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 Care Campaign For The Vulnerable

Care Campaign for the Vulnerable is learning of the pressures faced by conscientious led Care Providers striving to offer a caring and safe environment to both service users and staff. Safety monitoring is proving to be a invaluable care assist tool - bringing a more open and transparent culture into care homes as well as saving valuable resources within the care home sector and the NHS

Case Studies

''We want to shine a light on the proven neglect our Dad suffered in a care home ...''

Added on 22nd December 2020



'''We don't want any family to go through the hell our family has gone through. The final outcome letter substantiating the traumatic neglect my dear father suffered was an insult to his memory and to his deserving of good, safe care. We, along with Care Campaign for the Vulnerable are calling for a change in the law for safety monitoring to be mandatory in all care homes. Our Dad's neglect was ongoing and only because we wouldn't give up, our concerns were then heard. Our Dad suffered terribly and he didn’t deserve such distressing treatment .''

Care Campaign for the Vulnerable receives a high number of messages telling of alleged neglect suffered in care investigated by adult safeguarding teams. Many tell us no one is then held accountable for the emotional and physical harm suffered to their loved ones. We continue to call for the mandatory use of safety monitoring in the care of vulnerable elderly and our dedicated care staff. CCFTV understand while we raise awareness to unacceptable standards in the care of vulnerable elderly reported by families and care workers we accept there are care homes/Care Providers that exceed families and residents expectations. We support our dedicated care workers.


'' Dad was left unattended on a crash mat in his boxers and t-shirt. I walked in and saw him distressed next to a warm radiator left unattended. Is this care to an elderly person diagnosed with dementia?'' Karen, daughter.

''Our family received a final outcome letter about my Dad's neglect in a care home. I have provided lots of evidence including videos and photographs after the safeguarding incident was raised. Many questions though have not been answered .

So many NICE guidelines were breached. My Dad would have been left to die on the floor on a crashmat had I not intervened. After lots of emails and letters some claims have now been substantiated but the letters I have received all have the same copy and paste answer. eg " we are sorry that the care at your Dads care home did not meet the required standards that we would expect for residents within Lancashire and for any distress this has caused."

I have now had a Refusal of Dad's records I applied for under Subject of Access request. It was a long and complicated email from the Data protection officer for Lancashire County Council but the bottom line was ''your request is therefore refused by virtue of Sections 36(2)(c), 40(2) and 41(1) of the FOI Act''.

My Dads end of life drugs were administered without authorisation and at first staff said they had a recorded telephone conversation of me giving authorisation which was untrue and when challenged they now said it was a conversation that took place with me and it was written in my Dad's notes. No conversation ever took place . I was not power of attorney but it was my sister they should have authorised with this.

'' I really don't know where to go from here.''Karen.

''We were informed dad had fallen.. We asked the social worker to find out were the bed rails up as Dad was fully mobile using a walking frame at this stage. He had only been a resident for fifiteen days. We asked why he was confined to bed and was there a DOLs in place. We didn't receive a response to this which is why I applied for his care records.''

There is incorrect information on the paperwork I inspected at the crematorium and have been told by County Council to take this up with the authors of that particular document which was the statement of truth. The nursing home gave them the information needed when my father died in their care. The outcome I want from this shocking failture is to protect other residents in the EMI unit. We have been ignored and I also wanted someone held accountable for the numerous events that happened. I have received nothing but letter after letter from the County Council and don't know which way to turn next. Do I instruct a solicitor (I don't want a monetary award though as this would make me feel worse) Do I just go public with the horrendous care he received?

My Dad was worth more than a 'copy & paste' response. We understand he suffered dementia but the way someone dies lives in the memories of those who are still here. Even after he died my sister was told to leave as the on call doctor would be a while and after that the funeral directors would 'come and shift him' - this was said twice by the same member of staff - she is haunted by those words. Surely someone should be treated with dignity even after death?

