Summary: The Ombudsmen find Council-arranged domiciliary carers did not complete an adequate plan to help prevent a vulnerable person from getting pressure sores. The lady did develop painful pressure sores and it is likely better planning could have helped prevent them. Further, the Ombudsmen find both a Council and a hospital Trust failed to communicate effectively about a safeguarding concern. As a result, adequate investigations did not take place. The Council and Trust have agreed to apologise and make small financial payments to address the injustice.

The complaint

1. Mrs W complains about the care SOS Homecare Ltd (the Care Company) provided to her mother, Mrs D, in March and April 2016. Trafford Council (the Council) arranged the support the Care Company provided. As such, the Council is responsible for the care the Care Company provided. Mrs W complains the Care Company did not provide an adequate standard of care to Mrs D. Mrs W said Mrs D developed several painful pressure sores as a result.
2. Mrs D went into a Manchester University NHS Foundation Trust (the Trust) hospital at the start of April 2016. Staff in the hospital noted Mrs D had several pressure sores and made a safeguarding referral to the Council. Mrs W complains that no one from the Council or the Trust completed a safeguarding investigation. She said this means there is no evidence these events were taken seriously and no reassurance that lessons have been learned and improvements made.

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The Ombudsmen’s role and powers

3. 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).
4. 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).
5. 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

6. I read the correspondence Mrs W sent to the Ombudsmen and spoke to her on the telephone. I considered records from each of the organisations along with relevant legislation and guidance.
7. I shared a confidential copy of my draft decision with Mrs W and the organisations under investigation to explain my provisional findings. I invited their comments and considered those I received in response.

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What I found

8. There are standards for safety and quality care providers need to meet: The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations). The Care Quality Commission (the CQC) has written guidance to help care providers meet these standards: Guidance for providers on meeting the regulations (March 2015) (the Fundamental Standards).
9. Under the Regulations and Fundamental Standards, care providers need to make sure:

• They provide people with appropriate care, personalised to their needs. As part of this, care providers need to make sure assessments are regularly reviewed (Regulation 9)
• People are kept safe from avoidable risk and harm, and from unsafe care and treatment. This includes assessing risk and making plans to manage it. Care providers also need to make sure staff are appropriately trained, and that equipment is suitable and available (Regulation 12).

Pressure area care

10. Pressure sores are wounds caused by pressure on part of the body interrupting the blood supply to the skin. Under the European Pressure Ulcer Advisory Panel classification system, pressure sores are graded in severity from 1 to 4. All adults are at risk of developing pressure sores although people with mobility difficulties and who are over 70 are more at risk.

Chronology

Hospital and ‘Discharge to Assess’ facility admissions, January to March 2016

11. In January 2016 Mrs D lived at home with her husband. Mrs D was able to move about her home and prepare meals for herself and her husband.
12. Mrs D fell at home and went to hospital. The hospital admitted her. Around a month later Mrs D went to a ‘Discharge to Assess’ facility.
13. During her time in the facility staff noted there had been a notable deterioration in Mrs D’s mobility. They concluded this would not improve. Staff began using a hoist for all transfers.
14. The facility planned for Mrs D to go home with support from carers. Staff from the facility visited Mrs D’s home to check what equipment she would need when she got home.
15. The Council determined Mrs D would need help from carers four times a day, and that two carers would need to attend at each visit.

Return home in March 2016

16. Mrs D returned home in late March 2016. A member of staff from the Care Company visited in the late morning and completed a care plan and risk assessments. The plan noted the need for staff to help Mrs D between her bed, chair and the commode. They were also to check and change her incontinence pads and wash her in the morning. The plan noted that carers would need to give Mrs D a shower and wash her hair a couple of times a week. However, the Care Company noted the hoist would not fit into the bathroom. Mrs W’s husband said that he would remove the door to allow the hoist to fit. Mrs W said he did so later the same day.
17. The Care Company’s care plan recorded that Mrs D did not have any pressure sores but was at risk of developing them. It said district nurses were not involved.
18. Carers visited Mrs D for the first time in the late afternoon of the day she came home. They had a problem with the hoist and called a colleague who came to Mrs D’s home. Together the members of staff were able to hoist Mrs D out of her wheelchair.
19. Carers visited Mrs D four times a day for the remainder of March and into April.
20. Mrs W said she noticed a mark on Mrs D’s hip and called the District Nurses and asked them to come. She said the District Nurse wanted the carers to leave Mrs D in bed so she could check on her.
21. At the end of March carers noted they had been asked to keep Mrs D in bed at the request of a District Nurse. They also noted they ‘turned over onto other side as has a bad pressure sore’. Later that day the carers noted ‘District Nurse saw pressure sore but she says that is bruised on left hip’. The next day carers recorded ‘left hip has bed sore and starting to blister’.
22. A couple of days later, in early April, carers were unable to hoist Mrs D out of her chair at the tea time visit. They called an ambulance and were told that someone would call Mrs D back within an hour. The carers left to go to their next call.
23. Mr D called Mrs W and said Mrs D had fallen and he could not lift her. Mrs W called an ambulance and went to Mrs D’s house. Paramedics arrived and took Mrs D to an ambulance to assess her. Carers from the Care Company arrived for the bed time call as Mrs D was being taken to hospital.

