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London Borough of Hillingdon (17 003 012)

Category : Adult care services > Domiciliary care

Decision : Upheld

Decision date : 28 Mar 2019

The Ombudsman's final decision:

Summary: Mr B complains on behalf of his late great grandmother, Mrs C. He is unhappy with the care provided to her by a number of organisations which he says led to physical discomfort for her and distress for her family. There were some failings by the Council which it should apologise for and provide Mr B with details of how it will ensure these failings do not happen again. There were no failings by the other organisations involved in Mr B’s complaint.

The Ombudsmen’s decision

Summary: Mr B complains on behalf of his late great grandmother, Mrs C. He is unhappy with the care provided to her by a number of organisations which he says led to physical discomfort for her and distress for her family. There were some failings by the Council which it should apologise for and provide Mr B with details of how it will ensure these failings do not happen again. There were no failings by the other organisations involved in Mr B’s complaint.



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The complaint

  1. Mr B has complained about the care and treatment provided to his great grandmother, Mrs C. He has complained about London Borough of Hillingdon (the Council), Central and North West London NHS Foundation Trust (CNWL), Kincora Doctors Surgery (the Surgery), Hillingdon Hospitals NHS Foundation Trust (the Hospital Trust) and NHS England.
  2. Specifically, Mr B complains the Council:
    • provided inadequate care through an agency acting on its behalf
    • did not act on a vulnerable adult form; and
    • does not properly quality assure agency workers
  3. Mr B says that CNWL:
    • District nurses did not properly manage Mrs C’s leg infection
    • District nurses did not routinely read agency care workers’ notes
  4. He complains that the Surgery:
    • delayed carrying out a dementia assessment which led to a delay in diagnosis and treatment
    • did not provide enough help to organise a proper level of care for Mrs C
  5. Mr B says the Hospital Trust:
    • did not properly assess Mrs C in the 72 hours following a stroke
    • left Mrs C to go to the toilet in bed
    • did not manage Mrs C’s nutrition
    • left Mrs C in a side room
    • did not clean the side room
    • staff shouted at Mrs C
    • lost Mrs C’s property
    • showed a lack of sensitivity following Mrs C’s death
  6. Mr B also considers NHS England handled the complaint badly.
  7. Mr B said in some instances he has been told training and spot checks have been put in place. However, he has not been provided with any evidence of this. He would like the truth of Mrs C's care to come out and if we find fault the people involved made accountable. He also wants service improvements so other patients do not suffer.

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What I have investigated

  1. I have investigated all the matters above apart from the complaints against the Hospital Trust related to cleanliness, allegations of staff shouting at Mrs C, sensitivity towards the family following Mrs C’s death and property being lost. I have explained my reasoning for not investigating these matters at the end of this statement.

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The Ombudsmen’s role and powers

  1. 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 on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
  2. 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), as amended).
  3. If it has, they may suggest a remedy. Our 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.
  4. 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)
  5. 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).)
  6. In this case Mr B was continuing his complaint more than 12 months after the events complained about as he was still seeking a resolution locally. Therefore we have exercised our discretion in considering this complaint.

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How I considered this complaint

  1. During my investigation I have considered the following evidence:
    • Information from Mr B
    • Information from the Council, CNWL, Surgery, Hospital Trust and NHS England including the complaint files and Mrs C’s medical and care records
    • Independent advice from a Registered Nurse (our Nursing Adviser), GP (our GP Adviser), and a Consultant Physician (our Medical Adviser)
    • Relevant national guidance including Royal College of Nursing and NICE Guidelines
  2. I have written to Mr A and the bodies complained about with my draft decision and considered their comments.

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What I found

  1. Mrs C was 95 years old and suffered from heart failure and atrial fibrillation. Her family, carers and district nurses supported her in her home.
  2. In February 2015 Mr B found Mrs C unwell on her own at home. She was admitted to hospital but suffered a stroke and sadly died in hospital in March 2015.
  3. Mr B complained about Mrs C’s care and approached the Ombudsmen 2015. He then went back and complained to the bodies, receiving responses during 2016 and 2017 before approaching the Ombudsmen.

