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Royal Borough of Greenwich (17 000 791)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 07 Nov 2019

The Ombudsman's final decision:

Summary: A man complained about the care of his late mother by a council and NHS organisations. He said she received poor stoma care from agency carers and district nurses and inadequate arrangements for care following a discharge from hospital. The Ombudsmen find that the council and an NHS Trust failed to ensure his mother received the stoma care she needed. This caused her distress and embarrassment and also caused the family distress. The council will explain how it will improve stoma care in future. The NHS Trust did not follow the recommended discharge plan or visit as often as it should have. This did not cause harm to the woman concerned but it caused distress to her family. The NHS Trust has already made satisfactory service improvements. The council and NHS Trust will apologise and pay a financial remedy. Other elements of the complaint were not investigated.

The complaint

  1. A man I will call Mr P complained about the care of his late mother, who I will call Mrs D, by the Royal Borough of Greenwich (the Council), Oxleas NHS Foundation Trust (Oxleas), Kings College Hospital NHS Foundation Trust (Kings). and Bexley Clinical Commissioning Group (the CCG). He complained that:
      1. After Mrs D was discharged from hospital in April 2016 she did not receive adequate care and support to change her stoma bag. Carers from Blue Ocean commissioned by the Royal Borough of Greenwich (the Council) were not trained to do it, and district nurses provided by Oxleas NHS Foundation Trust (Oxleas) refused to help and train the carers. The Council provided contradictory information about whether carers should change the bag. As a result of inadequate care with her stoma bag, Mrs D frequently became covered in urine because of the bag leaking.
      2. When Mrs D was discharged from hospital in December 2016, the district nurses should have visited each day to check her weight and blood pressure. However, a district nurse decided on 13 December they would not do this. This caused distress and inconvenience to the family.
      3. When the district nurses were asked on 22 December to take over from the care agency, they failed to do this, and did not visit Mrs D as they should have over the following days. This meant Mrs D was left without care, and caused the family distress.
      4. District nurses twice failed to notice that Mrs D had symptoms of a blocked bowel, which resulted in emergency re-admissions to hospital in June and July 2016.
      5. Kings College Hospital NHS Foundation Trust (Kings) failed to ensure Mrs D had an adequate home care package set up prior to her discharge in December 2016.
      6. A social worker inappropriately interviewed Mrs D about her wishes and her financial situation.
      7. When Mr P raised concerns with Kings after Mrs D’s discharge it failed to engage with him. The discharge manager said she was not available, but she sent emails to colleagues during the time he was waiting for her.
      8. When Mr P raised his concerns with the Council as a potential safeguarding issue, it told him to use the complaints procedure despite this being a time-pressing matter.
      9. Following Mrs D’s discharge of December 2016 there were further problems with her stoma care, as her carers from another agency commissioned by the CCG were not sufficiently trained in stoma care. The district nursing service failed to provide help or training.
      10. One of the carers passed Mrs D a cold, which caused a chest infection.
      11. The care agency cancelled its service on 22 December with four hours notice.
      12. During the local investigation of the complaint, Mr P was prevented from providing evidence, the family’s information was not properly taken into account, and he was denied access to information which he feels he was entitled to see and was relevant to his complaint.
  2. Mr P seeks remedial action in relation to training on stoma care for care agency workers, and recognition of the grief and pain caused to him and other members of his family.

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What I have investigated

  1. I have investigated parts a – c of the complaint. At the end of this statement I have explained why I have not investigated the remaining parts of the complaint.

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The Ombudsmen’s role and powers

  1. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1)). If it has, they may suggest a remedy. Recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
  2. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
  3. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
  4. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
  5. The events in this complaint took place from April to December 2016. Mr P first complained to the Ombudsmen in April 2017, within twelve months of these events. We decided not to investigate then because the organisations concerned agreed to do further work on the complaint. Mr P approached the Ombudsmen promptly when this concluded. Therefore, we decided to use our discretion on the time limit and investigate the complaint.
  6. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
  7. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

  1. I considered information provided by the parties to the complaint, including relevant health and social care records provided by the Council, Kings and Oxleas, and information provided by Mr P by phone and in writing. I took account of relevant policy, law and guidance. I took clinical advice from a senior nurse with expertise in the care of older people and from a consultant geriatrician.
  2. I considered Mr P’s comments on a draft of this decision.