I have a full breakdown of everything that happened in date order which we shared with the social worker to investigate. So many things have been overlooked. I have tried to log a complaint with the local government and social care ombudsman but it's proving very difficult. It's been an incredibly long couple of years and I am now tired so mentally and physically. Too much neglect and too many people who give up the fight. Our father deserved so much better and those who say they failed him must be held accountable.''

Dad weighed 15 stone before he was moved to his care home for nursing care on 9th November. The reason for the move was because he had started to have regular falls and there were not the facilities at the home, he was in to deal with the number of falls.

We asked for a meeting with the Home manager – she said she was unavailable all day as her area manager was in. My sister said maybe the manager needed to hear some of our concerns about Dads care. We did this so issues could be addressed before it got any worse – alarm bells were already ringing, and we were unhappy with the managers response to our concerns and followed this up with a letter to arrange a meeting to which there was no reply.

''Our Dad had no dignity towards the end of his life''.

On the 24th November, dad was sent to the hospital by ambulance – he had gashed his elbow and had a fall, this was due to the bed rails being up on the bed and he climbed out at this stage dad was still mobile and able to walk around using a walking frame. Why was he confined to bed?? (photo)See Ambulance Report re safeguarding at later date about being in bed against his will?

There was a further admittance to hospital after a fall on 10th January and he was there until the 20th January. It was here that they discovered after x-rays that he may have pneumonia, and this was cleared up with antibiotics. We were then advised that there would be a referral to the SALTS team. Dad was not assisted with his personal care – we discovered that he had not had a bath for four weeks. On 1st February Dads notes say that he was unable to feed himself. There was no support for him, he was spitting food out there was still no SALTS team in place since January. His weight then was then 12 stone 8.

On 2nd February (Friday) Dad was in some sort of pain and morphine patches were authorised 10mg weekly but a prescription was not available, and we were told that we would have to wait until Monday. Dad was in pain. Pain management plan? On 8th February the EMI unit was on lockdown due to a sickness and Diarrhea breakout.

On 14th February I went to visit dad. I found him sat in the dining area in a wheelchair with no shoes or socks on. I don’t know how long he had been sat there he wasn’t even in front of a TV he was just sat near the dining table by himself. We had provided a brand new wheelchair for dad but the one he was sat in didn’t even have a cushion on it and when he tried to adjust himself later he said ouch and I noticed a screw sticking through the material at the back of the chair a cushion on the chair would have avoided this at least. He cut the back of his hand. When the evening meal came round, I personally fed him. It was minced meat, mash potato and peas. He was struggling to eat it, but I did manage to get him to eat some albeit it did take me over an hour and he drank two mugs of tea. After getting something inside him he was much less agitated, and we then were able to have a conversation.

I noticed during the meal times two residents were served their meals and woken up to eat. One lady turned her head away so rather than try again, her meal was left on the table next to her. Another resident was then approached with her meal and a similar thing happened the carer on duty then said '''Oh she doesn’t want it and took her food back and then came back for the other ladies’ food that had been left on the table. There was no support during the meal times for vulnerable residents. Thankfully I was there that day or Dad would not have eaten either and would have been labelled as'' refused to eat. '' On the 25th February Dad was visibly upset and crying – he was asking what he had done wrong to deserve this I have never in fifty years seen my Dad cry.

My sister witnessed Dad being hoisted – Dad was left dangling in the air because no one could decide how to move him from the chair to the bed. Personal slings not used for one person nor were they disposable. The hoist was used for all patients from patient to patient (cross-contamination) and she also witnessed a certain member of staff not wearing gloves whilst changing one of Dad's dressings.