Complaints about the Council

Provided inadequate care through the agency

  1. Mr B said in February 2015 he visited Mrs C at home and found her sitting in her own excrement in her living room chair very unwell.
  2. He checked the carers’ book as they should have attended that morning. Mr B said the last entry was 15 minutes before he arrived stating that she was well with no concerns. He said it was clear Mrs C was very ill. He also raised concerns about Mrs C having her leg cream applied for ulcers and her not taking her medication.
  3. The Council’s care plan stated Mrs C would have a 30-minute call at the preferred time of 9:30am for assistance with personal care, dressing, prompting medication, giving breakfast, making a sandwich for lunch and to take out a frozen meal for the evening. According to the Council, Mrs C had declined evening care despite needing to take one of her regular medications at night.
  4. The Council commissioned the care provider from November 2014 for a 30-minute daily visit. Its own support plan said carers were to assist with personal care which included washing, drying and cleaning Mrs C's legs, but that Mrs C was ‘independent on all other personal care'. According to the support plan she was also independent in managing medication.
  5. On reviewing the care provider’s documentation, Mrs C was having her legs washed, dried and creamed in accordance with her support plan. At the start of February 2015, a carer worried about the 'leaking' from Mrs C's legs and said she ‘will contact the GP on Monday'. The carer also noted that Mrs C was more out of breath and had not been taking her medications regularly. A few days later, following the carer’s concerns, a Practice Nurse visited and stated that Mrs C had cellulitis in her legs. She referred her to district nurses to dress the legs and antibiotics were commenced.
  6. On 14 February, a carer documented that Mrs C was ‘not very well’, she was not taking her medication and was confused. She gave Mrs C her breakfast. Mrs C's family were present at this time.
  7. There is no evidence of the reasons for not making a medical referral at this time. However, it would not have been unreasonable for the carer to assume if Mrs C's family had serious concerns at this time they could arrange a GP visit. Nonetheless, the care provider should also have informed the Council in order to for it to review Mrs C's care needs. This may have led to a change in the care package Mrs C received.
  8. The following day, the records show the carer made Mrs C a cup of tea and 'washed the pots'. Despite the concern the day before about medication it is documented that 'she refused to take meds'. This should have been reported back to the care provider’s office. It could have informed Mrs C’s family and this is another occasion when the Council should have been informed. Mr B then found Mrs C unwell shortly after this and the carer should have considered a medical referral at this time. To have not made a referral or called an ambulance was also fault on the part of the carer.
  9. After considering the care and support plans in place, the care records and nursing advice, there were failings in the support given to Mrs C. Carers did not always properly record when they treated Mrs C’s legs. In addition, safeguarding concerns were not escalated, especially in relation to medication and her physical deterioration.
  10. However, the physical impact on Mrs C is not clear. If the carers had reported the lack of compliance with medication with the care provider or the Council earlier it could have led to an amendment of Mrs C’s support plan. However, we cannot say, even on the balance of probabilities, this would have prevented her admission to hospital. If the carer on 15 February had called an ambulance this would have resulted in her hospital admission approximately 15 minutes earlier as Mr B called an ambulance when he arrived. However, Mr B also suffered distress from finding Mrs C in this state.
  11. The Council drew up an action plan for the care provider to complete by September 2015. This had actions related to training in escalating medication compliance, record keeping and support plans. This would be a satisfactory response to the failings identified. However, the Council has not provided Mr B with evidence of the actions the care provider carried out after this plan. Therefore, he cannot be satisfied the care provider and the Council has taken sufficient action.

Did not act on a vulnerable adult form

  1. Mr B said the paramedic who attended Mrs C on 15 February filled out a vulnerable adult form due to concern about Mrs C’s condition. Mr B complained the Council did not take this form seriously enough in relation to safeguarding.
  2. I could not find a specific response to this concern from the Council. However, the Council explained it did not initiate a safeguarding investigation as it did not think Mrs C was being neglected but rather she needed an update to her care plan.
  3. In the vulnerable adult form the paramedic filled out, the paramedic answered ‘No’ to the question ‘In your opinion, is this a safeguarding alert?’. However he raised concerns about Mrs C needing a review of her care package.
  4. Taking this into account I have not seen any evidence the Council did not place sufficient weight on the paramedic’s vulnerable adult form. The main concern put forward by the paramedic in the form was for Mrs C’s care package to be reviewed. The paramedic did not feel a safeguarding alert was required. Therefore, I find the Council did take the form seriously as it agreed Mrs C’s care package needed to be reviewed but a safeguarding alert was not required.