Hospital admission of April 2016

24. When Mrs D arrived at hospital staff checked her skin and found she had several pressure sores. They noted a grade 1 sore on her left ankle, a grade 3 sore on her sacrum (the bony part at the bottom of the spine) and an unstageable sore on her left heel. Staff recorded that they had all been there before Mrs D came into hospital. They referred Mrs D to the Tissue Viability Team, completed an incident report and asked the Medical Illustrations team to take photographs.
25. Several days later a Staff Nurse completed a Safeguarding Adult Referral Form about Mrs D’s pressure sores.
26. Mrs D sadly died later in April 2016.
27. Neither the Council nor the Trust completed a safeguarding investigation.

Complaints process

28. Mrs W complained to the Council in February 2017. After a meeting in March the Council sent a written response at the start of April 2017. The Council concluded there was no evidence to show the Care Company was responsible for Mrs D’s hospital admission. It said carers had applied Solvederm cream and District Nurses had looked at the pressure sores.
29. In terms of washing Mrs D, the Council said Mrs D’s shower chair would not fit into the bathroom. It said Mr W advised he would remove the bathroom door but this never happened.
30. The Council also concluded the carers followed the correct procedure on the day in early April when they could not use the hoist.
31. Mrs W was dissatisfied with the response. She wrote back to the Council in the middle of April. The Council provided another response at the start of August 2017, and a final response in February 2018. It did not acknowledge any significant failings in the Care Company’s or its own actions.
32. The Trust wrote to Mrs D toward the end of 2018. It concluded it followed the correct process in relation to the safeguarding referral.

Analysis

Care in the community

33. Records from the ‘Discharge to Assess’ facility show Mrs D had either a moisture lesion or a grade 1 pressure ulcer in March 2016. Some records referred to a moisture lesion on her sacrum. Other records said she had a grade 1 pressure sore on the sacrum. A moisture lesion is when there is an inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine, stool or perspiration. A pressure ulcer refers to damage to the skin and/or underlying tissue as a result of pressure.
34. Regardless of whether it was a moisture lesion or a pressure sore, hospital staff felt it was still there on the day Mrs D left hospital. On that day one member of staff noted Mrs D had a moisture lesion to her sacrum. Another noted there was a ‘Grade 1 / red sacrum’ and that cream had been applied. When the hospital discharged Mrs D it referred her to District Nurses because of the damage to her skin.
35. The Care Company assessed Mrs D on the day she left hospital. Contrary to the notes from the ‘Discharge to Assess’ facility, the Care Company recorded that Mrs D had previously had a pressure sore in hospital but did not have any when it assessed her. Nevertheless, the Care Company noted Mrs D was at risk of getting a pressure sore.
36. Under the guidance included in its assessment, this risk should have been ‘clearly documented…for staff to be aware and clear instructions for them to follow’. However, I have not seen evidence of clear instructions for staff to follow in terms of managing the risk of Mrs D developing pressure sores. There is one Risk Management Plan that notes ‘[Mrs D] needs a wash every day to prevent sore’. This is an insufficient plan to address all of the factors that could contribute to a pressure sore. This plan was inadequate and this amounts to fault.
37. There is evidence the Care Company kept to the brief plan it had to wash Mrs D. The Care Company’s records state that carers gave Mrs D a full body wash at every morning visit. They also report that carers frequently applied cream to her bottom, took her to the bathroom and changed her incontinence pad.
38. As noted above, the Care Company noted the hoist would not fit into the bathroom when it first assessed Mrs D. Mrs W said her husband removed the door to allow the hoist to fit. The Care Company said it did not know this had happened. It is evident from the records that carers did not give Mrs W a shower during the time she was at home and, instead, gave her a full body wash. I have not seen any evidence in the records of references to access to the shower, or of any discussions with Mrs D, her husband or the wider family about it. I do not know what happened here. It is apparent that communication could have been better but I have not found evidence of fault.
39. Having recorded that Mrs D did not have any pressure sores when she first came home, the Care Company’s records from the end of March noted she had ‘a bad pressure sore’. A note the next day records that this sore was to Mrs D’s left hip. There is evidence in the Care Company’s records to show that District Nurses visited to look at this area. The records state that carers followed the instructions of the District Nurses to keep Mrs D in bed so they could assess her.
40. This change in Mrs D’s condition (from having no pressure sore to having a ‘bad’ one) was an opportunity for the Care Company to review its care plans and risk assessments. However, while there is evidence of carers following the District Nurses directions, I have not seen any evidence to show the Care Company completed any new care plans or risk assessments at this time. This is further fault.
41. As noted above, on the day Mrs D went back into hospital staff noted she had several pressure sores, including a grade 3 to her sacrum. Based on the evidence in the Care Company’s records and hospital records, these pressure sores developed while Mrs D was being cared for at home.
42. While there is some evidence to show that carers were trying to keep Mrs D clean and applying cream, it remains that there was no clear plan in place to mitigate the known risk of Mrs D getting pressure sores. This was still the case after carers had found a new pressure sore. As detailed above, the lack of clear care plans is fault. It is possible that a clear, specific plan to address known risk factors may have helped prevent Mrs D from getting a pressure sore. Therefore, on the balance of probabilities, there is a link between the fault and an injustice: the pain and discomfort Mrs D experienced as a result of the pressure sores she had. This also caused Mrs W distress in seeing her mother in this condition. I have made recommendations to address this injustice below.
43. Mrs W also has concerns about the actions of the Care Company on the day Mrs D returned to hospital. The evidence shows carers came to Mrs D’s house in the early evening and found she had slipped down her chair with her hoist underneath her. The carers were unable to move Mrs D. They called for an ambulance and then left. Mr D was with Mrs D although, like the carers, he was unable to do anything to help move his wife. An ambulance came to Mrs D and took her to hospital.
44. While this was clearly a distressing event for Mrs D and her family I have not found fault with the Care Company’s actions. This is because it took steps to refer her to other professionals who were able to help.