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What I found

Legal and administrative context

Social care under the Care Act 2014

  1. The Care Act 2014 sets out local authority responsibilities to provide social care for adults. The eligibility threshold for adults with care and support needs and carers is set out in the Care and Support (Eligibility Criteria) Regulations 2014. The threshold is based on identifying how a person’s needs affect their ability to achieve relevant outcomes, and how this affects their wellbeing. Where councils have determined that a person has any eligible needs, they must meet those needs.
  2. The Care Act 2014 gives councils a legal responsibility to provide a care and support plan. This should consider what the person has, what they want to achieve, what they can do by themselves or with existing support and what type of care and support may be available in the local area. 

The Code for nurses and midwives

  1. The Nursing and Midwifery (NMC) issued The Code in 2009 (updated 2015). This sets out standards of conduct, performance and ethics for nurses and midwives. It says clear and accurate records should be kept of discussions, assessments, treatment and medicines given, along with how effective these have been. Nurses must work with colleagues to keep those they care for safe, and they must be accountable for decisions to delegate tasks to other people.

Complaint about the stoma care

  1. In March 2016, Mrs D had an operation to remove her bladder, because of bladder cancer. She then had a urostomy. This is a procedure where a small piece of bowel is used to form a passage for urine to leave the body via an opening created surgically in the abdomen. This is a stoma. Urine is collected in pouches called stoma bags.
  2. When someone has a new stoma, nurses should train them to care for it while they are in hospital. If the person is entitled to social care and because of their care needs they cannot manage the stoma care themselves, councils should provide carers to provide the care.
  3. When Mrs D left hospital in April after her surgery, she said she did not need help from district nurses to help her manage the stoma care because she could do it herself with support from her sister. A specialist stoma nurse visited to give her advice. She also had support from carers employed by the council with her stoma care.
  4. Later in April, Oxleas noted that carers from the Council were changing the stoma bag, while the Council noted that the district nurses were visiting Mrs D to help with stoma care. There is no information in the records about why Mrs D could no longer manage herself with help from her sister.
  5. On 13 May, the Council completed a social care assessment and commissioned a care agency called Blue Ocean to support Mrs D, rather than its own carers. The Council developed a care plan which said Blue Ocean should support Mrs D to empty her stoma bag in the mornings and attach her night bag. The care plan does not mention the need to change the stoma bag regularly.
  6. On 19 May, Mrs D told a district nurse from Oxleas that a carer refused to change her leaking stoma bag. The nurse changed the bag. On 21 May, a nurse I will call Nurse K noted that she provided Mrs D with minimal assistance to change her stoma bag, indicating that Mrs D needed a small amount of help with it. Nurse K noted that they would continue to monitor her.
  7. On 31 May, the Council recorded that Mrs D had been up all night because her stoma bag leaked, she could not reattach it properly, and her current carer had no training in stoma care. A nurse called Blue Ocean. The nurse said it was not the district nurses’ role to change stoma bags, and agreed to show the carer how to do it.
  8. The nurses arranged to train the carers on 8 June, but could not make the appointment. Nurse K changed the bag later that day and rearranged the training for 10 June. She visited again on 10 June and changed the bag, but there is no reference in her records to the training.
  9. The records say the district nurses continued to support Mrs D with her stoma care. They did so on 12,15,19 and 22 June. Mrs D was admitted to hospital on 28 June, and stayed there until 21 July.
