Summary: Mrs X complains HC-One Oval Limited’s Lyndon Hall Nursing Home failed to look after her late mother properly and failed to keep her family informed about the deterioration in her condition before she died, causing unnecessary distress. HC-One accepts Lyndon Hall failed to deal properly with two falls and failed to communicate properly with Mrs X after it stopped her visits. Lyndon Hall also failed to do a risk assessment for visits to Mrs X’s mother, adding further to her distress. HC-One needs to apologise and pay financial redress.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains HC-One Oval Limited’s (HC-One) Lyndon Hall Nursing Home (Lyndon Hall) failed to look after her late mother properly and failed to keep her family informed about the deterioration in her condition before she died, causing unnecessary distress.

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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)
3. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.

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How I considered this complaint

4. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the care provider 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 the care provider, and taken account of the comments received.

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What I found

Key facts

5. Mrs X’s mother, Mrs Y, had dementia. She went to live at Lyndon Hall in September 2019.
6. Lyndon Hall did risk assessments and produced care plans for meeting Mrs Y’s needs, which it reviewed and updated each month. It also produced records of the care provided for Mrs Y. I refer to the key contents in this statement.
7. Mrs Y could walk independently using a wheeled walker. However, she was at risk of falls because of impaired mobility, vertigo, dementia and the side effects of some of her medication.

Mrs Y’s March 2020 fall

8. On 4 March Mrs Y was agitated and refused help with personal care. She ate little. Mrs Y’s family noticed bruising on her legs, but Lyndon Hall did not record this.
9. Mrs Y remained agitated on 5 March, again refusing personal care and eating little. She was aggressive towards staff, pointing a knife at them. She pushed her wheeled walker into a member of staff, hurting their legs. Lyndon Hall told Mrs X about the knife, who questioned whether her mother may have had a urinary tract infection, but she tested negative. Lyndon Hall produced a body map, which says Mrs Y pushed her wheeled walker into a member of staff’s legs. The body map identified injuries to the right and left legs. This appears to relate to the member of staff, rather than Mrs Y.
10. Mrs Y had an unsettled night on 6 March, until a nurse gave her painkillers for “bellyache”. Mrs X says her sister handed in a letter about her mother’s injuries.
11. Mrs Y was more settled on 7 March. Mrs X visited again and asked staff to look at her mother’s leg. While she was there Lyndon Hall evaluated Mrs Y’s skin integrity. The record says she had bruising to her left leg and complained of pain, for which she took paracetamol. Staff were to monitor changes and call a GP if needed.
12. On 9 March Mrs X raised further concerns about her mother’s legs. Lyndon Hall contacted a GP in the afternoon about bruising and swollen ankles. The GP said to take her to hospital for an x-ray.
13. Lyndon Hall completed an Incident and Accident Review Form. This says:
• Mrs X reported bruising on Mrs Y’s left leg from knee to ankle and an “old scar on the knee” on 7 March;
• Mrs X “did not want to do anything (which she disputes)”; and
• Lyndon Hall contacted a GP on 9 March.
14. On 10 March the delay in seeking medical attention for her mother’s legs was reported to the local authority. The local authority recorded this as a safeguarding concern and made enquiries. On 24 March the local authority substantiated an allegation of “neglect and act of omission”. This was because Lyndon Hall was not proactive in seeking medical attention for Mrs Y. The local authority found:
• it took five days to seek medical attention for Mrs Y and only after Mrs X insisted on this;
• there was no record of Mrs X reporting her concerns;
• dates had been changed on documents;
• body maps were not completed on the day of the incident; and
• the records of a GP visit were unclear.
15. Mrs Y returned to Lyndon Hall on 12 March.
16. Mrs Y caught COVID-19 in April, for which she received treatment in hospital before returning to Lyndon Hall on 14 April. Mrs X says she was moved to a room far away from the nurses station. She says her mother could no longer stand and was doubly incontinent. The April review of her falls risk assessment says she needed supervision with mobility and staff were to prompt her to use her wheeled walker.

