Summary: Mrs X complains HC-One’s Priorslee House failed to provide her late father with the right support after he had a fall in February 2023, resulting in him sustaining an injury, spending time in hospital and moving to a nursing home, which otherwise could have been avoided. HC-One has made some changes following Mr Y’s fall and has apologised for any distress caused to him and his family. There is no need to ask HC-One to do more than it has already done.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains HC-One’s Priorslee House failed to provide her late father with the right support after he had a fall in February 2023, resulting in him sustaining an injury, spending time in hospital and moving to a nursing home, which otherwise could have been avoided.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)

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How I considered this complaint

3. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents HC-One has provided in response to my enquiries;
• considered the Ombudsman’s guidance on remedies; and
• shared a draft of this statement with Mrs X and HC-One, and taken account of the comments received.

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What I found

Key facts

4. Mrs X’s father, Mr Y, went to live in Priorslee House (the care home) in 2022. He was at high risk of falls, due to reduced mobility. He used a wheeled walker to get around the care home, with supervision from one member of staff. He had a wheelchair for use outside and for longer distances. The care home’s assessment from December 2022 said he was aware of his limitations and abilities, and consented to any assistance verbally. It said he did not need a hoist. There was a high risk to Mr Y’s skin integrity due to his age and medical condition.
5. In January 2023 Mrs Y went to hospital for observations after complaining of chest pain. When he returned to the care home on 13 January, he appeared a bit weak in the legs. Mr Y spent most of his time in his room watching TV. He also took his meals in his room. However, he continued to visit his family twice a week.
6. In the evening of 6 February Mr Y had a fall in the door to his bathroom. He crawled back to his bed and rang his call bell. Staff checked him for injuries, but there were none, and then hoisted him from the floor. He complained his left leg was sore.
7. On 7 February at 07.00 Mr Y complained of pain in his left leg and was given pain relief. By 11.00 he had severe bruising and blistering to his left leg. The care home sent photos and a referral to the GP. It also told Mrs X about the fall.
8. Mr Y spent 8 February in his room “due to his legs”. At 08.00 the GP practice told the care home a GP would call that morning. At 10.28 the care home told the district nursing service Mr Y had water blisters on his legs (inner thigh), one of which had burst. It asked for a visit. At 12.34 the district nursing service asked the care home to send photos. The care home sent two photos at 12.52. At 13.15 the district nursing service said a visit was not necessary, as the photos indicated the blisters would reabsorb, but to apply a dressing if they started to weep and to contact the district nursing service again. It said to send another photo in a week. The care home told the district nursing service it could not apply a dressing as they were not “clinical”. Mrs X visited. This was the first time his family had been able to visit since before the injury, as the care home had been closed to visitors because of an outbreak of illness.
9. At 16.50 the care home sent photos of Mr Y’s legs to the GP practices, as it was not satisfied with the response it had received from the district nursing service. It said the blisters needed dressing and asked for advice.
10. At 20.35 the care home called NHS 111 and was told a doctor would call. A doctor called at 21.25 and told staff to cover the wound while the doctor contacted the district nursing service. Staff cleaned and covered the wound.
11. At 02.30 on 9 February, staff gave Mr Y paracetamol, as he was in pain. At 05.00 he was experiencing increased pain and his blood pressure was high (178/98), so the care home called 999. Paramedics arrived at 05.14 and took Mr Y to hospital at 05.40. The care home tried contacting Mr Y’s family.
12. The care home made a safeguarding referral to the local authority and sent a statutory notification to the Care Quality Commission (CQC) because Mr Y had incurred a serious injury.
13. Mr Y received blood transfusions in hospital and was treated for a blood infection. When he left hospital he moved to a nursing home, as his condition had declined and he had to be cared for in bed. Mr Y died in November.
14. Mr Y’s family complained to HC-One about the injury to Mr Y, which they said had been caused by hoisting him from the floor using the wrong technique.
15. When HC-One replied to the complaint in June, it said:
• It apologised for the distress caused to Mr Y and his family.
• As Mr Y could not get off the floor on 6 February, trained staff decided to use a hoist and sling to help him up;
• Mr Y said his “left leg was slightly sore”;
• Staff contact NHS 111 for advice but did not receive a call back, so;
• Following the incident:
1. it had reminded the team of the need to follow up if external professionals did not respond;
2. the care home would ensure anyone prescribed anticoagulants would be seen by a medical professional following a fall;
3. the care home had put in place better systems to ensure effective handovers;
4. the care home had got a new sling to provide safe assistance following a fall to the floor and organised a slight change to training to support care homes when a resident has a fall who does not ordinarily use hoisting equipment;
5. it had revised the admissions process to make the difference between residential care and nursing care clearer.

Did HC-One’s actions cause injustice?

16. Mr Y’s injuries, which resulted in him being hospitalised, were not caused by the fall itself, but resulted from being hoisted. There was no care plan in place for hoisting Mr Y after he fell, as he had not previously needed hoisting. Because of what happened to Mr Y, HC-One has identified areas for improvement to reduce the risk of similar problems.
17. However, it is not possible to say what difference it would have made if these actions had all been taken before Mr Y’s fall. This takes account of the fact that his skin was clearly very fragile. Also, staff at the care home made several attempts to engage healthcare professionals over Mr Y’s injuries. While they could have done more to pursue a response, there is no way of knowing whether this would have resulted in a different outcome for Mr Y.
18. HC-One has apologised for the distress caused to Mr Y and his family. It is no longer possible to provide a further remedy for Mr Y, as he has now died.

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Final decision

19. I have completed my investigation on the basis there is no need to ask HC-One to do more than it has already done to remedy the injustice it has caused.
20. Under the terms of our Memorandum of Understanding and information sharing agreement with CQC, I will send it a copy of my final decision statement.

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Investigator's decision on behalf of the Ombudsman