  10. On 25 July, Mrs D’s GP contacted Oxleas to say Mrs D’s stoma bag kept leaking. A nurse I will call Nurse J visited the next day and asked Mrs D whether the carers were capable of changing the stoma bag. Mrs D said some were, and some were not. Nurse J wrote that she would try to contact the carers to show them how to change the bag, but I have not seen evidence this happened.
  11. Nurse J visited again on 1 August. Mrs D said she wanted a nurse to change her bag every two days. Nurse J said the carers could change the bag, but also that she would call them to “check this and to resolve the issue”. There is no record of this call. On 3 August, Nurse J recorded that Mrs D’s carers could change her bag and that Mrs D would ask them to do this. I have not seen evidence of how Nurse J established that they could change the bag correctly.
  12. Nurse J visited Mrs D again on 9 August. Mrs D said she was unhappy with “the miscommunication between the carers and the district nurses”. Nurse J called a manager at Blue Ocean, who said changing a stoma bag was the nurses’ job but some carers did change stoma bags. Mrs D’s carer told Nurse J she could change stoma bags and did so for other clients. She said she would not change Mrs D’s stoma bag because Mrs D’s care plan did not instruct her to do this. However, the carer agreed that if the bag leaked between the nurses’ visits she would change it.
  13. On 11 August, Nurse K visited Mrs D. She recorded that she had a long discussion with Mrs D about changing her stoma bag, and met with Mrs D’s carer. She wrote “It has been agreed that carers will assist [Mrs D] to change urostomy bag and we will assess on a weekly basis.” On 16 August Mrs D was admitted to hospital.
  14. On 9 September, the Council noted that Mr P felt the family and the carers should have training on managing the stoma bag. The Council reviewed Mrs D’s care plan, and recorded that the carers would support Mrs D to empty her stoma bag in the morning and change it at night. The Council still did not include any reference to the need to change the bag regularly. However, the Council emailed Blue Ocean on 12 September to say Mrs D was leaving hospital and would need support with changing the bag. The Council also emailed Mr P to tell him this, and to say the community stoma nurse would contact him to arrange training on managing the stoma bag. Mr P said when they had the training they discovered how to correctly apply the seal to keep the bag in place, which neither the family or carers knew before.
  15. On 14 September, Nurse K recorded that Blue Ocean was providing care with Mrs D’s stoma bag, but her son was unhappy with the care Blue Ocean was providing. Oxleas’ records say Nurse K told the family the carers would manage the stoma bag. Mr P says Nurse K argued with the carers in front of Mrs D about whose responsibility this was. On 21 September Mrs D was admitted to hospital and stayed there until December.
  16. In October, Mr P emailed Mrs D’s social worker and asked whether the stoma bag should be changed by the district nurses or the carers. The social worker replied that the district nurses should change it. The social worker rang Blue Ocean, which said the district nurses refused to manage the stoma care, so the carers had training on how to do this and were happy to continue.
  17. On 6 December, the Council wrote to Mr P to say it had checked with Oxleas, which said carers could manage routine stoma care with the correct training. The Council apologised that the social worker told them the stoma care was the responsibility of the nurses.
  18. In 2017, Mr P and his brother pursued the Council with their concerns about the stoma care. The Council told them it did not have any specific provisions in its contracts with agencies about stoma care. It checked with the care agencies it uses, which said they would manage stoma care if trained to do so by a nurse. The Council supplied further information about how it monitored the quality of carers.
  19. Mr P emailed Blue Ocean and asked whether the district nurses had offered any assistance to the carers with Mrs D’s stoma care. Blue Ocean said the district nurses did not help, but the stoma care nurse did and this was effective. It said the Council’s commissioning team had contacted it about suggestions for training which might support improvements in care.