On 4th March Paramedics attended to dad and were horrified with their findings and immediately raised a safeguarding enquiry, they did not want to leave him in the care home. He needed urgent assistance and should have been on 1-1 care but there were no staff in place or available. They were appalled that there were no disposable gloves in the room and not even a bin to put used clinical waste in. SEE Report

Later that day a care worker came into Dads room and sat with him and managed to get some food down him we had a conversation with him and told that it is usually bank or agency staff that come in and deal with this and we would have to speak to a manager and were told a manager would be the best person to speak to. We asked if we could get some thick and easy ourselves to get some nutrients of some kind inside him and was told we would have to make sure there was an official stamp and then “hopefully” he should get some assistance. There was still no SALT team referral and we were running out of time. (this conversation was recorded)

On 6th March his fluid intake chart shows he was still being given fluids clearly not thickened! There were no fluids on his chart after 14:55 (see photograph) – these records were photographed on 7th March as they were in his room.

On 7th March we were advised that there would be an unannounced social worker attending due to issues raised – this did not happen. I visited that day and was horrified at what I found Dad was on the floor (see video) I stood in the doorway and while helping I videoed this, how long had he been like this? He had just a pair of boxer shorts on and a t-shirt he was writhing around on the floor with his head against the heater (which was on) – the pipes were exposed underneath.

''The radiator cover was even coming off the wall...all evidenced''

He was left that evening to sleep on the crashmat – not even a proper mattress. After speaking to my sisiter who went every day to visit dad, she often found him huddled on the floor with just a pad on in his boxer shorts cold and lonely. On 8th March we were told that he was now on EOL drugs – none of the family or POA had been informed of this decision. Dad was lay on a mattress on the floor. I witnessed his mouth care was done with a toothbrush we used to clean his dentures. His fluid intake chart shows he was given spoonful’s of fluids that day some not thickened, no fluids were offered after 5:30. I was there all night. His last mouthcare was done at 7:55 again with a toothbrush. I gagged myself and managed to find some white cotton material which I soaked in cold water.

I stayed with Dad overnight. This prompted me to evidence a lot of the failures...There was a screw sticking out of the wall above the bed that dad had cut himself on many times even though it had been brought to the attention of the team on many occasions. There were medicines e.g. denture tablets, footcare spray, meds in a cupboard in his room that was left unlocked. I took a (photo) of the bloodstains that were on the cabinet and were there the previous day, these were not noticed by staff. I did not once witness his room being cleaned. On more than one occasion during that day I was asked if I was staff or a visitor by staff members? I spoke to a new member of staff outside who told me that she didn’t have a uniform as it was not issued until after six weeks. This leaves the home open to anyone walking in and accessing clients.

I stayed with Dad on the floor and was there for over 48 hours. I got offered one pot of tea and some biscuits. Dad needed 1-1 support but this wasn’t happening. You wouldn’t leave a dog on the floor when they are so ill. The Social worker did not return calls even though the neglect we witnessed had been reported by paramedics. The manager was unapproachable and did not acknowledge any member of the family or Dad. We had been told in no uncertain terms that he was at risk of dehydration and starvation.

On 9th March Dad was still left on the floor I spoke to the Manager who was on Duty that Day and asked who had authorised for Dad to be put on EOL drugs and she told me that he wasn’t on EOL drugs. She had just returned from holiday. I suggested that she rang the other manager that had been on the previous day and had now gone on annual leave and we needed to know was he or wasn’t on EOL drugs. She later returned to me and nodded that yes, he was on EOL drugs I asked her who authorised it, but she was unable to tell me which I appreciated because of confidentiality but there should have been family involvement about when EOL drugs would be commenced as my sister has LPOA. I asked to look at his care plan but was advised that these are removed out of a resident’s room once EOL is commenced. Later that day (FRI) we took it upon ourselves to pick Dad up together with his mattress off the floor and into bed. He was NOT going to die on the bedroom floor = his dignity was beyond compromise.


