Summary: Mr X complained the actions of his mother’s Care Home prevented him and other family members from seeing her before she died. There was no fault in the Care Home’s actions.

The complaint

1. Mr X complains the actions of his mother’s Care Home prevented him and other family members from seeing her before she died.
2. As a result, Mr X says the family has been caused unnecessary distress because they were unable to say their goodbyes to their mother.

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The Ombudsman’s role and powers

3. 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. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
6. If we are satisfied with a care provider’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
7. 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

8. I spoke to Mr X and considered his view of his complaint.
9. We made enquiries of the Care Provider and considered the information it provided. This included Mrs M’s daily notes and care file for December 2020 and complaints correspondence.
10. I gave Mr X and the Council a chance to comment before I made my final decision.

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What I found

11. Mr X’s mother, Mrs M, was a resident at a Care Home.
12. On 13 December at 5pm, Mr X says a family member (FM) received a call from a care worker at the Care Home. FM said the care worker expressed concern over Mrs M’s condition which had, in the care worker’s opinion, “worsened considerably”. Mr X said FM asked if they could visit and the care worker said she would have to check with the Care Home manager. Mr X said FM told him the care worker phoned back and said a visit would not be possible until the following morning.
13. At 2am on 14 December, Mr X says FM received a call from the Care Home to say Mrs M had died.
14. Mr X complained to the Care Home. He said FM had asked to visit straightaway but had been refused. He questioned the basis on which the manager made the decision to delay the family’s visit until the morning, despite Mrs M’s worsening condition. He said he and FM could have been there promptly.
15. The Care Home manager replied in January 2021. She said neither she nor the manager on duty said the family could not visit Mrs M. She said “The home has always planned and organised all end of life visits very well… obviously sometimes there isn’t time in emergency situations but we would never purposely or otherwise not organise end of life visits”.
16. The manager said she had spoken to the person in charge that day and they did not remember a visit being requested from FM. The response went on to say “she felt the next day would have been fine as she didn’t feel that it was an emergency for that day. She does not at any time recall telling you or [FM] that a visit was not possible. She believes if you had asked for a visit, she would have arranged one but did feel personally that it could wait until the next day. She called myself and explained the situation and I agreed if she was happy to wait until tomorrow for the visit then I could only agree as she was the person looking after your mum”.
17. The manager said that in hindsight, the decision to wait to the next morning was wrong and apologised for the family not being able to say their goodbyes to Mrs M. She said the situation would have been different without the COVID-19 restrictions because the family would otherwise have been able to sit with Mrs M for as long as they had wanted.
18. Mr X remained unhappy and complained to the Ombudsman.
19. As part of my investigation, I examined Mrs M’s daily care notes. On 9 December they record the Care Home phoned Mrs M’s GP and spoke to the GP’s secretary. This was to inform the GP that Mrs M was “declining/unable to swallow her medication, explained it is a regular occurrence, I also mentioned [Mrs M] is struggling to eat normal soft food and isn’t chewing/swallowing, secretary said she would pass this on”.
20. On 10 December, the Care Home chased the GP’s response. It was advised that Mrs M had been referred to speech and language therapy and the Care Home was to continue to try to give Mrs M her medication.
21. At 08:34 on 13 December the care notes recorded Mrs M did not look well and was pale, barely drinking any fluids and very sleepy. At 13:50, the notes recorded Mrs M was no different and her temperature and oxygen “were fine”. The notes said close observations would continue.
22. At 17:33 the notes recorded a care worker called FM. They said “I explain from this morning [Mrs M] has not looked well, has not eaten anything and isn’t herself… [FM] was aware [Mrs M] was slowly deteriorating within health, I explained I would call back before my shifts finished to let her know how [Mrs M] is”.
23. At 19:40, the carer called FM back and said they would be in touch in the morning to arrange a visit.
24. The notes recorded Mrs M was checked 11 times between 19:41 and 00:46. The notes did not record any further concerns. At 2:10am, a care worker called FM to say Mrs M had died. The notes recorded by the care worker stated “I assured her that [Mrs M] wasn’t by herself and that it was very peaceful and quick, she didn’t present with any obvious signs that would have led me to think death was imminent”.
25. I also examined the emails sent from the care worker in charge on 13 December to the Care Home manager. An email in the morning indicated the care worker considered Mrs M’s health was deteriorating and that a visit with the family should be arranged for the coming week. An email later that day at the point of handover, requested whether a visit the following day would be possible.

My findings

26. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
27. The family was distressed at not being with Mrs M when she died. And the manager had also said that with hindsight, the decision not to ask the family to come in immediately, was the wrong one. However, that does not mean the Care Home acted with fault.
28. The care notes for December 2020 are comprehensive and detailed. In the 48 hours before Mrs M’s death, they record a decline in her health. However, none of the records, including the emails from the care worker to the manager, support the view that Care Home staff were aware, or considered, Mrs M's death was imminent. Staff regularly monitored Mrs M or had other interactions with her up to two hours before her death and again, these did not flag up any immediate concerns. On balance, there was no fault in the way the Care Home made its decision not to call the family in on the evening of 13 December.
29. Mr X said FM told him they were refused a visit on 13 December. The Care Home states FM did not request a visit. The care notes do not record a request from FM for an immediate visit. This is not definitive evidence that FM did not request one. It is possible they requested one but the Care Home did not record this. However, because I was not there I cannot say, even on the balance of probabilities, what was said. Therefore, I cannot achieve anything meaningful by investigating this matter further.

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Final decision

30. I have completed my investigation. There was no fault.

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Investigator's decision on behalf of the Ombudsman