Safeguarding referral

45. Records from the hospital show that staff tried to speak to a safeguarding team on the day after Mrs D returned to hospital. Staff completed a safeguarding referral several days later. On the same day a Charge Nurse at the hospital noted in a memo that the hospital safeguarding team had received the referral. They noted that ‘Due to the nature of the concerns raised it has been referred on to the relevant external Social Services screening team. They will review the information and then assign a Social Worker to investigate’.
46. The Council received the referral and screened it. A Council Senior Practitioner emailed the Trust later in April. She noted it was unclear when the pressure damage first appeared. The Practitioner also noted the hospital had completed an incident report. She said she assumed this would leave to an internal audit of events. The Practitioner asked the hospital to let her know if any further action was required after this took place.
47. I have not seen any evidence of any further contact between the Council and Trust about this matter. Neither organisation completed a safeguarding investigation.
48. The failure to complete more detailed enquiries about this safeguarding referral is fault. The Care Act 2014 places the ultimate responsibility for safeguarding on councils. However, NHS organisations also have responsibilities to participate and engage in safeguarding matters. Organisations need to make sure they work together to keep people safe. This did not happen effectively here. In this instance it was not appropriate for the Council to assume the Trust was going to do more work. It needed to get confirmation about this. Equally, after the Council contacted the Trust about this it had an opportunity to provide more clarity about the situation and what it was (or was not) planning to do. Better communication by both the Council and Trust would have ensured the safeguarding referral was not lost. Therefore, in this instance I find both the Council and Trust have some responsibility for the fault that occurred.
49. As a result of this fault there was a lost opportunity to complete proportionate and robust safeguarding enquiries. As Mrs W notes, this, in turn, means there was a lost opportunity to learn from these events and address any shortcomings. Further, the fault exacerbated Mrs W’s distress as she had no reassurance these events were taken seriously. This is an injustice to her.
50. Given the length of time that has passed and the available evidence I do not consider it would be helpful to attempt a retrospective safeguarding enquiry. However, it would be appropriate for both the Council and Trust to review what happened. I have made recommendations to address this fault and injustice below.

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Agreed actions

51. Within one month of the date of the final decision the Council will write to Mrs W and acknowledge the care provider it arranged for Mrs D did not complete adequate care plans to address her risk of getting a pressure sore. It will also acknowledge that better care planning may have prevented Mrs D developing the pressure sores she got. Further, the Council will apologise to Mrs W for the distress she experienced in witnessing Mrs D’s suffering.
52. Within one month of the date of the final decision the Council will pay Mrs W £250 as a tangible acknowledgement of the distress its fault caused.
53. Within one month of the date of the final decision both the Council and the Trust will write to Mrs W and acknowledge they did not handle the safeguarding concerns about Mrs D adequately. Specifically, the Council and Trust will acknowledge that better communication would have ensured further investigation took place. The Council and Trust will also apologise to Mrs W for the additional distress this caused to her, on top of her worry about her mother’s condition.
54. Within one month of the date of the final decision both the Council and the Trust will, individually, pay Mrs W £100 as a tangible acknowledgement of the distress their faults caused.
55. Within three months of the date of the final decision the Council and Trust will review this case and the arrangements they have for investigating safeguarding concerns. They will consider whether any relevant policies and procedures were properly followed and whether those policies and procedures are adequate. If they find any shortcomings, or identify any better ways of working, they will produce an action plan to make sure improvements are implemented. The Council and Trust will share the results of this work with the Ombudsmen.

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Decision

56. I have completed my investigation on the basis there was fault on the part of both the Council and Trust and this led to an injustice. The Council and Trust have agreed to take action to put things right.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman