The woman was found dead in October 1991 after she had been left unsupervised in the bath for 35 minutes at a residential care unit. The coroner concluded the most likely cause of the drowning was an epileptic fit.
The woman was in her mid 30s but had a mental age of around three. In her teens she had suffered epileptic fits but medication to prevent this was stopped just before her move in 1987 to the six bed unit where she died.
A year before the death the unit's staff discussed with her parents the idea of drawing up a 'goal plan' which included enabling their daughter to bath independently.
No formal plan had been drawn up aimed at enabling Ms Smith to bathe herself. On the night she died one member of staff had gone home 15 minutes early leaving just one person on duty, contrary to council policy.
Her parents complained to the council and a senior officer investigated. They were still not satisfied and put their case to the social services complaints review panel made up of an independent chair and two council members.
At the panel's hearing the Smith family faced three of Cleveland's legal staff and two from social services. Ombudswoman Patricia Thomas was unimpressed by Cleveland's claim that legal staff were there as unbiased observers and described the involvement of one of the officers as 'unwise at the very least'.
The panel said it had not found proof Ms Smith died through lack of care, claiming the coroner ruled out lack of care as the cause of death. This was untrue.
The ombudsman concluded there was maladministration in the way Ms Smith was cared for and maladministration causing injustice to her parents in the way their complaint was handled.
Mrs Thomas recommended the council paid the parents compensation for the distress caused by the handling of the complaint. She stopped short of concluding the maladministration caused Ms Smith's death as the coroner had been unable to ascertain why she drowned.
David Behan, Cleveland's deputy director of social services, said a team of officers had been set up to ensure residents in all the council's homes received a consistent level of care.
Chief executive and treasurer Bruce Stevenson told LGC the council would be discussing a recommendation to accept the report. 'We hope we can reach a satisfactory financial settlement with the family', he said.