Findings and analysis

  1. As it identified in May that Mrs D needed support to manage her stoma care, the Council should have included on the care plan that Blue Ocean’s carers needed to support Mrs D with this, and ensured they were competent to do so. If it had, the confusion about whose role it was and consequent difficulties for Mrs D and her family could have been largely avoided. The Council wrongly believed changing the bag was a nursing need.
  2. Though stoma care is generally a personal care need rather than a nursing need, nurses should identify any gaps in care delivery when completing assessments. They should ensure people are safe and should take responsibility for delegating tasks to others. Therefore, when problems became apparent with Mrs D’s stoma care, Oxleas’ district nurses should have changed the bag until they were satisfied that the care staff could do this competently.
  3. The evidence shows a mixed response from Oxleas to the problems with Mrs D’s stoma care. There are numerous entries in the records showing that Oxleas did help Mrs D with her stoma care, contrary to what Blue Ocean told Mr P. However, I am not satisfied that Oxleas made sure the carers were adequately trained when it became apparent that some of them could not competently manage the stoma care.
  4. I asked Oxleas about the training which was scheduled for 10 June. It responded that the training took place. But there is no documentation supporting this, and it is clear that the problems continued after 10 June. In July and August Oxleas said the carers should change the bag even though it knew that not all of them could do this and that it was not on the care plan the carers worked to.
  5. In its conflict with Blue Ocean over which of them should change the bag, Oxleas appears to have lost sight of Mrs D’s need to receive competent support consistently. There were also inconsistencies in the approach individual nurses took, with Nurse J taking one position on 9 August and Nurse K taking another on 11 August. It is therefore unsurprising the family became distressed and frustrated.
  6. Oxleas’ records of later in the year say Mrs D could manage her stoma bag herself but she and the family refused to do it. Mr P says this is not correct. He says she started “down the road of independence” but became unable to manage the stoma care because of shortness of breath and a tremor in her hand from Parkinson’s Disease. He says leaks from the bag caused damage to mattresses and carpets and that Mrs D was frequently left sitting in urine all night.
  7. Taking into account all the evidence I have seen, which includes various references in the records to Mrs D’s bag leaking and her seeking help with this, I find it more likely than not that Mrs D could not manage her stoma care without help. Therefore, I find that the failure of the Council and Oxleas to ensure she consistently received competent care and support with her stoma care caused Mrs D to experience distress and embarrassment due to leaks from the stoma bag. In turn, this caused distress to her family.

Complaint about the district nurses deciding not to visit every day in December

  1. Mrs D had heart failure which was difficult to control because she also had chronic kidney failure. Before she left hospital on 12 December, there was a discharge planning meeting. The hospital said if her weight increased by more than 2-3 kg in a week she would need to see a GP or heart failure nurse, because this would mean she was retaining too much water.
  2. A doctor completed funding paperwork for the Clinical Commissioning Group (CCG). This said Mrs D would have daily visits from the district nurses to help with stoma management. The heart failure nurse would review her ‘intermittently’. The CCG sent this paperwork to Oxleas on 5 December and asked that the district nurses assist with Mrs D’s care. The CCG told Mr P the district nurses would help Mrs D with pain and symptom control.
  3. The hospital made a referral to Oxleas which said the district nurses should visit Mrs D each day. Her stoma bag needed changing twice a week, and the district nurses should monitor her weight.
  4. Nurse K visited Mrs D at her sister’s home on 13 December, the day after she left hospital. Nurse K recorded that Mrs D’s carers were managing her personal care and stoma care. Mrs D could move around the house with a walking frame, and was eating and drinking regularly. Nurse K decided the district nurses would visit her weekly to provide support with skin integrity and palliative care.
  5. On 15 December Mr P sent an email expressing concerns about the district nurses. Oxleas’ records say Nurse K spoke with the hospital’s discharge nurse, who said it would be appropriate for them to visit weekly to check Mrs D’s weight. Nurse K noted that Oxleas would probably visit 2 – 3 times a week for palliative support and weight management, but would reassess Mrs D’s needs.
  6. On 16 December, another member of Oxleas’ staff visited Mrs D to assess her needs. They agreed that district nurses would visit daily to check Mrs D’s blood pressure and weight. After this, nurses visited and checked Mrs D’s blood pressure and weight each day to 20 December. On 21 December they checked her blood pressure but she was too unsteady to stand on the scales.
  7. Oxleas produced an investigation report in October 2017 following the family’s complaints. Its findings included that Nurse K assessed Mrs D along with “[Mrs D’s] GP”, they decided jointly that she did not need daily visits and Mrs D agreed.

