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New Public Interest Report: Failings in management of support for a vulnerable adult who died whilst receiving care services commissioned by Wrexham County Borough Council

The Public Services Ombudsman for Wales has issued today a public interest report regarding Wrexham County Borough Council. She has concluded that the Council did not adequately support a vulnerable adult with learning disabilities, who later died.

The Ombudsman launched an investigation after receiving a complaint from Mrs X about support provided to her sister, Ms Y, by Wrexham County Borough Council.

Ms Y, an adult with learning disabilities and history of alcohol dependence, had been moved by the Council into supported living accommodation, managed for the Council by a contracted provider. Mrs X was unhappy that the provider delayed in telling the Council of increasing concerns about Ms Y’s behaviour, and that when the provider finally contacted the Council they were unable to access support for Ms Y.  Ms Y sadly died in April 2020.

The Ombudsman upheld the complaint. She found that the provider did not escalate matters to the Council quickly enough and that the Council did not appropriately manage Ms Y’s care when matters were eventually escalated. She also found that the Council did not explore the opportunities to share with Mrs X information about her sister’s condition. Finally, the Ombudsman also found failings in how the Council handled Mrs X’s complaint about her sister’s care, with conclusions of an independent investigator not fully included in the investigation findings, nor shared with Mrs X.

Commenting on the report, Public Services Ombudsman for Wales, Michelle Morris, said:

“This is a sad case of grave injustice and we extend our sympathy to the family.

We acknowledge that when Ms Y died, the COVID-19 pandemic had already placed severe pressure on the Council’s services.

Nevertheless, we decided that, given that Ms Y was a vulnerable adult with a history of known alcohol dependence, concerns about her condition should have been escalated sooner, and the Council should have offered support when matters were finally escalated.

Our report is clear that we cannot know whether earlier interventions by the Council would have altered the sad outcome for Ms Y. However, we are also clear that several opportunities to intervene were lost.

One of those opportunities was to ensure that Ms Y had all the chances to receive support from her family. Sadly, we found that because the Council did not seek Ms Y’s consent about sharing information with her family, her sister was unaware of Ms Y’s condition and unable to extend that support.

We were also concerned about how Mrs X’s complaint to the Council was considered and managed. The failings that we identified in that process call into question the robustness of the investigation and its findings.

Although the Council was not directly providing day to day care for Ms Y, as the body with overall responsibility for the delivery of its social care functions, the Council was responsible for the failings.

We welcome that Wrexham County Borough Council has now accepted these findings and conclusions and has agreed to implement the recommendations in full.”

The Ombudsman recommended that Wrexham County Borough Council issues a meaningful apology to Mrs X for the shortcomings identified in the Report and

  • implements all the actions identified during the Council’s investigation of the original complaint by Mrs X
  • reminds those it contracts to undertake independent investigations on its behalf to ensure that any findings or critique of the service provided to a client are reflected in their report and findings and not shared separately with the authority
  • reminds relevant staff of the importance of regular contract monitoring in relation to the delivery of social care services by third party providers, to ensure appropriate intervention if there are concerns about the provision of service or a change in a client’s needs.

Read the full report here