Does not properly quality assure agency workers

  1. Mr B complained about how the Council audits care providers to make sure they carry out appropriate care. He said that there is only one person who quality assures six agencies across the borough of Hillingdon.
  2. The Council told Mr B its Care Governance Board meets monthly. It is part of a framework to identify, monitor and respond to serious quality issues or identified risks to service users. The Board agrees what action is necessary in response to concerns about care providers on a case by case basis.
  3. This response does not specifically answer how the Council quality assures its care agencies but rather how it responds to concerns. This is not a satisfactory response and Mr B cannot be reassured that the Council is properly overseeing the care agencies it commissions.

Complaints against CNWL

District nurses did not properly manage Mrs C’s leg infection

  1. Mr B criticised the district nurses’ care of Mrs C’s leg ulcers as they were badly infected when he found her.
  2. CNWL told the Ombudsmen Mrs C did not actually have leg ulcers, but rather cellulitis. Cellulitis “Presents as the acute and progressive onset of a red, painful, hot, swollen and tender area of skin.” (Clinical Resource Efficiency Support Team Guidelines (CREST), 2005)
  3. CNWL stated district nurses were aware of the infection on 4 February when a referral took place for visits and antibiotics to treat the infection. CNWL said there was an error in the response it sent to Mr B as it was 6 February, not 5 February when district nurses first visited Mrs C. It went on to say the district nurses undertook a full holistic assessment on this occasion and then visited Mrs C several more times. CNWL said it could not be certain Mrs C took her antibiotics but the legs were seen to be improving on 9 and 12 February.
  4. On 12 February, the district nurses visited Mrs C and found her legs were red and had superficial wounds to each leg. CNWL said that Mrs C’s legs could have further deteriorated in the time between 12 and 15 February when the paramedic attending found leg ulcers ‘very infected’.
  5. From the information provided by CNWL and the records Mrs C had cellulitis with the first visit by district nurses on 6 February. As CNWL has said, CREST Guidance (2005) is used for treatment of cellulitis. The guidance states on the first visit to examine site area affected and give analgesia. The guidance also states that there should be a care plan and holistic assessment.
  6. There is an issue in that CNWL have told the Ombudsmen a holistic assessment was carried out but it was in the ‘home’ records and it cannot obtain the assessment. District nurses have in the past had home records and electronic records. The home records remain property of district nurses service but are kept in the patient’s home. If the patient dies and lives on their own the district nurses will then not have access to these records. Mr B has provided evidence in the form of extracts from his great grandmother’s records to CNWL. However, he has said no holistic assessment exists. I have not seen any evidence a holistic assessment was done.
  7. Mrs C’s cellulitis was managed over a short time frame, from 6 February and she was admitted to hospital on 15 February. The district nurses’ role would be on each visit to do an assessment and dress Mrs C’s legs. A dressing could be kept in place for up to seven days. The care plan for Mrs C’s legs is not detailed but it is within CREST guidance.
  8. The plan was to use bandages if the cellulitis got worse. Mrs C’s skin broke on the 12 February. CNWL said district nurses reverted to two layer bandages. The records show on the district nurses did this on 12 February. This was reasonable practice within the guidance. In addition the lack of a holistic assessment did not have a detrimental effect on Mrs C’s leg infection as it was managed appropriately by the district nurses.
  9. By 15 February Mrs C had what appeared to the paramedic when they examined her, and to our Nursing Adviser from the records, to be leg ulcers. Leg ulcer guidance usually says leg ulcers cannot be diagnosed until after four to six weeks. However, Mrs C had a history of bad circulation and other relevant issues. When she was admitted the hospital said she had leg ulcers. It was reasonable for them to make this conclusion on the evidence available. Taking into account CNWL’s response to the Ombudsmen and all other evidence the district nurses acted reasonably. According to the available evidence Mrs C’s legs broke down in the period after seeing her on 12 February and she developed leg ulcers. Therefore I have not found fault with CNWL in managing Mrs C’s leg infection.

District nurses did not routinely read agency care workers’ notes

  1. Mr B felt the district nurses should have been checking the care workers’ notes to keep up to speed with Mrs C’s ongoing condition.
  2. If there is a concern over the condition of a patient, it is useful to review documentation from other sources. However, there is no requirement to do this. Therefore, after considering nursing advice I have not found fault with the district nurses not consulting the notes although I agree it would have been useful to help form a picture of Mrs C’s ongoing condition.

