Borough fined and made to apologise

Man (not pictured above) died shortly after council launched safeguarding probe

May 30, 2022

Wandsworth Council and the local NHS trust have been ordered to apologise to a woman who had “sleepless nights” over her father's care.

The woman, referred to only as Miss A in a Local Government Ombudsman report, challenged the care her dad with dementia was receiving when she saw his pressure ulcer without a dressing.

Miss A complained about the care her father, named Mr B in the report, received from the Central London Community Healthcare NHS Trust between September and November 2020. She also complained about Wandsworth Council's safeguarding investigation.

A new ombudsman ruling reads, “Miss A explains she was caused anxiety and stress at witnessing the pain her father was in. She experienced sleepless nights and is unable to grieve because of the unanswered questions about his care. She has spent hundreds of pounds in continuing with the complaint in printing and postage.”

Mr B, who had dementia, lived at home and received a care package from the council with carers coming four times a day. Hospital records from 15 September, 2020 show Mr B had a grade three pressure ulcer on his sacrum, with grade four being the worst type of pressure ulcer.

The trust referred Mr B for district nursing home care for the pressure ulcer, but Miss A was worried the nurses weren't looking after him properly. The report also says Mr B's ulcer got worse during another stay in hospital. The council opened a safeguarding probe in November 2021 after Miss A raised her concern on 27 October. Mr B died in late November.

The report found district nurses didn't always take photos of Mr B's pressure ulcer in line with guidance, note clinical observations for the ulcer, record whether they had cleaned or dressed ulcer, order or chase outstanding orders for dressings or complete risk assessments on multiple occasions.

The report says: “I do not have enough clinical evidence to say whether an earlier safeguarding referral could have prevented further decline of Mr B's sacrum pressure ulcer. However, I can agree this caused unnecessary distress and frustration to Miss A.”

It adds, “Miss A and her family were frustrated and distressed due to the lack of communication between the different teams caring for Mr B. Miss A felt she had no choice but to raise her concerns with all parties. She felt the organisations were not helping him.”

Miss A said she was given “contradictory accounts” by the council when she pursued her complaint. The report found the council did not action its safeguarding enquiry immediately and it was “not open and honest” with Miss A during the complaint process. It found fault with the record-keeping by district nurses and the way they ordered dressings along with the “lack of a multidisciplinary team approach” to Mr B's care.

The trust and the council have been ordered to apologise to Miss A and to pay her £250 each. The organisations have also recommended service improvements following the probe.

A Wandsworth Council spokesperson said: “This case involved a wide ranging series of complaints against a hospital trust, district nursing services and social workers. For our part we have accepted fault with the way our investigation was conducted into the complaints relating to council services and have agreed to write a formal letter of apology to the complainant and pay compensation of £250.”

A Central London Community Healthcare NHS Trust spokesperson said, “CLCH takes all complaints very seriously and we have been liaising with the Ombudsman, Miss A and the council regarding this case.”

Charlotte Lillywhite - Local Democracy Reporter