Summary: Two sisters complain The Sycamores, where the Council placed their late mother, failed to tell them about the decline in her health, which meant they could not spend any time with her before she died. The Sycamores failed to record all its contacts with the sisters and failed to tell them about calling NHS 111 on 14 June 2020. The Council needs to apologise for the distress caused by these failings and work with The Sycamores to improve its record keeping.

What I have investigated

1. I have investigated the actions of the Council and its care Provider, The Sycamores. The initial complaint raised concerns about the actions of NHS staff. I explain at the end of this statement why we have not investigated those concerns.

Back to top

The complaint

2. The complainants, whom I shall refer to as Mrs X and Mrs Y, complain The Sycamores, where the Council placed their late mother, failed to tell them about the decline in her health, which meant they could not spend any time with her before she died.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)
5. 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 Council and care provider followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
6. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

Back to top

How I considered this complaint

7. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Mrs X and the Council, and invited comments for me to consider before making my final decision.

Back to top

What I found

What happened

8. Mrs X and Mrs Y’s mother, Mrs Z, had dementia, impaired mobility and other age‑related health conditions. She also had a chronic obstructive pulmonary disorder for which she used an inhaler. She was at high risk from COVID-19 so was advised to shield. She lived at The Sycamores, where Mrs X and Mrs Y used to visit her every day before COVID-19. After the first lock-down started in March 2020, it was no longer possible to visit people in care homes. Mrs X visited three times a week to see and speak to her mother through her window. Her sister also visited. She says they both called every day they did not visit.
9. The Sycamores kept records of the care provided for Mrs Z. I summarise the key contents from the records for 27 May until Mrs Z died. I also include Mrs X’s account of her visits and contact with The Sycamores. The Sycamores recorded very few of its conversations with Mrs Z’s family.
10. On 27 May Mrs Z ate most of her breakfast. She stayed in bed as she felt unwell. She declined lunch and supper but was described as “content”.
11. On 28 May Mrs Z ate all her breakfast and most of her lunch and teatime meal. She declined help with personal care. She was “content”.
12. On 29 May The Sycamores called the GP‘s surgery, as Mrs Z was struggling to breathe. A nurse called and advised checking Mrs Z’s oxygen levels and calling an ambulance if they dropped below 90% (which they never did).
13. When Mrs X visited on 30 May her mother was in bed. Mrs Z told her daughter she felt unwell and sick. Staff said she had not eaten and there was a case of COVID-19 in the home. According to The Sycamores’ records, Mrs Z was helped to sit in a chair at 09.31, but there is no record of when she went back to bed. Mrs Z ate most of her breakfast but no lunch and just a little of her tea-time meal.
14. When Mrs X visited on 31 May her mother was still in bed. Staff said she was not eating, so they would call the GP and test her for COVID-19. But there is no record of calling a GP or of a COVID-19 test. The Sycamore’s records say Mrs Z declined lunch as she “didn’t feel well” but remained “content”.
15. When Mrs X visited on 1 June staff said they were waiting for the GP to call. Mrs Z was still in bed. The Sycamores’ records say Mrs Z ate most of her breakfast and a little of her lunch and teatime meal. Before going to bed Mrs Z used her inhaler.
16. The Sycamores’ records for 2 June say Mrs Z ate most of her breakfast. Staff called a GP as Mrs Z had not “picked up from the last antibiotics”. The GP prescribed more antibiotics. Mrs Z declined lunch and ate very little of her teatime meal but remained “content”. When Mrs X rang the Sycamores it told her the GP had prescribed steroids and antibiotics.
17. On 3 June Mrs Z ate most of her breakfast. She declined help with some personal care tasks and “self managed”. She ate a little lunch but declined all other offers of food. Mrs X says she called twice and was told her mother was still in bed taking little food.
18. In the morning of 4 June Mrs Z was “unhappy” and had five puffs of her inhaler. Afterwards she was “content” but declined breakfast. She did not want to get dressed and went back to bed as she felt tired and unwell. She declined lunch but ate a little at teatime. When Mrs X called she was told Mrs Z’s condition had not changed, more senior members of staff were off with COVID-19 and a few residents also had it.
19. On 5 June Mrs Z ate most of her breakfast, lunch and teatime meal. She was “content”. Mrs X says she waited three hours for someone at the Sycamores to call her back. She was told Mrs Z had not changed but more residents had COVID-19. She asked for a GP to be called, as she was concerned Mrs Z would be dehydrated.
20. When Mrs Z and Mrs Y visited on 6 June, Mrs Z was in bed but did not interact with them. They were told she had tested negative for COVID-19 but they remained concerned about her lack of appetite. The Sycamores’ records say Mrs Z ate most of her breakfast but nothing at lunchtime but most of her teatime meal. She tested negative for COVID-19 and was “content” all day.
21. When Mrs X visited in the morning of 7 June Mrs Z was asleep. Staff tried to wake her but she just turned over. When Mrs X rang in the afternoon she was told Mrs Z had a little lunch but was sleeping again. The Sycamores’ records say Mrs Z ate most of her breakfast, a little of her lunch and most of her tea-time meal.
22. Mrs X and Mrs Y visited in the morning of 8 June. Mrs Z’s medication was in a cup beside her bed. They raised concerns about her being so ill and unresponsive. The Regional Manager suggested Mrs Z may be depressed and said they would speak to a GP. The Sycamores’ records say Mrs Z had some porridge for breakfast. Mrs X and Mrs Y were concerned Mrs Z had deteriorated and “given up”. It told them Mrs Z had an infection and was on repeated antibiotics. The sisters suggested Mrs Z needed more prompting. The Sycamores said it would pass this on to staff and would also contact a GP to see if anything could be done to improve Mrs Z’s mood. The Sycamores contacted the GP surgery and left a message. Mrs Z ate very little of her lunch, apart from the desert. Later that day the GP prescribed an antidepressant. The Sycamores passed the information on to Mrs Y.