Complaints about the Surgery

Delayed carrying out a dementia assessment which led to a delay in diagnosis and treatment

  1. Mr B complained the Surgery refused to do Alzheimer's and dementia tests on Mrs C with a home visit. It insisted she went to the surgery. Mr B felt this delay meant his great grandmother did not get proper dementia treatment until she was in hospital.
  2. The guidance which is relevant here is NICE guidance on dementia, CG 42 2006: ”Early identification of dementia Primary healthcare staff should consider referring people who show signs of mild cognitive impairment (MCI)11 for assessment by memory assessment services to aid early identification of dementia, because more than 50% of people with MCI later develop dementia”
  3. There is evidence the Surgery did make several assessments of Mrs C’s cognitive function before August 2014, but there were no concerns. In August 2014, routine screening identified a decline in the memory test. The score had fallen from 30/30 to 24/30. However, the Surgery did not make a referral at this time.
  4. The steps towards diagnosis only began on the prompt of Mrs C's granddaughter two months later on 17 October 2014, with a face to face consultation resulting in referral on 27 October 2014.
  5. There was a delay of two months in the referral for a specialist assessment for memory impairment. However, the impact of this on Mrs C’s Alzheimer’s progression would have been slight.
  6. After carrying out a significant event investigation the Surgery said that it should have taken earlier action after the reduced score on the assessment in August 2014. The Surgery apologised and changed its method so a duty doctor is alerted on the same day following an irregular assessment or home visit.
  7. The steps taken by the Surgery to address the issues that led to the delay, the reporting of abnormal results and communication between the team, have been appropriate and I would not recommend any further action.

Did not provide enough help to organise a proper level of care for Mrs C

  1. Mr B felt the Surgery, along with the district nurses, did not properly manage Mrs C's leg infection. In addition, he felt Mrs C's medication was not managed correctly considering she was 95 and suffering from dementia.
  2. With regard to medication the Surgery outlined the visits the Practice Nurse made to Mrs C. At these visits the Practice Nurse would ask Mrs C how she was managing with her medication. The Practice Nurse would also take note of Mrs C's environment to check she was managing ok.
  3. The Surgery said it saw Mrs C about her legs on 14 January 2015 and 4 February 2015 where it made a referral to district nurses due to infection and prescribed antibiotics.
  4. The Surgery said it worked as a separate entity to the district nurses and was not in a position to dictate the frequency of their visits. It went on to say it prescribed Mrs C appropriate medication for her health conditions and conducted medication reviews.
  5. There is no indication in the medical record that the Surgery was made aware of the carers’ concerns about medication compliance. Mrs C had medication prescribed at timely intervals by the Surgery who managed her medication appropriately.

Complaints about the Hospital Trust

  1. The Hospital Trust never received a complaint from Mr B and declined to respond to my enquiries. It did however provide us with Mrs C’s medical records. Therefore, I took nursing and medical advice on the issues that I could investigate.

Did not properly assess Mrs C in the 72 hours following a stroke

  1. Mr B said Mrs C had a stroke in the afternoon of the 28 March 2015. He said he spoke with a female doctor on the 29 March who was very helpful. However Mr B said she also confirmed she was just weekend cover and that staff had not yet assessed Mrs C, this being 24 hours since the stroke. Mr B said Mrs C could not communicate and had clearly suffered a major stroke.
  2. Mr B said Mrs C died from a further stroke on the 31 March still having not been assessed by a doctor, 72 hours after the initial stroke.
  3. With regard to a lack of medical assessment, the records show staff medically assessed Mrs C on 28, 29, 30 and 31 March. Therefore, there was frequent assessment and the documentation includes a long note each day on her condition. Taking into consideration the records and medical advice, the Hospital Trust assessed Mrs C promptly, frequently and the care was in line with national guidance (NICE guidelines on stroke management 2008 last updated 2017)

