Burnt woman left screaming for three hours by care workers

A woman recovering at home from a stroke, was left screaming in pain with serious burns to her leg when her care workers moved her too close to a hot radiator.

The lady was left on a commode near her bathroom radiator by home care workers, causing her to shout out in pain and suffer nine red marks on her leg - measuring seven to 12.5 cm in length.

Despite her screams, it took her home care workers almost three hours to decide she needed urgent medical attention and three and a half hours for her to receive any pain relief.

An investigation by the Local Government and Social Care Ombudsman, following a complaint by the woman’s family, reveals the incident on 20 October 2017 took place during a visit by two care workers commissioned by Blackpool Council from ICare domiciliary care agency.

The watchdog highlighted that although care workers made a note in their case records of red weals on the woman’s leg at 8am, there was ‘a delay of between two and three and a half hours in the woman getting pain relief’, with none given until paramedics attended after 11.30am.

The ombudsman's report stated: ‘It is of grave concern that the carers did not seek urgent medical help, so that Ms Y could have some pain relief quickly. The paramedics too seem to have been informed of the weals just as they were leaving, rather than having been told about them on arrival’.

‘Avoidable pain and distress’

The agency’s case record (made at 8am to 9am that morning) stated the woman was 'fine assisted to wash and dress assisted into lounge, prepared cup of tea, meds prompted. Pain in Ms Y’s arm on standing. Noticed the red weals on upper thigh. DN [district nurse] to be informed'.

The watchdog found the care agency had caused ‘avoidable pain and distress’ with the care workers’ failure to seek urgent medical attention. It also said the care workers had ‘failed to provide an accurate account of what happened’.

Because of her stroke, the woman had been using a wheeled commode at home and required two home care workers to change her position, give personal care, prompt her to take her medication and prepare meals.

The woman possessed little feeling on the right side of her body because of a stroke she had in 2016. She also had difficulty communicating due to dysphasia caused by the stroke, (which meant parts of her brain - used to translate thoughts into spoken language - were damaged). The woman, as a result, during the incident said her arm was hurting.

When her daughter arrived at the house, the paramedics were present. The relative describes her mother as very distressed and told the ombudsman there was no mention of red marks on her leg and she was fully dressed.

The paramedics gave pain relief and were about to leave, when care workers took her mother to change her and one told paramedics: ‘you had better come and look at this’.

After seeing the burns, paramedics took the woman to hospital, but her wounds became infected. She has been unable to return home and now lives in a care home.

Her daughter believes the woman suffered a significant loss of independence and a decline in her health and believes the council and agency’s failings caused her to lose her independence and be moved to a care home.

The ombudsman said the relative could have sued the council and the agency for negligence.

A ‘misleading’ breach of candour

The watchdog’s report stated: ‘We reject the Council’s position that there is insufficient evidence to conclude carers were not open and transparent about Ms Y having sustained a serious injury. We consider the carers should have been clear when calling medical assistance that: Ms Y had red weals on her leg.’

The ombudsman highlighted a failure to identify ‘obvious environmental risks’ in the woman’s home (in particular the small bathroom, hot radiator, proximity of commode to radiator) and to design a care plan to minimise those risks.

It also noted a ‘failure to provide an accurate account of what happened and noted ‘inconsistencies in the agency’s account of what was known about the injury and when’.

The agency ICare Group, told homecare.co.uk ‘No further comment will be given. The comment is in the ombudsman’s report’.

In the report, the agency told the watchdog: ‘The carers overheard the paramedics say the red marks were not fresh and were crusted over. It did not know why the paramedics did not mention this in their report. It did not know Ms Y had reduced feeling in her right side; and Ms Y could communicate her needs.’

However the report stated: ‘We find the statement from the Agency about the marks being not fresh, which is repeated in the council’s complaint response, as well as the suggestion that carers did not know about the marks until they changed Ms Y’s clothes, to be misleading and a breach of the duty of candour and therefore fault.’

'Horrified'

The ombudsman has ordered the council to apologise to the woman and her family and pay £5,000 to her and £500 to her daughter.

It has recommended the council make sure its contractors complete risk assessments and regularly ‘quality monitors’ the agency to determine whether it has effective risk assessments.

ICare's existing contract with the local authority is scheduled to last until 1 April. The council has since renewed the care provider's contract for the next five years.

Councillor Amy Cross, cabinet member for adult service and health at Blackpool council, said: “There are more than a thousand Blackpool residents receiving care in their home every week and thankfully incidents like this rarely happen.

“I was horrified when I saw the picture of the injury that this lady suffered. On behalf of the council I unreservedly apologise for the distress that she and her family have experienced. It is not acceptable and it should not have happened.

"We have worked very closely with the company delivering this care and all our other providers to ensure that risks such as this are better managed in the future.” Local Government and Social Care Ombudsman, Michael King, said: “This distressing case serves to reinforce the need for carers to undertake thorough assessments of the care environment and the risks that they may pose.

“I hope the measures the council will now be putting in place will enable it to keep closer oversight of the agencies it contracts to carry out care on its behalf.”