23. When Mrs X rang on 9 June she was told Mrs Z had not changed and they were waiting for some tablets to arrive. The Sycamores’ records say Mrs Z had a pressure injury on her groin and bottom. She had four puffs of her inhaler. She ate some of her breakfast but no lunch or anything at teatime. She remained “content”.
24. When Mrs X rang on 10 June, The Sycamores said it would call a GP as Mrs Z was not eating and was deteriorating fast. The Sycamores’ records say Mrs Z had four puffs of her inhaler shortly after midnight. She had two more at 03.34 and by 04.21 her breathing was better. She had most of her breakfast but did not want to get dressed as she was not feeling well. She declined help with personal care and remained in bed. She weighed 41.25 kg. She was helped to sit in her chair for lunch, eating little, apart from desert which she finished. At 15.52 she was sick and “a little bit ill” but was “content”. Mrs Z had a bath, after which The Sycamores called the GP because she was not eating and drinking. The GP put this down to dementia and referred Mrs Z to the speech and language therapists. At 16.03 Mrs Z was sick. She said she felt OK and did not appear to be aware she had been sick. She ate most of her teatime meal. She was sick again after taking painkillers at 20.50. The pressure injury on her groin and bottom hurt “even more”.
25. When Mrs X rang on 11 June, she was told Mrs Z had been sick for a couple of days so they would call a GP as she was really unwell. The Sycamores’ records say Mrs Z had four puffs of her inhaler at 02.45. Her oxygen levels were ok (98%). She ate very little breakfast. When cream was applied to her groin and bottom at 10.37 she was “unhappy”, but was otherwise “content”. The Sycamores spoke about Mrs Z’s health to a relative, who was going to ring back in the afternoon but there is no record of a further call. Mrs Z did not want to get up saying she wasn’t well. She declined lunch. The Sycamores told the GP surgery she had been sick again and was not her usual self. The GP did a video call with Mrs Z and said she appeared to be deteriorating and to call NHS 111 if she got worse. Mrs Z had two puffs of the inhaler before going to sleep.
26. On 12 June Mrs Z was “very unhappy” at 04.02, having been incontinent. She was unhappy at 07.57 when staff helped with continence. Mrs Z was sick and “a little bit ill”. She declined breakfast and lunch but ate a little of her teatime meal. A District Nurse said to keep applying cream to the sore between Mrs Z’s legs, which was hurting even more. Later in the evening Mrs Z was described as “content”. When Mrs X rang in the morning, she was told Mrs Z had a little porridge for breakfast, was struggling and just wanted to lie down.
27. When Mrs X and Mrs Y visited in the morning of 13 June, Mrs Z was in bed and became agitated when staff tried to wake her, saying she wanted to be sick. She made no sense when responding to their questions. The Sycamores’ records say Mrs Z was “content”. She ate some breakfast. The District Nurse visited to check the sore between her legs and said to put cream on and keep the wound clean and dry. At 11.02 Mrs Z was sick a little. She declined lunch and ate nothing of her teatime meal.
28. When Mrs X called on 14 June she was told Mrs Z was OK and had a cup of tea and a little breakfast. She says they were told the same thing in the afternoon. The Sycamores’ records say staff called NHS 111 at 03.12 because of concerns over Mrs Z’s breathing. She had four puffs of the inhaler. By 03.41 Mrs Z was unhappy. According to the records, a GP agreed to visit. Mrs Z declined breakfast. At 09.19 her oxygen levels were low (90%). She was “content”. Mrs Z declined everything she was offered for lunch. At 14.49 the GP said no more steroids or antibiotics could be prescribed as they were not working. The GP said to call if Mrs Z’s breathing got worse. Mrs Z declined all food but drank some of what she was offered.
29. Mrs X and Mrs Y visited at 10.30 on 15 June Mrs Z was laid half on the bed with her legs out of bed. A Senior Carer told them they were waiting for a GP to call. Mrs X and Mrs Y said they would go to the GP’s surgery to see if they could find anything out. However, they were not allowed into the GP’s surgery because of COVID-19 and were advised to telephone the surgery. As they were on their way back to the Sycamores, they received a call saying Mrs Z had died. When they arrived Mrs Z was in the same position as she had been at 10.30. After a wait, they were allowed to see their mother, wearing PPE.
30. The Sycamores’ records say Mrs Z was “content” when awake at 06.18 on 15 June. By 08.49 she was unhappy. She could not take her medication because she was retching. She drank a little water at 09.03 but declined breakfast. Between 09.21 and 10.02 she declined further offers of drinks and breakfast. She declined further drinks. Staff recorded providing personal care at 10.30. Her temperature was 37c. The records describe her as “content”. At 11.36 the records say Mrs Z declined a cup of tea but was “content”. The Sycamores recorded calling an ambulance at 11.39 as Mrs Z did not have a pulse. Her family were informed. The Ambulance Service called The Sycamores and said not to move Mrs Z or anything in her room as she had not been identified as end-of-life, so the Police may visit as well. Paramedics arrived around 13.00 and confirmed Mrs Z had died.
31. Mrs X complained to Burlington Care (Yorkshire) Limited, which runs The Sycamores, about the events leading up to her mother’s death. When Burlington Care replied in July it said:
• when the Manager was off work from 1 June, other more senior managers stepped in to run The Sycamores;
• District Nurses saw Mrs Z and The Sycamores called the GP surgery or out of hours service nine times from 19 May;
• care homes cannot demand a GP visit, but staff at The Sycamores provided Doctors with information about Mrs Z’s symptoms, temperature, pulse, blood pressure and oxygen levels;
• unfortunately, despite treatment, Mrs Z continued to decline;
• Mrs Z did not complain of feeling sick until 10 June, but she had been struggling to breathe, despite taking antibiotics, steroids and often using her inhaler;
• it denied any fault over the failure to tell Mrs X about the calls to NHS 111 in the early hours of 14 June;
• The Sycamores had called the GP surgery by 10.00 on 15 June but did not receive a call back until after Mrs Z had died;
• when the first resident was diagnosed with COVID-19 on 1 June, it prioritised telling the relatives of those diagnosed.

