Learning from Experience Database - Serious Case Reviews

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Mrs B (Blackpool)

Mrs B relocated to Blackpool in January 2010 to be closer to her granddaughter after being discharged from hospital to a care home following a fall at home. Mrs B had lost the sight in her left eye, had history of frequent falls and was known to have vascular dementia and a range of other health issues. Between April and September 2010, Mrs B’s granddaughter twice contacted BC to raise concerns about the standard of care her grandmother was receiving and requesting information about how to arrange an alternative placement. These concerns included incidents of apparent poor care, poor staffing levels and a degree of restraint being used. Following the second alert, an unannounced joint visit to the home took place some time after. Some of the family’s concerns had been addressed and the family are reported as feeling that staff were being more attentive to Mrs B. An alternative placement was discussed. The family agreed for Mrs B to remain at the home and the owner was advised to apply for a Deprivation of Liberty Authorisation with regards to Mrs B’s best interests.  A week after the visit, Mrs B was taken to hospital in an ambulance following a fall. She was seen in A&E and given treatment for a cut to her head. Mrs B was then transferred back to the care home.  A safeguarding referral was made regarding injuries Mrs B had sustained possibly from falls. The allegations could not be substantiated and it was not possible to establish what happened to Mrs B who died in hospital on 6 November 2010.

Professional learning:

  • There is limited evidence to show that Mrs B’s needs were adequately met and there were at least two occasions when safeguarding procedures should have been triggered. A more proactive and timely response to Mrs B’s care needs would not have had a positive impact on the quality of her life.
  • Assumptions were made that others were doing what was necessary and/or making a referral to another agency and these actions were not verified. It was the view of social workers, nurses (including the owner of nursing home) that Mrs B was suffering from dementia yet no one arranged for her assessment by an appropriate specialist.
  • Throughout the time Mrs B was a resident at BNH her family had reservations about whether she was receiving an appropriate standard of care to meet her needs. Staff should explore with relatives who express concerns their reasons for these and these to be recorded in the client record.
  • Families should had the opportunity to attend safeguarding meetings (or part) to provide their perspective and contribute valuable information about the care provided to their relative.

2012 April Serious Case Review regarding Mrs B (Blackpool)