Findings and analysis

  1. After Mrs D’s discharge of 12 December, Oxleas should have followed the instructions on the discharge plan, which included visiting Mrs D daily and monitoring her weight and blood pressure.
  2. In response to my enquiries about her visit of 13 December, Nurse K said district nurses always complete their own assessment of nursing needs when someone is discharged from hospital, and Mrs D did not need daily visits.
  3. I recognise that district nurses can and should complete their own assessments, however they should follow recommended discharge plans unless they have established, in liaison with other professions as appropriate, that the recommendations are no longer required.
  4. Nurse K’s record of her visit of 13 December says a GP was present. Oxleas’ investigation report incorrectly said this was Mrs D’s GP. Mr P provided evidence Mrs D’s GP did not visit that day. In response to my enquiries, Oxleas said a trainee GP from a different GP practice who was spending time with the district nurses that day was present. Therefore, this was not someone who could make decisions about Mrs D’s care.
  5. In this context, departing from the discharge plan was fault. I have not seen evidence that this caused any harm to Mrs D, but it clearly caused unnecessary anxiety and stress to Mr P.

Complaint about the district nurses not visiting from 22 December

  1. On 21 December, an Oxleas health care assistant visited Mrs D. Also that day, the district nurses decided to reduce their visits to Mrs D visits to three times a week. They did not record why they decided this or whether Mrs D and her family knew about the change.
  2. In the morning of 22 December, the care agency called the CCG to say it would stop providing care to Mrs D that evening. The CCG emailed Oxleas and asked that the district nurses assist Mrs D with her personal care. The CCG emailed Mr P to say the district nurses would assist and provided their contact number.
  3. In the evening of 22 December, a nurse from Oxleas phoned Mrs D and she said she was comfortable and did not need a visit.
  4. In the morning of 23 December, a health care assistant from Oxleas visited Mrs D. The district nurses recorded that they tried to phone in the evening but there was no answer and they left a message. During Oxleas’ investigation a staff member gave a statement that Mrs D and her sisters agreed that the next visit would be 26 December, but there is no mention of this in the nursing records.
  5. The only district nursing record on 24 December was a note at 21:06 which says the nurses could not contact Mrs D.
  6. On 25 December, Mrs D went to hospital by ambulance. The hospital records say she had become more short of breath and wheezy in the past two days. Mrs D had pneumonia and her heart failure got worse after she was admitted to hospital. She was treated with antibiotics but the treatment did not work. She sadly died on 28 December.