Is there evidence of fault by the Council which caused injustice?

32. With reference to paragraph 6 above, the Council is accountable for the actions of its care provider, The Sycamores, as it funded Mrs Z’s placement there.
33. The records show Mrs Z’s condition steadily declined. Mrs X and Mrs Y were aware of that decline as they witnessed it through her bedroom window. This was distressing for them. They also raised their concerns with The Sycamores. However, The Sycamores did not record all the contact it had with Mrs Z’s family. That was fault, for which the Council is accountable. As set out in our Good Administrative practice during the response to COVID-19, basic record keeping is vital during crisis working. Although I cannot identify any specific injustice arising from this fault, the Council needs to work with The Sycamores to ensure it records its contact with family members.
34. During the first lockdown, families were not allowed to visit people in care homes. Mrs X believes her mother should have been sent to hospital and, if that had happened, they would have been able to spend time with her before she died. However, The Sycamores was not at fault over the fact Mrs Z did not spend her last days in hospital. The Sycamores had regular contact with NHS staff about Mrs Z’s condition, and acted on the advice received. Mrs Z’s oxygen levels remained above the level which would have prompted calling for an ambulance.
35. The Sycamores was at fault for failing to tell Mrs X and Mrs Y about calling NHS 111 on 14 June. This caused them avoidable distress.

Back to top

Agreed action

36. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of The Sycamores, I have made recommendations to the Council.
37. I recommended the Council:
• within four weeks writes to Mrs Z and Mrs Y apologising for The Sycamore’s failure to record all its contacts with them and the distress caused by its failure to tell them about calling NHS 111 on 14 June 2020;
• within eight weeks works with The Sycamores to ensure it makes records of its contact with relatives in future, and provides evidence it has done this.

The Council has agreed to do this and The Sycamores has confirmed it will improve its recordkeeping.

38. 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.

Back to top

Final decision

39. I have completed my investigation, as the Council has agreed to take action to remedy the injustice caused by The Sycamores.

Parts of the complaint I did not investigate

40. I have not investigated concerns about the actions of NHS staff, as Ms X told us she did not want to pursue them.

Back to top

Investigator's decision on behalf of the Ombudsman