Elderly man with Alzheimer’s died after being left without a carer overnight

Organisation we investigated: Jane Lewis, Chester 

Date investigation closed: June 2017

The complaint

Rachel Adamson complained to us about the death of her father, Robert Adamson, who was living with Alzheimer’s disease and in his early eighties. He died after a fall in the night when an agency failed to provide his regular care. His daughter found him the next morning on the floor. 

Ms Adamson wanted an explanation of what happened to her father the night before he died, assurances that action had been taken to stop anyone else being in the same position, and a financial remedy for the injustice suffered.


Mr Adamson had been receiving night care for several months. A carer was due to arrive at his home by 10pm. When no one arrived a number of calls were made to the health and care agency by his wife and daughter.

Following assurances from the agency that a carer would arrive, his wife went to bed at 11pm. His wife is elderly and would not have been able to provide her husband with the support and assistance required through the night. Ms Adamson found her dead father on the floor the following morning. 

What we found

We partly upheld this case. We found a number of failings in the service provided to Mr Adamson on 8 August 2016. We did not find that these failings contributed to or caused his death.

We found poor service by the care agency which caused Mr Adamson a significant injustice as he was unexpectedly left that evening without a carer to provide the support he needed. This was likely very distressing for him.

We also identified poor communication by the agency with the family. For example, on the night the agency wrongly assumed that Mr Adamson’s wife was his live-in carer. Mrs Adamson was too frail to look after her husband. 

His daughter had to cope with the trauma of finding her father dead the following morning and the family were left with a great deal of uncertainty about what had happened, which was very distressing for them.

Our clinical advisor found it plausible that the apparent fall could have been prevented if a night carer had attended as planned. However, given Mr Adamson’s underlying conditions - End Stage Alzheimer’s Disease, high blood pressure and heart disease - it was difficult to find a clear causal link between the fall and his death.

Putting it right

We recommended the organisation acknowledge the failings and apologise to Ms Adamson for the poor service and distress it caused her and her family. We also recommended that £1,000 be paid to Ms Adamson for the injustice suffered especially the uncertainty of not knowing whether her father would still be alive if a night carer was with him the night before he died.

We recommended that the organisation develop an action plan to address the failings and that this should identify any specific reasons for the failings and the learning it has taken from these issues. It should explain what it will do differently in future, who is responsible and timescales for each action, and how these will be monitored.