London Borough of Waltham Forest (21 005 164)

Category : Adult care services > COVID-19

Decision : Not upheld

Decision date : 22 Feb 2022

The Ombudsman's final decision:

Summary: Mr X complains about the care his late mother, Mrs Y, received in the Council’s care home, Mapleton Road, in December 2020. There is no evidence Mapleton Road failed to meet Mrs Y’s care needs.

The complaint

  1. The complainant, whom I shall refer to as Mr X, complains about the care his late mother received in the Council’s care home, Mapleton Road, in December 2020. He also complains about the failure to provide him with copies of his mother’s care records.

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What I have investigated

  1. I have investigated Mr X’s complaint about the care his mother received at Mapleton Road. I explain at the end of this statement why I have not investigated his complaint about the failure to send him copies of his mother’s care records.

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The Ombudsman’s role and powers

  1. 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)
  2. 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)
  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 council 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

  1. I have:
    • considered the complaint and the documents provided by Mr X;
    • discussed the complaint with Mr X;
    • considered the documents the Council has provided; and
    • invited comments on a draft of this statement from Mr X and the Council, for me to consider before making my final decision.

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What I found

What happened

  1. Mr X’s mother, Mrs Y, had dementia. She went to stay in Mapleton Road, which the Council owns, on 13 December 2020 when she left hospital, as it would not have been safe for her to return home. In hospital she had received treatment for dehydration. She also started a trial of food supplements. Her family could not visit her at Mapleton Road because of COVID-19 restrictions. On 13 December Mrs Y ate a little of her supper and said she was tired.
  2. On 14 December Mapleton Road told Mr X he could not visit but could have a video call with his mother. Its records say Mrs Y was drinking well but not eating by herself. She had a very small breakfast but ate a “significant amount” when helped by staff at lunchtime.
  3. On 15 December Mapleton Road asked the surgery to get a GP to prescribe food supplements for Mrs Y. Mrs Y ate and drank well with help from staff.
  4. On 16 December Mrs Y ate all her cornflakes for breakfast and drank a cup of tea. Staff helped her eat lunch. She was “very weak”. Mapleton Road asked the prescription nurse at the surgery to add food supplements to Mrs Y’s prescription. Mrs Y had a drink in the afternoon and later she had her evening meal.
  5. In the morning of 17 December Mrs Y was not eating or drinking properly. Her head was slumped. Staff transferred her to bed and encouraged her to take sips, but she would not drink. She would not open her mouth so could not take her medication. At lunchtime Mrs Y was still not eating and only had a few sips of drink. Mapleton Road checked Mrs Y every 30 minutes for any changes in her condition.
  6. Mrs Y’s family had a video call with her at 15.00.
  7. At teatime Mrs Y was still not eating or drinking properly. She had a few sips of juice but could not hold anything in her mouth after that and was “very weak”. Mapleton Road contacted the NHS Rapid Response Team at 19.35, as Mrs Y remained unwell. The Rapid Response Team advised calling for an ambulance. Mapleton Road called for an ambulance at 20.35. The ambulance arrived at 22.50 and took Mrs Y to hospital at 23.30. Mapleton Road informed Mr X.
  8. On 19 December the pharmacy delivered food supplements for Mrs Y.
  9. Mrs Y died in hospital on 26 December.
  10. When responding to Mr X’s complaint, the Council said:
    • it found no fault with the actions of Mapleton Road, as staff chased medical professionals to obtain a supply of nourishment drinks to supplement Mrs Y’s diet;
    • when Mrs Y declined to take medication on 17 December, staff had no authority to give it to her covertly;
    • Mapleton Road did not contact Mr X until after Mrs Y went to hospital, as staff were concentrating on ensuring she received the treatment she needed;
    • it accepted Mapleton Road needed to record discussions with family members more consistently and was taking action to ensure this happened; and
    • it was unlikely it would be able to share Mrs Y’s records with him, but explained how he could make a formal request, which would enable him to pursue his concerns with the Information Commissioner’s Office.

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

  1. Mapleton Road’s records show Mrs Y was weak when she arrived and needed help eating. She received what help she needed and Mapleton Road requested food supplements, but they did not arrive until after she had left. That was not because of fault by the Council’s care home. On 17 December Mrs Y’s condition declined and in the evening she was taken to hospital. There is nothing to suggest that was due to poor care.

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Final decision

  1. I have completed my investigation on the basis there has been no fault by the Council.

Parts of the complaint I did not investigate

  1. The Information Commissioner's Office considers complaints about freedom of information. Its decision notices may be appealed to the First Tier Tribunal (Information Rights). So where we receive complaints about freedom of information, we normally consider it reasonable to expect the person to refer the matter to the Information Commissioner.
  2. I have not investigated the Council’s decision not to share his mother’s care records with him. It has told him that if he wants a formal decision he will be able to pursue this with the Information Commissioner’s Office. This is the appropriate body to deal with such matters, and would open up the right of appeal to the First Tier Tribunal if he did not agree with its decision.

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Investigator's decision on behalf of the Ombudsman

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