Council criticised for failures after death of vulnerable Worcestershire man

Worcestershire County Council under fire for care failures

Worcestershire County Council under fire for care failures

First published in Local Droitwich Advertiser: Tom Edwards Exclusive by , Political Reporter

A FRAIL pensioner died after being moved to a cheaper, less suitable care home in Worcestershire - despite an advance assessment warning it would be "detrimental" to his health.

Worcestershire County Council has been heavily criticised by an official watchdog after a catalogue of failures surrounding the death of a 70-year-old man.

The Local Government Ombudsman has accused the council of trying to "contract out the responsibility" for his death in a shock report.

The county pensioner, who cannot be named for legal reasons, went to hospital with a history of dementia, diabetes, epilepsy, heart and stroke problems in December 2010.

In February 2011 he left Worcestershire Royal Hospital and was placed in an £800-a-week private care home funded by the NHS.

The emergency funding package, under the NHS' "continuing health care" model came to an end in October 2011 and the county council took over responsibility for him.

A report by the Local Government Ombudsman says the county council's "usual rate" of care is £495 a week, so it moved him to another private care home one month later which was a "cheaper" and "less suitable" despite its own assessment warning it would be detrimental to his complex health needs.

The report then says:

- The new nursing him was "not suitable" and within 10 days of the move his condition got much worse

- Within a month his son complained to social workers about him developing pressure sores, being fed pureed food and being found in bed fully-clothed covered in sweat, as well as other instances of poor care

- Important notes were missing from his records and he was being sent to his room regularly for "shouting out"

- Despite complaints from the family the council never completed a safeguarding investigation properly and he died in January 2012, less than two months after his move, after going to hospital with pneumonia and dehydration.

The man had limited mobility, needed help from carers to get around, was doubly incontinent and needed support with his medication, eating and drinking, which he was getting at the old home.

The critical report also says council staff "failed" to give his family correct information on 'top-up' payments and "did not consider" if it should pay the old £800 weekly rate, even though it could have done so.

The council also failed to follow the statutory complaints process properly, and a follow-up investigation by the care home was found to be "incomplete".

Dr Jane Martin, Local Government Ombudsman, said: "Worcestershire County Council’s social workers ignored their own recommendations which stated any move would have a detrimental effect on the man’s health and well-being and should have considered if any move should take place in these circumstances.

“While I cannot say that the new home and carers themselves caused the man’s condition to deteriorate, it is significant that his condition did worsen once he was moved.

“The council should have done more to check that the placement at the second home was suitable, and officers should have done more to follow up the son’s concerns.

“I would like to remind councils that while they can contract out care for the elderly to private homes such as this, they cannot contract out the responsibility."

Following the report the council have agreed to pay his family £1,500 and review its procedures.

All social care staff will be checked to ensure they know how to identify a complaint, what procedures to follow and how adult safeguarding works.

A council spokesman said: "We fully accept the findings of the Ombudsman in this case and are, as agreed, working on an agreed action plan to remedy the issues raised by the complaint.

"We have apologised to the family and also agreed to pay them £1,500 for the distress caused.

"Procedures at the council are currently being reviewed so similar instances do not occur in the future."

The identity of the care homes have not been revealed.

Comments (21)

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8:35am Tue 28 Jan 14

saucerer says...

This is totally scandalous and yet another example of our public-funded council failing the public and compromising our safety and welfare, while in this case someone tragically died because of these failings. The fact that the council were warned beforehand about the consequences of moving this gentleman, and failed to undertake safeguarding investigations, makes it all the more sickening and simply sums up the attitude of, and care, provided by council staff. They are quite happy to play Russian roulette with our lives.

The council staff responsible should be named and shamed and sacked and they should never ever be employed in such a position of responsibility again. And remember, this is yet another worrying failure from Worcestershire county council, particularly under Trish Haines' tenure. Perhaps she should consider leaving asap.
This is totally scandalous and yet another example of our public-funded council failing the public and compromising our safety and welfare, while in this case someone tragically died because of these failings. The fact that the council were warned beforehand about the consequences of moving this gentleman, and failed to undertake safeguarding investigations, makes it all the more sickening and simply sums up the attitude of, and care, provided by council staff. They are quite happy to play Russian roulette with our lives. The council staff responsible should be named and shamed and sacked and they should never ever be employed in such a position of responsibility again. And remember, this is yet another worrying failure from Worcestershire county council, particularly under Trish Haines' tenure. Perhaps she should consider leaving asap. saucerer
  • Score: 21

8:59am Tue 28 Jan 14

jb says...

All social care staff will be checked to ensure they know how to identify a complaint, what procedures to follow and how adult safeguarding works.

"Procedures at the council are currently being reviewed so similar instances do not occur in the future."