Mrs Y’s weight

17. Mrs Y had a normal diet. However, on 31 May a GP prescribed nutritional supplements because of weight loss. Staff were to weigh Mrs Y weekly and refer her back to the GP if there was no improvement or she continued to lose weight. There is no record of her weight on 31 May. Lyndon Hall’s records of her weight say she weighed:
• 67.5 kg on 5 April;
• 62.0 kg on 15 April;
• 63.3 kg on 16 May;
• 61.0 kg on 7 June;
• 62.5 kg on 14 June;
• 62.1 kg on 27 June;
• 62.45 kg on 4 July; and
• 64.15 on 12 July.

Mrs Y’s June 2020 fall

18. The records say staff found Mrs Y on the floor at 00.30 on 6 June, when she went to the toilet in her room. This should have said 23.30 on 5 June. Mrs Y was checked over and had a settled night. In the morning she had bruising to both shoulders and her left hand was swollen. She complained of a headache and was given painkillers. Her vital signs were normal. Lyndon Hall called 999. An ambulance arrived at 08.30 and took Mrs Y to hospital. Lyndon Hall told her family. The hospital discharged her Y later that day.
19. Mrs X visited on 8 June and 9 June, when she asked for physiotherapy to be arranged for her mother. Lyndon Hall reviewed Mrs Y’s falls risk assessment. This says she needed continuous monitoring and had a bed movement sensor which needed to be in place when she was in her room. It also says she needed the help of two people when walking and transferring.
20. On 9 June Lyndon Hall reported a safeguarding concern to the local authority about the fall at 23.30 on 5 June. On 30 July the local authority partially substantiated the safeguarding concern because of Lyndon Hall’s failure to contact emergency services until the next day.
21. Mrs X continued to visit her mother each day up to 18 June.

Mrs Y’s final weeks at Lyndon Hall

22. On 19 June Mrs Y moved to another room. There is nothing in her records to explain the move. HC-One says Mrs Y moved from Lyndon Hall’s dementia nursing community to its general nursing community, as her nursing needs had become the primary focus. Her family was not allowed to visit after the move. HC‑One says this was because of COVID-19 restrictions. It says the unit Mrs Y was living in was closed to indoor visits, except on compassionate grounds. Mrs X says staff told them they could not visit because no one upstairs had COVID-19.
23. Mrs X says they got no information from staff at Lyndon Hall about her mother’s condition after her move upstairs. Mrs Y screamed on 19 June when staff took her to the lounge and asked to be taken back to her room. Staff reassured her. But she was unsettled again later.
24. Mrs Y slept overnight on 20 June, had a settled day but was agitated and vocal in the evening.
25. On 21 June Mrs Y was settled apart from an episode of screaming. She settled again after returning to her room. She refused snacks and needed repeated prompting to take her medication.
26. On 22 June a GP reviewed Mrs Y’s medication. The GP discontinued some medication and changed paracetamol from a capsule to a dissolvable tablet.
27. Mrs Y was distressed on 23 June, asking to be taken home. Staff reassured her. She had a poor diet.
28. On 24 June Mrs Y was distressed again, shouting at times and sometimes tearful.
29. Mrs Y sat in the lounge on 25 June without shouting or screaming.
30. On 26 June Mrs Y had a settled day.
31. On 27 June Mrs Y tried to walk in the lounge unaided. She shouted and cried at times.
32. Mrs Y was tearful at times on 28 June.
33. On 29 June Mrs Y remained in her room but was settled.
34. Mrs Y was also settled on 30 June.
35. On 1 July Mrs Y was tearful at times and received reassurance.
36. On 2 July Mrs Y was agitated and vocal at lunchtime. She would not hand her knife over to a Care Worker but threw it, missing another resident. Lyndon Hall told Mrs X.
37. Mrs Y remained settled until 7 July when she was tearful after lunch and was given medication for anxiety.
38. On 8 July Mrs Y declined her medication and was tearful around dinner time.
39. Mrs Y remained settled until 11 July when she became agitated in the evening and was given medication for anxiety.
40. On 12 July Mrs Y occasionally shouted.
41. Mrs Y was sometimes unsettled on 13 July. Later she was “chattering” to herself. Lyndon Hall told Mrs X it soon hoped to arrange visits to her mother in the garden.
42. Mrs Y remained settled until 17 July when she was “very vocal”. She was then a little unsettled but slept during the night.
43. Around 15.00 on 18 July Mrs Y was found in someone else’s bedroom leaning against the bed. A care worker asked if she wanted to go to the lounge. Mrs Y said “yes”. Mrs Y started walking with her walker but became unbalanced in the corridor. The care worker asked her to walk straight but she started to lower to the floor, so the care worker held on to her waistband and another care worker helped ease Mrs Y to the floor. She was unresponsive, so Lyndon Hall called paramedics who confirmed she had died.

Mrs X’s complaint

44. Mrs X complained to Lyndon Hall on 2 October.
45. When HC-One responded to Mrs X’s complaint on 20 January 2021, it said:
• Lyndon Hall had not done a body map or recorded the bruising when it found Mrs Y on the floor on 4 March 2020;
• the Manager had asked staff to contact a GP when Mrs X raised concerns on 5 March;
• Lyndon Hall had no record of a letter Mrs X said she handed in on 6 March;
• Lyndon Hall had wrongly claimed Mrs X first raised concerns on 9 March, as the correct date was 5 March;
• it could find no overwritten dates in Mrs Y’s care records;
• it took “every opportunity to learn the lessons from actions taken”;
• staff had found Mrs Y on the floor at 23.30 on 5 June, not 00.30 on 6 June;
• staff checked on Mrs Y two hourly at night and hourly during the day;
• Mrs Y had been able to walk, so a crash mat would have increased the risk of falls;
• it would be reviewing its incident management process to ensure prompt referral to external medical professionals after a fall;
• it could have offered weekly calls with Mrs Y and her family and communication could have been more sympathetic;
• it would offer more frequent communication in future; and
• it apologised for any distress caused by the way staff had spoken to her and was taking steps to ensure this did not happen again.
46. When responding to my enquiries, HC-One said Lyndon Hall had made these changes:
• scheduling care reviews every three to six months, depending on needs;
• completing body maps every week;
• the Home Manager now oversees incident management;
• weekly rounds from GP surgeries;
• implemented training in Early Warning Signs for frailty, escalating deterioration and end-of-life;
• daily recording of temperature, oxygen levels and breathing;
• using the local authority’s Rapid Response Team; and
• communicating regularly with key family members.

Did the care provider’s actions cause injustice?

47. There is no dispute over the fact Lyndon Hall failed to seek immediate medical attention following Mrs Y’s falls in March and June 2020. Its records relating to both incidents are inadequate.
48. HC-One accepts Lyndon Hall did not communicate properly with Mrs X after she was prevented from visiting her mother. There is also nothing in its records to explain the decision to stop Mrs X visiting. HC-One’s policy at the time was to allow one 20-minute visit a week from two people from the same household. However, the records show Lyndon Hall had been operating its own more liberal visiting policy. HC-One says Mrs Y moved to a part of Lyndon Hall which was closed to indoor visits, except on compassionate grounds. It should have communicated more clearly with Mrs X about the reason for stopping visits.
49. It is noticeable from Lyndon Hall’s records that Mrs Y’s agitation increased after Mrs X stopped visiting her. It is not for me to say whether there was a causal link between these events. But I would have expected Lyndon Hall to consider whether that was a possibility and, if so, consider whether there were compassionate grounds for visits to resume. Mrs X used to visit her mother every day and it caused her great distress when those visits stopped, which was made worse by the lack of communication from Lyndon Hall about her mother’s condition. The failure to do a risk assessment for visits and consider whether there were compassionate grounds for visits to resume added to Mrs X’s distress. HC-One needs to apologise and pay financial redress.
50. However, there is nothing in Lyndon Hall’s records to suggest there was a significant decline in Mrs Y’s condition until she collapsed on 18 July. Indeed, the records show Lyndon Hall addressed Mrs Y’s loss of weight and the supplements prescribed by the GP were successful in reversing the decline.

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Recommended action

51. I recommend HC-One within the next four weeks writes to Mrs X apologising for the failings I have identified and makes a symbolic payment to her of £300 in recognition of the distress caused. HC-One has agreed to do this.
52. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

53. I have completed my investigation on the basis that Lyndon Hall’s actions have caused injustice for which a remedy is warranted.

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Investigator's decision on behalf of the Ombudsman