A WATCHDOG has hit out at the substandard investigation carried out into the death of a woman suffering from dementia by Oxfordshire county council.

The Local Government Ombudsman said the local authority’s actions as well as those of Caring Homes Healthcare Group Ltd which runs the care home where the woman was looked after, were not up to scratch.

It comes after the husband of the woman said his wife was left severely dehydrated and suffering from oral thrush after a week-long respite stay at the Huntercombe Hall Care Home in Henley.

The investigation revealed how the woman, who had advanced dementia, needed full-time care and could not say when she was hungry or thirsty. She struggled to swallow and needed a thickening agent added to her drinks.

The woman’s husband privately arranged and funded the stay at the Henley-on-Thames home and spoke to the carers there about her special circumstances.

When the husband returned to pick her up, he described her as ‘less responsive and limp’ and her mouth had a coating of white spots.

He contacted the care home’s GP and the woman was taken to hospital, with paramedics giving her a drip.

The woman stayed in hospital for three weeks, with her records showing dehydration and problems with her kidneys.

She passed away just a week after being discharged from hospital.

The husband complained to the Caring Homes about his wife’s care, and raised his worries with the county council.

The care home responded to the man’s complaint but found no shortfalls in its treatment of the woman.

Meanwhile the council conducted its own investigation, but at no point involved the husband.

In a damning verdict, the investigation revealed the council did not conduct a strategy meeting, but asked for a report from the provider.

But it did not chase that report swiftly when the provider was slow to respond – potentially putting other vulnerable residents at risk.

The council’s report into the situation appeared to accept the provider’s version of events, but also recorded a finding of ‘neglect – partially substantiated’.

But the local authority did not recognise the inconsistency in the care provider’s records for the woman and an account given by the GP who saw her on the day she left the home.

The council closed the initial assessment, taking no further action, but it was not clear if it told the provider it had come to a finding of partial neglect, or told the regulator the Care Quality Commission and its own contract department about the findings.

The investigation also found the council did not act in accordance with the law and relevant government guidance.

Dr Jane Martin, Local Government Ombudsman, said: “While nothing can make up for the loss of a loved one, I hope my investigation will give this woman's family some reassurance that lessons have been learnt and other vulnerable adults will not have the same experience.

“Neither the care provider nor council’s investigations were up to the standard I expect, and failed to give the family proper answers as to what went wrong. Organisations can only learn from events like these if they conduct thorough and searching investigations.

“I welcome the significant steps Oxfordshire council has already taken to improve its policies, procedures and staff training in this area and am pleased it has agreed to my further recommendations. I now call on the care provider to reflect upon my report and implement the remedies I have recommended.”

Oxfordshire County Council has already apologised to the man and has also been asked to pay him £250 for the time and trouble he has been through in pursuing the complaint and £500 for the distress caused.

Oxfordshire County Council director of adult social services John Jackson said: "We pride ourselves on very high standards in our management of adult social care in Oxfordshire. Our satisfaction ratings from service users are always very high and we were recently ranked 6th out of 152 councils nationally for delivering outcomes for service users.

"I have never before or since seen a case in Oxfordshire in which actions dropped below those high standards in this way. The way we handled this case was very disappointing.

"We have not hesitated to apologise to the husband and as the Ombudsman has acknowledged, we have implemented robust and extensive improvements to procedures, even though even at the time this was an isolated case of poor practice and in no way systemic or representative of the general standards to which we operated in 2014 or now."

The ombudsman ordered the care provider to issue a full written apology to the man for its failure to provide adequate care to his wife and also apologise for its failure to deal with his complaint properly.

It also said the company should also waive the full fee for her stay in the home.

A spokesman from Huntercombe Hall Care Home said: "We are deeply disappointed by this report, and apologise unreservedly to the family for falling short in this instance of the high standards we set ourselves, and that residents rightly deserve.

"When concerns were first brought to our attention, we worked closely with the local authority and took their guidance on addressing these issues.

"We have subsequently implemented a range of measures at the home to further strengthen our monitoring and record keeping processes. Following the LGO report, a full written apology will be sent to the family in the coming days, and we will also waive all associated fees.

"The health and wellbeing of residents remains our number one priority. The home has a strong reputation for providing high quality care, so we are doubly disappointed not to have lived up to our own very high standards in this case. We will continue working closely with all partners, and we are confident the care being provided at the home is of a consistently high standard."