These two statements sum up the situation completely, poorly trained and monitored staff, lack of management monitoring and the same old meaningless 'this won't happen again' assurances. This tragedy occurred due to the focus being solely on funding and NOT on the well being of this gentleman therefore in my opinion the council failed in their duty of care. Lessons are NEVER learnt, I went through the complaints procedure with Worcestershire county council and the comments regarding procedure reviews. Staff training etc were almost exactly the same. The staff should be trained and experienced enough to know procedures, to understand what a complaint is (they get enough of them!) , to know to follow up if a persons care support needs are being met but the fact is they don't because it means more money needs to be spent, Blind eyes are being turned and sadly this outcome is the result of just one incident. My condolences to the gentlemans family.
All social care staff will be checked to ensure they know how to identify a complaint, what procedures to follow and how adult safeguarding works. "Procedures at the council are currently being reviewed so similar instances do not occur in the future." These two statements sum up the situation completely, poorly trained and monitored staff, lack of management monitoring and the same old meaningless 'this won't happen again' assurances. This tragedy occurred due to the focus being solely on funding and NOT on the well being of this gentleman therefore in my opinion the council failed in their duty of care. Lessons are NEVER learnt, I went through the complaints procedure with Worcestershire county council and the comments regarding procedure reviews. Staff training etc were almost exactly the same. The staff should be trained and experienced enough to know procedures, to understand what a complaint is (they get enough of them!) , to know to follow up if a persons care support needs are being met but the fact is they don't because it means more money needs to be spent, Blind eyes are being turned and sadly this outcome is the result of just one incident. My condolences to the gentlemans family. jb
  • Score: 19

10:03am Tue 28 Jan 14

JRBBroadway says...

Why has the identity of the homes been hidden? To protect the guilty? We need to know; we have loved ones of our own in homes & the CQC reports are not enough to go on when considering where is best.
Why has the identity of the homes been hidden? To protect the guilty? We need to know; we have loved ones of our own in homes & the CQC reports are not enough to go on when considering where is best. JRBBroadway
  • Score: 16

10:22am Tue 28 Jan 14

Jabbadad says...

This shamefull case has only come to light due to this papers reporting, Thank You Worcester News.
It also shows the pathway that Commisioners are taking seemingly, and as suggested, guided by FUNDING COSTS. And don't let us look away since it could well be the destiny for all of us with the County Council services being OUTSOURCED to allow the Councills to become Commisioners only, exposing any of us perhaps to this disgraceful treatment of this elderly person during Later Life days..
And yes this Care Home responsible should be NAMED & SHAMED. Hopefully it will appear When / If a Care & Quality Commision inspection is instigated.
This shamefull case has only come to light due to this papers reporting, Thank You Worcester News. It also shows the pathway that Commisioners are taking seemingly, and as suggested, guided by FUNDING COSTS. And don't let us look away since it could well be the destiny for all of us with the County Council services being OUTSOURCED to allow the Councills to become Commisioners only, exposing any of us perhaps to this disgraceful treatment of this elderly person during Later Life days.. And yes this Care Home responsible should be NAMED & SHAMED. Hopefully it will appear When / If a Care & Quality Commision inspection is instigated. Jabbadad
  • Score: 19

12:23pm Tue 28 Jan 14

cvbnm, says...

Sadly this will be just the tip of the iceberg and will affect those cared for in their own homes too. Apparently the council could and obviously should have funded the gentleman's care. In the very near future- because councils have had their budgets slashed by central government-council's are contracting out the home care services to private home care companies; their staff are not adequately trained(2 days!). This is my experience with parents in another part of the UK but I've no doubt it will happen here. These companies have glossy literature, informative web sites but unfortunately are accepting contracts on false pretexts.
Sadly this will be just the tip of the iceberg and will affect those cared for in their own homes too. Apparently the council could and obviously should have funded the gentleman's care. In the very near future- because councils have had their budgets slashed by central government-council's are contracting out the home care services to private home care companies; their staff are not adequately trained(2 days!). This is my experience with parents in another part of the UK but I've no doubt it will happen here. These companies have glossy literature, informative web sites but unfortunately are accepting contracts on false pretexts. cvbnm,
  • Score: 10

12:49pm Tue 28 Jan 14

jb says...

On reading this again another thought has occurred to me, this gentleman had ongoing complex HEALTH needs so I fail to see that a decision to move him from a nursing environment to what seems to be a care environment was anywhere near 'suitable'. If someone needs long term health care then it's still down to the NHS to fund or partly fund this surely? I know fairly recently NHS and social care funding is or has been lumped into one (with still a lot of bickering about what is a health or social need) Someone correct me if I'm wrong but a person cannot legally be denied care on purely financial grounds and this was blatantly solely down to finances.
On reading this again another thought has occurred to me, this gentleman had ongoing complex HEALTH needs so I fail to see that a decision to move him from a nursing environment to what seems to be a care environment was anywhere near 'suitable'. If someone needs long term health care then it's still down to the NHS to fund or partly fund this surely? I know fairly recently NHS and social care funding is or has been lumped into one (with still a lot of bickering about what is a health or social need) Someone correct me if I'm wrong but a person cannot legally be denied care on purely financial grounds and this was blatantly solely down to finances. jb
  • Score: 11

6:52pm Tue 28 Jan 14

CHANDBRUSH says...

