National Ombudsmen
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Kent Council delayed investigation of elderly man’s injury in care home

Kent County Council delayed in investigating how an elderly man came to be seriously injured during an altercation with another resident of his care home. The man died in hospital a few days later.

In her report, issued recently (19 October 2012), Local Government Ombudsman Anne Seex says that “the Council’s three failures to investigate the incident caused the man’s daughter significant injustice. She had to wait for more than a year for an answer to whether her father’s death could have been prevented. This has caused her significant distress.”

Mr B lived in a residential care home, where his care was arranged and paid for by the Council. One day he had an altercation with another resident, Mr K. Both men fell to the floor. Mr K suffered a minor head injury and Mr B a broken hip. They went into hospital by ambulance. Mr B underwent surgery but failed to regain full consciousness. He died 11 days later of pneumonia.

Mr B’s daughter. Mrs B, complained that the Council did not properly investigate how the incident came about, failed to keep her father safe, and gave her wrong information.

It took a safeguarding investigation, a complaints investigation, an internal Council investigation, and a complaint to the Ombudsman, before a second internal Council investigation properly looked at whether the incident involving Mrs B’s father could have been avoided.

The Ombudsman commended the Council’s second internal investigation, which found serious cause for concern, notably that the previous investigations had not uncovered relevant evidence or identified the home’s failure to assess the risk or manage the situation. Also, the home had not raised a safeguarding alert when it should have done, and had inadequate risk assessment and management.

The Ombudsman recommends that the Council should:

  • pay Mrs B £5,000 to recognise the injustice of her justified feeling that her father’s death could have been avoided, and distress caused during the year she waited for a credible investigation
  • pay her a further £1,000 to recognise that it was her efforts that enabled it to identify systemic weaknesses in parts of its adult care service, and
  • provide up to £1,500 for Mrs B to choose a memorial to her father.

The Council has begun to review and improve the way it monitors the quality of care when it has arranged for people to have residential care. The Ombudsman recommends that elected councillors should monitor the reviews and system developments.

Report ref no 11 009 473

Note: For the Ombudsman’s purposes, the law says that when a Council exercises a function through an arrangement with another person, their actions are taken on behalf of the Council and in the exercise of its function. The Council arranged for Mr B to be cared for in the home. It did this to discharge its duty to him under Section 21(a) of the National Assistance Act 1948. The home’s actions were, therefore, on behalf of the Council and in the exercise of its functions.


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