Elderly man with Alzheimer’s disease died when agency failed to provide night care

An elderly man with Alzheimer’s disease died following a fall from bed when an agency night carer failed to attend his home. A Parliamentary and Health Service Ombudsman investigation found service failings by the nursing agency and made recommendations to ensure that these were not repeated. 

For several months Mr Robert Adamson had been receiving essential night care at his home from Chester-based nursing agency, Jane Lewis. Robert, who was in his early eighties, was unable to get out of bed without assistance or look after himself. The night carer’s role was to keep him safe and comfortable and provide respite for the family. 

On the night of the incident, the carer did not arrive at the usual time. The family made calls to the agency and were assured that a carer would come that evening. Robert’s wife went to bed on the understanding that her husband would receive the support and assistance he needed during the night.

The following morning Robert’s daughter, Rachel, found her father dead on the floor beside his bed. When the family complained, the agency did not appear to appreciate the level of distress caused and disagreed with the family about what had happened. 

Unsatisfied with the agency’s response, Rachel complained to the Ombudsman. The subsequent investigation identified that the agency’s poor communication and administrative errors left Robert without a carer on the night he died. Robert’s family received an apology from the agency, a payment that acknowledged the emotional impact and distress caused as a result of the service failings and the agency took steps to ensure that errors were not repeated. 


Parliamentary and Health Service Ombudsman, Rob Behrens, said: 

‘This case illustrates the significant impact on families when failings occur and the benefit of bringing unresolved complaints to the Ombudsman.  

While we recognise health care staff are under significant pressure and applaud the fantastic job they do, communication and reliability are key elements of their work and, when things go wrong, it is vital that this is recognised and steps are made to improve services.’ 

Mr Robert Adamson’s daughter, Ms Rachel Adamson said:

‘Night care enabled my father to continue to live safely at home with my mother. His death in the absence of a carer demonstrates how essential that support was. 

Our complaint to the Ombudsman led to the agency acknowledging its mistakes and apologising. Our family’s loss has helped ensure that the same thing does not happen again and others do not experience the distress that we did.’  

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Available for broadcast interview on Monday 19 November: 
Rob Behrens, Parliamentary and Health Service Ombudsman
Duncan Adamson, son of Robert Adamson

Contact Parliamentary and Health Service Ombudsman press office:  
jeanette.ward@ombudsman.org.uk | 0300 061 4639 | 07387 414 844
Out of office hours | press@ombudsman.org.uk | 0300 061 4444

Note to editors: 
The Parliamentary and Health Service Ombudsman provides an independent and impartial complaint handling service for complaints that have not been resolved by the NHS in England and UK government departments. We look into complaints where someone believes there has been injustice or hardship because an organisation has not acted properly or has given a poor service and not put things right. We share findings from our casework to help Parliament scrutinise public service providers and to help drive improvements in public services and complaint handling.