Left Mrs C to go to the toilet in bed

  1. Mr B said on one occasion Mrs C was asking to be taken to the toilet, he asked numerous staff to help her as she required assistance in moving by this point. He said he was continuously told they would assist however 30 minutes later still no one was there to help. Mrs C cried out to be taken to toilet but a nurse told her to just toilet on the bed. He challenged the nurse and her response was that it did not matter as there were sheets down. Mr B pointed out that she deserved to be treated with dignity and respect. He said the nurse just said sorry.
  2. Nursing staff completed a moving and handling assessment at the start of Mrs C’s admission. It stated Mrs C was at 'medium risk' in that she was prone to falls, could only partially weight bear and needed assistance from two members of staff with toileting. Mrs C wore pads for urinary and faecal incontinence.
  3. Mrs C was catheterised because of urinary retention on 22 February and continued to need pads for faecal incontinence. She was documented as wheezy and short of breath on mobilising. This was apparent from the end of February and it would not have been appropriate to mobilise her to the toilet from this time on.
  4. Mrs C continued to deteriorate during this admission. Physiotherapy notes indicate that she could not weight bear beyond 20 seconds and therefore she was not able to use the toilet during this admission. Taking this into account whilst I agree Mrs C should have been treated with respect and dignity, she was not physically able to be taken to the toilet. In light of this and the fact the staff apologised at the time there is nothing more the Ombudsmen could achieve on this issue.

Did not manage Mrs C’s nutrition

  1. Mr B said he noticed Mrs C had not eaten for three days and upon raising his concerns about this he said staff told him she had eaten. He had to take the dietary sheet and show it to the nurse to confirm that Mrs C had not eaten in three days. According to Mr B the nurse looked very concerned by this fact and walked off stating she would inform the doctor. Mr B pointed out his great grandmother was weak, and criticised that this had not been picked up by the people responsible for caring for her.
  2. Staff assessed Mrs C's risk of malnutrition on admission and this was repeated on 21 and 28 March. A nutritional care plan was in place from 1 March because of 'poor food intake'. This is in line with national guidance (NICE CG32 2006 'Nutrition support in adults'). There are also records of oral intake within the file and a patient meal and snack plan from 20 March.
  3. Mr B was not specific about the dates when Mrs C had not eaten. However, there was a period of time, post stroke, when Mrs C was nil by mouth. This was a clinical decision rather than a sign of neglect. I am satisfied, considering nursing advice, that over the whole hospital admission, staff effectively managed Mrs C's nutrition in accordance with national guidance.

Left Mrs C in a side room

  1. Mr B said after Mrs C died staff showed him to a side room where she was. He said it was bad enough to think that was where her dead body had been placed. However, he later found out she was put there the day before whilst still alive. No explanation has been given as to why she was moved.
  2. We cannot comment on exactly why Mrs C was placed in a side room. However, staff will often move end of life patients to a side room when possible. This is to allow family members to spend more time with the patient outside of the usual visiting hours.
  3. Furthermore, the patient's dignity, privacy and comfort is of paramount importance and often it is difficult to maintain comfort in a busy and frequently noisy ward area.
  4. Whilst I accept an explanation should have been given, after considering nursing advice I do not find fault in Mrs C being placed in a side room due to her being sadly at the end of her life.

Complaints against NHS England

Complaint handling

  1. Mr B complained NHS England should have taken more action with the Surgery following his complaint. This included delays in the Surgery responding to his complaints.
  2. NHS England said it noted the Surgery had admitted failings in relation to the lack of action following the memory test and communication with the family. It said it looked at the remedial action taken by the Surgery, took clinical advice and decided the response was appropriate and reasonable. In addition it was noted the Surgery had apologised for the delays in responding to the complaint.
  3. I also came to the conclusion the Surgery took sufficient action to address the failings it identified. Therefore, I do not find fault with NHS England’s response to the complaint.

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  1. I have at this stage identified fault with the Council. Therefore, I recommend:
  2. Within one month of my final decision, the Council should:
    • Write to Mr B acknowledging and apologising for the impact the faults identified in Paragraphs 25 to 28, 30 and 37 had on Mrs C and Mr B; and
    • Provide Mr B with evidence of the action it has taken to address these faults

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Final decision

  1. Subject to further comments by Mr B and the bodies complained about, I intend to uphold the complaint against the Council but not CNWL, the Surgery, the Hospital Trust or NHS England.

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Parts of the complaint I have not investigated

  1. Mr B also complained about cleanliness, staff members shouting at Mrs C, lost property and a lack of sensitivity with the family after she died by the Hospital Trust. Although I understand these events were distressing for Mr B and his family, I do not consider the Ombudsmen can achieve anything more for Mr B. Mr B has not complained to the Hospital Trust about these issues, there is little documentary evidence and significant time has passed since these incidents.

Investigator’s final decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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