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Serious care failings after woman dies of sepsis
By Local Democracy Reporters
Thursday, September 27, 2018 5:54 pm
UPDATED: Thursday, September 27, 2018 5:56 pm
Nottinghamshire County Council © westbridgfordwire.com
An elderly woman was left in appalling conditions in her home due to delays and poor communication.
The council has been criticised by the independent ombudsman over what happened to the woman, who has not been named.
Despite getting frequent visits from health workers, the woman's home contained urine-stained furniture and carpets, and there was a problem with mice.
She was omitted to hospital with sepsis – a serious complication of an infection – and died just days later.
Nottinghamshire County Council, which was responsible for the woman's social care, says it has apologised unreservedly, is learning lessons, and will pay £400 in compensation to the woman's daughter.
A damning report from the Local Government and Social Care Ombudsman found a catalogue of errors including poor cooperation, bad communication and persistent delays from multiple agencies, which exacerbated her daughter's upset in an already distressing situation.
The woman had dementia, chronic leg ulcers, and deafness, among other conditions. Her daughter was her main carer, and she was also visited by care workers arranged by the council who came in a few times a day.
The daughter, known as Mrs B, made a number of criticisms of the council, including that:
The council delayed taking action to deal with mice and potentially other pests at her mother's house
The council failed to take action about her sister in law removing items from her mother's house.
District nurses failed to alert the GP that her mother's legs were getting worse, or arrange further treatment.
Mrs D contracted sepsis because of poor care.
The ombudsman's report said it was not possible to say with certainty that the sepsis was a result of the actions of the council and the NHS Trust (Which is not named).
However it says: "We must say that this would be a distressing situation even if there was no fault involved, but we recognise the actions in this case exacerbated Ms B's upset.
"Many different bodies were involved in Mrs D's care. They did not coordinate well together to act in Mrs D's best interests.
"We fully understand Ms B's concerns for her mother's welfare and how distressing it must have been seeing her mother living in those conditions.
"The professionals involved could have taken action about this sooner than they did, as the concerns were known several months before the council completed its mental capacity assessment and best interests decision about continence.
On the issue of the pests in the house, the report found: "Mrs D saw her GP about possible bites, the GP noted spots which may have started as insect bites. The care agency workers and the health care workers failed to tell the council about this issue; the council found out by a report from Ms B.
"The council says it referred the matter to the district council's environmental health team though I have seen no evidence of that.
"The council asked Ms B to catch one of the bugs and bring it to its office to examine. Ms B tried but could not even see the bugs to be able to catch one. Ms B also raised a concern about mice.
"Six weeks later an Environmental Health officer (EH officer) visited the property. The EH officer found no evidence of a mite, flea or insect infestation, but did find evidence of mice.
"The EH officer advised Ms B to block up the hole where mice were getting in. The district council's website says once you lodge a request for pest control it aims to carry out any treatment within two working days.
"The delay of six weeks is fault; it is unclear when the county council made the referral to EH, and whether it chased the matter.
The ombudsman's final conclusion said: "The council delayed completing capacity assessments for a vulnerable adult about their social care.
"The council failed to keep the daughter informed at certain stages.
"The various bodies involved did not coordinate well in the best interests of the service user. This led to increased upset for the service user's daughter."
Paul McKay is the adult social care and health service director at Nottinghamshire County Council.
He said: "We provide adult social care services to around 20,000 Nottinghamshire residents a year and the vast majority of services users receive an excellent service that meets their needs.
"The council has unreservedly apologised to Mrs D's daughter for the delays in arranging the appropriate support for her mother, which meant she was not provided with a walk-in shower and a new chair and carpet as she required.
"We recognise that we could have worked more effectively with health partners in this case and kept Mrs D's daughter better informed in response to her complaint.
"We have reviewed our training of staff who lead on mental capacity assessments to improve how these are carried out in future, which has included briefing employees on the learnings from this case.
"We are also working with the NHS to improve our partnership working practices and have provided Mrs D's daughter with £400 in compensation in line with the Ombudsman's recommendations.
"The communication issue was an isolated incident as we always strive to follow a complainant's communication preference."
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