Findings and analysis

  1. The district nurses should have continued to visit Mrs D each day from 22 December to offer personal care and perform it if needed and to continue to monitor Mrs D’s weight and blood pressure.
  2. Oxleas staff said Mrs D could manage her personal care, her sisters provided food and drink, and the family knew how to contact the nurses with any concerns.
  3. There is evidence that Mrs D could manage much of her personal care. A heart failure nurse visited on 19 December and made detailed records, which included that Mrs D could manage except that she needed help to wash her back. However, she did need some care and the district nurses should not have stopped visiting without properly establishing through assessment and care planning that Mrs D did not need this. This was particularly important after they were advised on 22 December that the care agency would no longer visit.
  4. There are several entries in Oxleas’ records which say staff could not contact Mrs D by phone so left a voicemail. Mr P says when they retrieved the answerphone from Mrs D’s own house they discovered messages on it from the district nursing service, who had clearly rung Mrs D’s own house rather than her sisters’ house, where she was staying. Mrs D had been living at her sisters’ house for months, and this information was stored on Oxleas records. It appears the staff on duty in the evenings were calling the wrong phone number, even though they had the right number.
  5. Oxleas has a policy for when a patient does not answer the door (the “no answer policy”). It says staff should make sure they have the correct address and telephone numbers. If a patient does not answer the door, there is a list of actions for staff to follow, including phoning them, looking and calling through the letter box, contacting their next of kin, speaking to the neighbours, and contacting their GP. Though the policy applies to home visits, staff should still have contacted Mrs D’s next of kin when they did not make contact with her.
  6. In consequence of these failures, Mrs D was left without care from 22 to 25 December. This caused distress to her family.
  7. Mr P said the family believe Mrs D died prematurely because the district nurses did not visit for four days. He said if they had, they would have seen signs that Mrs D was unwell and she could have been treated sooner. They said this was extremely distressing. I have considered this point carefully, and have concluded that Mrs D’s death would not have been prevented if the district nurses had visited each day. I will explain why.
  8. We do not know when Mrs D became unwell with pneumonia, and we do not know whether the nurses would have seen signs of this had they visited on 23 and 24 December.
  9. There is evidence in the hospital records that Mrs D had no cognitive difficulties on 25 December, indicating that she had the capacity to seek help earlier had she felt she needed it.
  10. Older people and people with impaired immune systems often do not show signs of infection in the same way that younger people do. When Mrs D was admitted to hospital she was very unwell but she had no fever and she was not coughing up sputum. This indicates that her immune system was impaired, which would be expected given her age and how unwell she was.
  11. By the time Mrs D left hospital on 12 December she had heart failure, kidney failure, and fluid around her lungs which was getting worse. She was unlikely to live for long. The family said they were told she would live for months, rather than weeks. But it is not possible for doctors to predict the number of weeks or months someone is likely to live with any degree of certainty. Pneumonia is commonly the cause of death for people with the illnesses Mrs D had.
  12. The hospital treated Mrs D’s pneumonia with antibiotics, but the treatment did not work. Given Mrs D’s poor health, it is unlikely that treatment would have worked even if there was cause for her to be admitted to hospital a day or two earlier.
  13. Taking all of this into account, I find it unlikely that Oxleas’ failure to visit Mrs D in the last days she was at home had any effect on her chance of surviving the infection.
  14. During its investigation in 2017, Oxleas identified failings with Mrs D’s care and actions it needed to take to make improvements. It has provided evidence that it took a number of actions to address this and prevent similar failings in future. These included addressing the issues found with staff individually and at team meetings, providing training, introducing care plan audits, and sharing the lessons learned with other district nursing teams. I am satisfied that Oxleas has taken adequate action to prevent similar failings within care occurring again.

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Agreed recommendations

  1. Within one month of this decision the Council will:
      1. Write to Mr P and his brother to acknowledge what went wrong with its part in Mrs D’s care and to apologise for the impact of this on them.
      2. Pay them each £250 in a symbolic acknowledgement of this impact.
      3. Explain what it will do to prevent similar failings in care occurring in future, and in particular how it will ensure that those who need assistance with stoma care receive it from competent staff.
      4. Copy its correspondence to the Ombudsmen.
  2. Within one month of this decision Oxleas will:
      1. Write to Mr P and his brother to acknowledge what went wrong with its part in Mrs D’s care and to apologise for the impact of this on them.
      2. Pay them each £250 in a symbolic acknowledgement of this impact.
      3. Copy its correspondence to the Ombudsmen.

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  1. I find that:
      1. The Council is at fault because it failed to include the need for carers to assist Mrs D with stoma bag changes on her care plan, and failed to ensure she was supported with this by carers trained in stoma care. This contributed to Mrs D experiencing distress and embarrassment from leaking stoma bags, and also caused the family distress.
      2. Oxleas is at fault for not continuing to assist Mrs D with stoma care until it had made sure she had care from trained and competent carers with this. This contributed to Mrs D experiencing distress and embarrassment from leaking stoma bags, and also caused the family distress.
      3. Oxleas is at fault for not following the recommended discharge plan from 12 – 15 December. This did not cause injustice to Mrs D but it caused Mr P unnecessary anxiety and distress.
      4. Oxleas is at fault because nurses did not visit Mrs D from 22 – 25 December. This left Mrs D without access to personal care, and caused distress to her family. However, it did not contribute to her death.
  2. As the Council and Oxleas have agreed to my recommendations to remedy the injustice to Mr P and his brother, I have completed my investigation.

