Vulnerable Pensioner ‘Failed By System’

A vulnerable great-grandmother who died after her home help did not report a serious fall which left her with eight broken ribs was failed by the system, a council watchdog has concluded.

Sheffield Council has been rapped over its use of agency staff following an inquiry into the death of Sheffield widow Maria Stones, by Local Government Ombudsman Anne Seex. The council has agreed to pay £1,000 to the 94-year-old’s estate for her family to create a memorial and undertake an independent review of its procedures.

Before the incident, relatives of the pensioner had complained about missed or late calls by home helps supplied by agency Sheffcare on behalf of Sheffield Council.

Maria, who walked with the aid of a frame, was injured after falling against a table while rushing to turn on the kitchen light after the home help arrived late, after dark, and could not see to operate a digital keypad which operated the door lock.

But care worker Nicola Norton did not report the incident on January 17, 2004. And when Maria, of Thornbridge Drive, Frecheville, saw a doctor, he did not diagnose the problem correctly. As a result, she did not receive appropriate treatment, contracted pneumonia and died two weeks later in the Royal Hallamshire Hospital.

Ms Seex said Maria was “failed by the system which was supposed to protect her”. In her report, she found Sheffield Council had “no effective system” for dealing with missed or late calls by agency staff to vulnerable people.

Maria’s son had complained about this to both the agency and the council, but nothing had been done, Ms Seex said. Ms Seex added: “It can never be acceptable for elderly people whose care is the responsibility of the council to have to wait long periods of time. Councils must respond to reports of missed or late calls by agency staff and follow up complaints as a matter of urgency.”

Ms Norton was dismissed by her agency for failing to report the incident and Sheffcare terminated its contract with the council in April 2005. Until Maria’s death, Sheffield Council did not realise it had not responded to the earlier complaint, Ms Seex said.

Ms Seex concluded: “The council’s failure to take up complaints of missed calls promptly with the care agencies was maladministration. The failure to monitor the actions of the agencies, and to take action when problems were identified, led to unnecessary suffering and distress. The council also delayed in dealing with complaints, leaving the impression it did not care about its elderly and vulnerable clients.”

Sheffield Council has agreed to implement a series of measures to try to eliminate missed visits to vulnerable residents, which will subjected to an independent audit in the autumn to check if they are working.

Maria’s son Edward Stones, from Ecclesall, said he first complained about missed visits to his mum in November 2003 but never had a reply, even after her death, when he found out a meeting had been held by the council about the case.

Following an inquest in November and December 2004 – where coroner Chris Dorries was highly critical of Maria’s care – a complaints review hearing was held by Sheffield Council.

Its director of adult social care Cath Roff assured Mr Stones changes would be made to eliminate missed calls but he said he “still had concerns” and reported the case to the ombudsman.

Mr Stones said: “I accept the findings of the ombudsman’s report and welcome the fact there is going to be this evaluation of the home care service in six months time. Unfortunately, in the ombudsman’s report, my mum’s social worker said matters have not improved since her death in respect of missed calls.

“My mother’s life was cut short. Because nothing has been done about missed calls in the past I am reluctant to accept things are going to change. I would love to be proved wrong.”

Mr Stones said his mother had been “unhappy” about her care but she was a “stoical woman” who did not complain. He believes there may be many other elderly people not receiving the proper number of visits but who also have a reluctance to complain, so the true amount of failings may not have come to light.