The persons who should be held to acccount are the head of the Council and the Chief Executive but they never are.
The persons who should be held to acccount are the head of the Council and the Chief Executive but they never are. CHANDBRUSH
  • Score: 8

8:09pm Tue 28 Jan 14

shot123 says...

I just hope they name the care home , terrible .
I just hope they name the care home , terrible . shot123
  • Score: 8

9:51pm Tue 28 Jan 14

VantagePoint says...

Don't understand the secrecy! All anyone needs to do is go to the Local Government Ombudsman's website. Look up the complaints for residential care and this is the first case that comes up. Click on the link on the right hand side of the page and you get the full report including the names of the homes. There's no reason whatsoever why the Worcester News needs to take legal advice. It's a public document issued by the Ombudsman so covered by qualified privilege!
Don't understand the secrecy! All anyone needs to do is go to the Local Government Ombudsman's website. Look up the complaints for residential care and this is the first case that comes up. Click on the link on the right hand side of the page and you get the full report including the names of the homes. There's no reason whatsoever why the Worcester News needs to take legal advice. It's a public document issued by the Ombudsman so covered by qualified privilege! VantagePoint
  • Score: 7

10:00pm Tue 28 Jan 14

Denver's Son says...

Vantage point you are incorrect they only give fake names.
Vantage point you are incorrect they only give fake names. Denver's Son
  • Score: 6

10:16pm Tue 28 Jan 14

VantagePoint says...

I understand Denver's Son. However, there are actually care homes with the names the LGO has chosen so there would be a case for saying that the homes' real names should be given to distinguish them from the fictitional ones in case anyone thought these were the ones referred to.

I have every sympathy as I dealt with muppets at Worcestershire NHS and the county council for a number of years. For the most part they were clueless, badly trained jobsworths who failed repeatedly to follow laid down procedures.
I understand Denver's Son. However, there are actually care homes with the names the LGO has chosen so there would be a case for saying that the homes' real names should be given to distinguish them from the fictitional ones in case anyone thought these were the ones referred to. I have every sympathy as I dealt with muppets at Worcestershire NHS and the county council for a number of years. For the most part they were clueless, badly trained jobsworths who failed repeatedly to follow laid down procedures. VantagePoint
  • Score: 4

9:44am Wed 29 Jan 14

Redhillman says...

Denver's Son wrote:
I am the son and tried to get the Worcester News to print the name of this home. They went ahead and printed this anyway.
I really am so sorry to read what happened. I can only imagine what an emotional and distressing experience this was, but I also expect that anger was also felt towards the council, which I would fully understand due to their failings which led to the tragic loss of your father.

Sadly, I feel Worcestershire county council fail the public all too often, and this story shows that their ineptitude not only affects people's lives, but their lack of ability, common sense and care can lead to something much worse. If I were you Denver's Son, I wouldn't let this matter rest and I'd demand answers to find out exactly what happened and why council staff failed, while those responsible need to be exposed publicly. In fact, would those responsible be culpable for manslaughter because the direct result of their actions led to the tragic loss of your father? As saucerer said, those people should never be employed in such a position again. I appreciate it would be a distressing exercise, but the council must not be allowed to continue to operate in this manner. They are playing games with people's lives.
[quote][p][bold]Denver's Son[/bold] wrote: I am the son and tried to get the Worcester News to print the name of this home. They went ahead and printed this anyway.[/p][/quote]I really am so sorry to read what happened. I can only imagine what an emotional and distressing experience this was, but I also expect that anger was also felt towards the council, which I would fully understand due to their failings which led to the tragic loss of your father. Sadly, I feel Worcestershire county council fail the public all too often, and this story shows that their ineptitude not only affects people's lives, but their lack of ability, common sense and care can lead to something much worse. If I were you Denver's Son, I wouldn't let this matter rest and I'd demand answers to find out exactly what happened and why council staff failed, while those responsible need to be exposed publicly. In fact, would those responsible be culpable for manslaughter because the direct result of their actions led to the tragic loss of your father? As saucerer said, those people should never be employed in such a position again. I appreciate it would be a distressing exercise, but the council must not be allowed to continue to operate in this manner. They are playing games with people's lives. Redhillman
  • Score: 10

4:39pm Wed 29 Jan 14

shot123 says...

i say name the Care home ....
i say name the Care home .... shot123
  • Score: 5

7:38pm Wed 29 Jan 14

Ron Chambers says...