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Parts of the complaint that I did not investigate

  1. I did not investigate the complaint that district nurses twice failed to notice that Mrs D had symptoms of a blocked bowel. The records show that Mrs D had one admission to hospital with a blocked bowel, and the most recent visit by a nurse was five days earlier. Therefore, it is unlikely we would find evidence of fault.
  2. I did not investigate the complaint that Kings failed to ensure that Mrs D had an adequate home care package in December 2016. At the point of discharge, Kings had made arrangements for Mrs D’s care. Kings is not responsible for the quality of care provided by other organisations after Mrs D’s discharge.
  3. I did not investigate the complaint that a social worker inappropriately interviewed Mrs D about her wishes and her financial situation. I have seen that the Council apologised for this in December 2016. I have not seen indications that this caused a significant injustice, and an investigation would be unlikely to achieve any more.
  4. I did not investigate the complaint that the discharge manager at Kings failed to engage with Mr P after Mrs D’s discharge. I appreciate that Mr P was stressed and frightened at the time. However, Mr P wanted to discuss concerns about decisions made by Oxleas, which were not within Kings’ control. The discharge manager did liaise with Oxleas on Mr P’s behalf to try to resolve the matter. Mr P considers that the discharge manager was not truthful when she said she could not attend because she was with another patient. This is because he received a copy of an email she sent about his mother’s care while he was waiting for her. This is not evidence that she lied about her whereabouts to deliberately avoid him, as Mr P believes. I do not consider it likely that we would achieve a worthwhile outcome through investigating this complaint.
  5. I did not investigate the complaint that when Mr P raised his concerns with the Council as a potential safeguarding issue, it told him to use the complaints procedure. I cannot see any indication that any potential faults in the care commissioned by the Council may have contributed to Mrs D’s hospital admissions. The Council’s complaints team promptly responded to offer a meeting, noting that it would see whether it could do anything quickly to help Mrs D. Therefore, I have not seen indications of fault causing injustice. I have not investigated Mr P’s concerns about the Council’s subsequent correspondence with him and his brother about this. We do not investigate concerns about complaint handling unless we are also investigating the subject of the complaint.
  6. I did not investigate the complaint that there were further problems with stoma care in December 2016 and the district nurses failed to help. I have seen that most of the carers were trained in stoma care and arrangements were in place for newer staff to have training. There is a record from one day in December that the bag leaked, the district nurses were not available to attend at the time but they contacted the care agency to request an earlier visit. We could not establish that this leak was because of poor care. I have not seen sufficient indication of fault causing injustice.
  7. I did not investigate the complaint that one of the carers passed Mrs D a cold, which caused a chest infection. Colds are infectious from a few days before symptoms appear, therefore an infection could have been unknowingly introduced into the house by anyone visiting. We would not be able to establish a link between a carer having a cold and Mrs D’s illness.
  8. I did not investigate the complaint that the care agency commissioned by the CCG cancelled its service on 22 December with four hours notice. The agency said it planned to stop its service on 16 December because of tobacco smoke in the house. Mr P does not agree that the house continued to be smoky, but there are conflicting accounts of events here which an investigation by the Ombudsmen would not resolve. At the time, the CCG was responsible for Mrs D’s care and it made a referral to the district nursing services to take over Mrs D’s care. I do not consider that investigating the role of the CCG or agency would achieve significantly more.
  9. I did not investigate the complaints that Mr P was prevented from providing evidence, the family’s information was not properly taken into account, and he was denied access to information. Mr P raised concerns about information he wished Oxleas to consider. I have seen that Oxleas did consider relevant information provided by the family. It did not interview the family, but it was not required to. There are no indications of fault. The Information Commissioner’s Office is better placed to consider complaints about lack of access to information.

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Investigator's decision on behalf of the Ombudsman

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