Ms Y, was suffering with dementia when she was admitted to hospital in October 2022 then, the following month, transferred to a care home outside Dudley borough.
Ms Y returned to hospital in Mid-December 2022 where it was recorded she has developed a significant pressure sore. Her condition worsened and she was discharged to a different care home where she died a few days later.
A report from the Social Care Ombudsman said: “The records show when the safeguarding was initially raised in November 2022 it did not include the name and address of the referrer.
“However, notes show when the social worker spoke with Mrs X, she confirmed she had raised the safeguarding.”
The ombudsman found despite the council’s claim it could not share information with Mrs X because the referrer’s details were not recorded, the authority should have updated Mrs X after the social worker’s confirmation.
The ombudsman found the council’s failure to do so ‘delayed her opportunity to raise her concerns about the outcome in a timely manner which has prolonged her distress and uncertainty’.
The council was also found to have failed to have properly considered Mrs X’s concerns about how her mother was discharged from hospital to the out of area care home.
Mrs X told the council her mother was not eating or drinking in the hospital, was left in bed for weeks and was subsequently unable to walk. The council was also told Ms Y was being sent to a care home in an area she was not familiar with, which was against her wishes.
Councillor Andrea Goddard, Dudley cabinet member for adult social care, said: “We acknowledge and agree with the findings of the ombudsman’s report and have apologised to the complainant.
“The learning from this case has been shared with frontline practitioners to ensure it is reflected and followed in future discharges. We have supplied evidence on the action we have taken to the ombudsman.”
The ombudsman concluded: “The council was at fault for not informing Mrs X of the outcome of the investigation and for not properly considering her concerns about Ms Y’s discharge to a care home.”
The hospital involved was not identified in the report however the ombudsman found it had investigated a complaint from Mrs X which had been partially upheld.
The ombudsman’s report found the hospital’s investigation: “Concluded that overall Ms Y’s care, and its communication with Mrs X, could have been better. The hospital trust identified further training required for its staff.”
Cllr Goddard added anyone with concerns about abuse or safeguarding can report them via the tell us pages in the safeguarding portal on the council’s website.
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