Name the people who in their specialised field being paid x number of pounds to send some very ill person some where totally not suitable. Obviously these people have not got a clue what they are doing or care. They must be held responsible and dismissed from their post. Please don't tell everyone that lessons have been learnt and things will change they never do. Now with the supporting peoples grant being stopped things will get far worse putting more pressure on care homes, doctors, hospitals and carers but this is does not seem to bother the council. Instead of yes councillors we need people to get of their seats and question the government.
Name the people who in their specialised field being paid x number of pounds to send some very ill person some where totally not suitable. Obviously these people have not got a clue what they are doing or care. They must be held responsible and dismissed from their post. Please don't tell everyone that lessons have been learnt and things will change they never do. Now with the supporting peoples grant being stopped things will get far worse putting more pressure on care homes, doctors, hospitals and carers but this is does not seem to bother the council. Instead of yes councillors we need people to get of their seats and question the government. Ron Chambers
  • Score: 8

8:36pm Thu 30 Jan 14

kimik8 says...

Firstly .. the usual amount of care fund of £495 per week is not written in stone , it is a base line used by Adult Social services. This figure has not changed to my knowledge for the last 3 years despite RPI increases.that affect the homes
**** tried to insist that my family found the top up for my Dad who was in a Nursing Home in 2012 as fees had increased. They threatened to move him if we could not find the extra fees.
I fought them and I flaming won.NHS don't want to pay for continuing care
This is not about the care home this poor man ended up in, it is about the budget Worcestershire Adult Social Services are being given to look after our elderly who deserve the best treatment avaliable at the end of their lives. Cameron is more than happy to send billions to places like India when our own elderly are being treated worse than people in prison
Firstly .. the usual amount of care fund of £495 per week is not written in stone , it is a base line used by Adult Social services. This figure has not changed to my knowledge for the last 3 years despite RPI increases.that affect the homes **** tried to insist that my family found the top up for my Dad who was in a Nursing Home in 2012 as fees had increased. They threatened to move him if we could not find the extra fees. I fought them and I flaming won.NHS don't want to pay for continuing care This is not about the care home this poor man ended up in, it is about the budget Worcestershire Adult Social Services are being given to look after our elderly who deserve the best treatment avaliable at the end of their lives. Cameron is more than happy to send billions to places like India when our own elderly are being treated worse than people in prison kimik8
  • Score: 8

1:21am Fri 31 Jan 14

Jabbadad says...

Kimik8 What a powerfull posting.
There has been a differance of responsability as to who pays what and the different Council departments seem to be continuously at a stalemate over this.
However I recall that gordon Brown brought in a policy which said that the Nursing Care would be paid for by the Government and the Hotel side, Room and care home charges after means testing, would be paid by the adult services, and should there be a shortfall they do ask members of the family to pay top up fees, or the person can be moved to a less expensive Care Home or even be asked to room Share, which does suit some people who prefer company. But both parties have to be compatible. The sooner they all work together in the interests of the older people the better, since mistakes such as this one we are discussing can also mean a very sad loss of life.
Kimik8 What a powerfull posting. There has been a differance of responsability as to who pays what and the different Council departments seem to be continuously at a stalemate over this. However I recall that gordon Brown brought in a policy which said that the Nursing Care would be paid for by the Government and the Hotel side, Room and care home charges after means testing, would be paid by the adult services, and should there be a shortfall they do ask members of the family to pay top up fees, or the person can be moved to a less expensive Care Home or even be asked to room Share, which does suit some people who prefer company. But both parties have to be compatible. The sooner they all work together in the interests of the older people the better, since mistakes such as this one we are discussing can also mean a very sad loss of life. Jabbadad
  • Score: 5

1:17pm Fri 31 Jan 14

Denver's Son says...

My Dad was Denver Kendrick
My Dad was Denver Kendrick Denver's Son
  • Score: 3

2:42pm Fri 31 Jan 14

shot123 says...

good on you Denvers son for naming the care home
good on you Denvers son for naming the care home shot123
  • Score: 4

7:27pm Mon 3 Feb 14

Denver's Son says...

Seems they have deleted my posts here too!
Seems they have deleted my posts here too! Denver's Son
  • Score: 1

10:42pm Mon 3 Feb 14

Jabbadad says...

Its a pity they don't get the Editing organised when several postings are not able to be commented on both in News and Letters and the letters are sometimes several days behind in being posted.
Its a pity they don't get the Editing organised when several postings are not able to be commented on both in News and Letters and the letters are sometimes several days behind in being posted. Jabbadad
  • Score: 1

11:10pm Mon 3 Feb 14

Denver's Son says...

Jabbed ad there is a new story on this in today's news, labour are asking for an inquiry.
Jabbed ad there is a new story on this in today's news, labour are asking for an inquiry. Denver's Son
  • Score: 0

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