Summary: Ms C complained that the homecare provider failed to alert the district nurse and/or the family, when they found her grandmother (Mrs G) unresponsive on arrival. As a result, Ms C and her mother did not have an opportunity to say goodbye to Mrs G, in an appropriate manner, when she passed away. The Ombudsman found fault with the actions of the care provider, for which the care provider has agreed to apologise.

The complaint

1. The complainant, whom I shall call Ms C, complains that the care agency, who provided homecare support to her grandmother (whom I shall call Mrs G), failed to contact the District Nurse and/or Ms C’s mother, when carers found Mrs G completely unresponsive.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. If we are satisfied with a care provider’s actions or proposed actions, we can complete our investigation and issue a decision statement.

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How I considered this complaint

5. I considered the information I received from Ms C and the care provider. I shared a copy of my draft decision statement with Ms C and the care provider and considered any comments I received, before I made my final decision.

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What I found

What should have happened

6. Advice given by health professionals in general is that: if somebody is found unresponsive but breathing, one should immediately call 999 or 112.

What happened

7. Mrs G lived together with her disabled daughter. Mrs G was receiving end of life care, which included four visits a day by two carers and regular visits by the district nurse.
8. According to the records, including statements from the staff involved, two of Mrs G’s regular carers arrived on 31 August 2019 at 7.55am. They found that Mrs G was completely “unresponsive but still breathing”. The carers were unable to provide Mrs G with any food or drinks. However, the carers checked Mrs G’s pads, creamed her legs, made some tea and told her sister to give it to Mrs G when she wakes up.
9. The carers were concerned about a ‘rattling noise’ when Mrs G was breathing and therefore called the office. The ‘on call’ stated that all concerned were already aware of the ‘rattling’ noise. The ‘on call’ said in her statement that she did not contact the district nurse or the family because they were already aware of the issues the carers had reported.
10. According to the available records and the carer statements, the carers were not concerned that Mrs G was completely unresponsive. This was not discussed as a concern with the ‘on call’ and, as such, there was no decision made whether that issue should be escalated. One of the carers said in her statement that Mrs G had been like this on many calls recently but would usually be awake by the lunch or tea call.
11. I looked into this further, by reviewing Mrs G’s daily care records, which showed that:
• Mrs G often experienced issues around pain, and occasions when she felt (very) sleepy or was less alert. However, on other occasions she was very alert and interacting with carers in a normal manner.
• Carers regularly contacted the office when they had concerns about Mrs G’s presentation and/or when they were (as a result) unable to deliver some of the care. The care provider also had regular contact with district nurses to discuss any changes, issues and concerns.
• I found three previous recent occasions where carers were unable to wake her:
1. 6 August 2019 (11am): Mrs G didn't wake up throughout the visit, and the carers were having trouble waking her.
2. 16 August (8pm): Mrs G was asleep and there was no response from her. Carers contacted the on call who said it was OK to let her sleep.
3. 28 August (1pm). Mrs G very peaceful. Tried to wake her but no luck.
12. Following the discussion between the carers and the ‘on call’, the carers left, because the care provider concluded that Mrs G’s presentation was not concerning; not out of the ordinary for her.
13. Ms C arrived at her grandmother’s house for a visit, along with her young child, about 30 minutes later (at 920am). Ms C told me she immediately knew that something was wrong and called the district nurse and her mother when she saw her grandmother. However, Mrs G had passed away when her mother and the district nurse arrived.
14. Ms C told me the care agency should have called the district nurse and/or her mother. While this would probably not have avoided Mrs G passing away, it would have given her mother an opportunity to say goodbye to Mrs G. Furthermore, rather than having to look after her own daughter and her disabled aunt at the same time, Ms C herself would have been able to focus more on, and be more with, her grandmother during her last moments.
15. Following the events, the care provider took statements from the three staff members involved, and sent a copy of this to Ms C. However, under the circumstances, the care provider should have sent a cover letter with these statements.
16. When Ms C made a complaint to the care provider, it did not accept that it should have contacted the district nurses or her mother. The response only said the carers had contacted the field care supervisor who assessed the situation and made a decision.

Assessment

17. When a client is at the End of Life stage, it is particularly important to constantly be on the look-out for any changes and deteriorations in the client’s presentation, so this can be immediately fed-back to health professionals.
18. The records showed that, overall, the care provider was in regular contact with the district nurses and raised concerns about pain and any deteriorations when needed, until 31 August 2019. While Mrs G was asleep on arrival on some occasions, carers were usually able to wake her and subsequently interact with her.
19. However, this was not the case on 31 August 2019. General healthcare guidance is clear that, when somebody is found unresponsive but breathing, then this is something that should immediately be raised with healthcare professionals. It will subsequently be for a healthcare professional to determine what action needs to be taken. This did not happen on this occasion, which is fault.
20. This also meant that the carers should have remained with Mrs G, until the office had obtained advice from a healthcare professional. This did also not happen, which is fault.
21. Having established there was fault in the actions of the care provider, I have to determine what would have happened if the fault had not occurred. I found that, on the balance of probabilities, Ms C and her mother would have been given an opportunity to say goodbye to Mrs G, in an appropriate manner.

Agreed action

22. I recommended that, within four weeks of my decision, the care provider should:
• Provide a written apology for the faults identified above and the distress this has caused Ms C and her mother.
• Share the lessons learned with its staff
• Develop staff guidance that says how its staff should involve healthcare professionals when they find a client completely unresponsive (but breathing).
23. The care provider has told me it has accepted my recommendations.

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Final decision

24. For reasons explained above, I upheld Ms C’s complaint. I am satisfied with the actions the care provider will carry out to remedy this and have therefore decided to complete my investigation and close the case.
25. Under the terms of our Memorandum of Understanding with the Care Quality Commission (CQC), I have shared a copy of my final decision statement with the CQC.

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Investigator's decision on behalf of the Ombudsman