Staff were not aware of thickened fluids and there was no written information to ensure drinks were e given at the correct consistency. Dad was thirsty for weeks, not just at End of Life. I personally visited regularly and was only ever offered a drink myself once Dads hydration status was not assessed daily nor discussed with Power of Attorney. No one was asked about options for hydration. Dad could have been clinically hydrated if we had been asked, this would have relieved the distressing symptoms we witnessed. He was thirsty – this was proved in the hospital – after clinical hydration, he could even tell the time. Hydration was withheld which had a negative impact on the dying process – were they following the pathway?

Under NICE guidelines there was no information how to contact the team involved in Dads case, there was no one available to ask questions. There was no shared decision making in the last days of life – there were no oral hygiene sponges used.


There was no record consulted as to where meclizine had been injected. I personally witnessed the Care Home manager say to the nurse “where did you inject him last time?” The reply was “in his left thigh” The Care home manager then said do it in the right thigh this time then. No records MAR form were looked at or filled in, there was no acknowledgement or reassurance to Dad about what was about to happen. She just waited until the injection had been given and walked out of the room and didn’t even acknowledge any of us either. The syringe driver was commenced on Saturday 10th March set up via the out of hours service (who authorised this) Controlled drug … NICE guidance not followed. The morphine drive was in an unlocked box with information missing (photo x 2 & Video) Syringe should be labelled with date, drug names, dosages and diluent. (avoid the numbers on the barrel of the syringe so that the amount remaining can be easily seen)

RESPECT AND CARE AFTER DEATHWhen Dad passed away only my sister and her husband were present in the room. Shortly after a male carer came in and said he would go and get the nurse to confirm what had taken place.

The personal care after he was pronounced dead was virtually immediate. My sister was told to leave the room so that they could “check Dad's pad for secretion as this it what sometimes happens when someone dies” There was no need for a running commentary about what they were about to do. It showed lack of sensitivity to his family.

My sister was then allowed to sit in with dad as the funeral directors had now been informed but she was told 5 minutes later that she may as well leave because the on-call doctor to certify death would be a while as he was on another call. She was then told that once the death is certified the funeral directors would “COME and SHIFT him” – this was said twice by the same member of staff and this sentence was inappropriate and lacked dignity to our Dad. My sister is still haunted by those words, and to me Dad was not spoken about as a person with respect. There was no support for the family at such a traumatic time.

Surely the Home Manager is responsible for ensuring that professional carers are trained appropriately for Care after Death. Dad was not cared for with dignity even after he passed away. The day after my sister arrived to clean his room, she was not acknowledged or assisted by any member of staff she was just left on her own to clear Dads things away. The cremation paperwork said Dad was admitted to the hospital with community-acquired pneumonia and was then placed on the end of life pathway. He was admitted after a fall and the EOL pathway was not commenced until March The hospital admission was in January? This information was not accurate.

It says the person present at time of death was a staff member as far as we are aware, she was not on duty that evening. My sister should have been named as the last person who had nursed the deceased.All previous CQC reports regarding this home say that they have found evidence of neglect, but nothing has been done. The CQC has failed as it had concerns over safeguarding and management in the last three visits and have not acted upon their findings. I need one email address only for all concerned – why was no action taken? Action needs to be taken against the person who authorised anticipatory meds. Privacy and dignity were not protected. Personal needs were not met as well as too many inconsistencies in medical notes.

Care Campaign for the Vulnerable is fully supporting this family and will be working to highlight the neglect against their late father in a care home. CCFTV has seen the final report on the neglect of their late father and all correspondence. The family support our call for the urgent need for safety monitoring in the care of vulnerable elderly. Care Campaign for the Vulnerable contacted the care provider. A meeting with senior management and the family was facilitated and we are waiting on the outcome.

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Care Campaign for the Vulnerable is learning of the pressures faced by conscientious led Care Providers striving to offer a caring and safe environment to both service users and staff. Safety monitoring is proving to be a invaluable care assist tool - bringing a more open and transparent culture into care homes as well as saving valuable resources within the care home sector and the NHS

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