A vulnerable man choked to death after a care provider failed to undertake an appropriate risk assessment and produce an acceptable plan for his care, the Public Services Ombudsman for Wales has found.

The Ombudsman launched an investigation after receiving a complaint about the care provided to Mr N (anonymised) between 2015 and the time of his death in March 2017 by three bodies; Gwynedd Council, Betsi Cadwaladr University Health Board and Cartrefi Cymru.

Mr N suffered from drug-induced psychosis and a severe brain injury which meant he required around-the-clock care. At the time of his death, he was living in his own rented home with a package of 24-hour care, which was provided by Cartrefi Cymru – a registered domiciliary care provider – and funded jointly by the Council and the Health Board.

The Ombudsman found that there was no documentation relating to the awarding of the care contract to Cartrefi Cymru, nor any specific terms relating to Mr N’s care needs and the respective responsibilities of all parties involved in his care.

The Ombudsman found that this amounted to maladministration on the part of the Council and the Health Board.

In addition, he also found there was no documentation to demonstrate that the Council, as lead commissioner, had monitored the delivery of the care service provided to Mr N.

The investigation also found that Cartrefi Cymru failed to undertake a comprehensive assessment of the risk of Mr N choking, even though he was hospitalised following a choking episode in 2016, and problems with his chewing and swallowing were recorded as far back as 2015.

Commenting on the report, Nick Bennett, Public Services Ombudsman for Wales, said:

“I am extremely concerned at the multiple failings in communication between the three bodies involved in providing care to Mr N. It’s impossible to say with any certainty whether any of the bodies involved had seen a risk assessment relating to the risk of him choking, but given his obvious vulnerabilities, it was clear to me that the care provider should have carried out its own risk assessment at the earliest opportunity.

“While I cannot conclude whether any of the failings I have identified caused or contributed to Mr N’s death, his family have been left with the uncertainty that, were it not for these failings, things might have been very different. I sincerely hope lessons are learned from this tragic case.”

The Council and the Health Board have agreed to several recommendations, including:

  • Apologising to Mr N’s family for the failings identified in the report.
  • Reviewing their respective contract governance arrangements to ensure they are in line with best practice as set out in the Wales Procurement Policy Statement.

In addition, Cartrefi Cymru has agreed to provide refresher training for staff on the importance of reviewing care packages and carrying out appropriate risk assessments as soon as they are contracted to provide care to an individual.

To see the report click here.