Summary: Mrs X complains about the care her late mother (Mrs Y) received at the care home, OSJCT Langford View, arranged for her by the Council. The care home’s records do not support what it said to Mrs X when responding to her complaint. It also failed to record her daughter’s visit to Mrs Y. While this did not impact significantly on Mrs Y’s care, the Council needs to apologise for the distress caused and work with the care home to improve its record keeping.

The complaint

1. The complainant, Mrs X, complains about the care her late mother received at the care home, OSJCT Langford View, arranged for her by the Council.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended)

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What I have and have not investigated

5. Having spoken to Mrs X, we have agreed that I will investigate the events leading up to Mrs Y’s death. I have not therefore investigated historic concerns about the care Mrs Y received at the care home.

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How I considered this complaint

6. I have considered evidence provided by Mrs X and the Council, as well as relevant law, policy and guidance.
7. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What happened

8. In 2022 Mrs Y went to live in the OSJCT Lanford View (the care home), which is run by the Order of St John Care Trust (the care provider). Mrs Y had Parkinson’s disease, which affected her mobility. She used a walking frame and needed support from one member of staff when walking. She had another condition which affected her continence.
9. In January 2024 the care home reviewed Mrs Y’s needs. She was at low risk of malnutrition, so there was no need for staff to monitor her food and fluid intake.
10. The care homes’ records for February 2024 show that up to 12 February, Mrs Y spent time each day with other residents in the lounge and dining room. The care home had assessed Mrs Y as needing two-hourly checks at night. She appears to have slept most nights, requiring occasional help with continence, and waking around 06.00 each day.
11. Mrs X visited her mother on 9 February. She says a care worker said her mother was “not usual” and she was sat in her room not communicating. Mrs X says her mother was “not with it”. At 11.06 the care home recorded Mrs Y as having been involved in an organised activity in the lounge and another communal area. At 14.06 Mrs Y was “settled” and chatting with Mrs X in her bedroom.
12. On 10 February Mrs Y spent time in the lounge and in her bedroom.
13. The care home’s records for 11 February are incomplete. It appears Mrs Y went to the dining room for breakfast. There are no records for the afternoon. By 18.33 Mrs Y was back in her room watching TV.
14. During the night of 11/12 February, staff checked Mrs Y at 22.22 (sleeping, 00.13 (sleeping), 02.33 (awake, “being assisted by one carer”), 04.09 (awake and in bed), 05.16 (assisted to the toilet) and 06.14 (awake and watching television).
15. On 12 February, Mrs Y was in her bedroom at 07.49. The care home made no other records for the morning. At 12.42 Mrs Y was in the dining room. At 15.13 she was in the lounge watching TV. By 19.41 she was in bed asleep.
16. During the night of 12/13 February, staff checked Mrs Y at 22.47 (sleeping), 00.08 (sleeping and pad change), 02.06/7 (awake, declined repositioning), 03.08 (activated call bell asking to get up, as thought it was time to get washed and dressed, reassured), 04.08 (sleeping), 05.04 (continence care), 05.07 (complained about cramps in right leg), and 06.26 (awake, watching TV).
17. On 13 February, Mrs Y remained in her room. The records describe her as “settled” at 10.21. At 10.59 she wasn’t well and was not responding as she normally did. She declined the offer of help with breakfast. A member of staff encouraged her to eat. At 12.05 she was “not herself today” but “in her room having breakfast, but declined the offer of help”. At 14.31 the care home noted Mrs Y was eating and “contented”. At 14.50 a GP asked the care home to get a urine sample. The GP said they would ask a district nurse to get a blood sample. The records say a dip stick result (from a urine sample) was needed to assess if a urinary tract infection (UTI) was ongoing. Mrs Y was described as “drowsy and sleepy”. At 18.55 Mrs Y was in her bedroom watching TV.
18. At 21.34 a member of staff noted they had tried multiple times to get a urine sample from Mrs Y, but the samples were contaminated so they could not test for a UTI. They passed responsibility for getting a urine sample to staff working the next day.
19. Mrs X’s daughter visited Mrs Y in the evening of 13 February. She took a video of Mrs Y which shows she could not fully engage when her granddaughter spoke to her. The granddaughter told Mrs Y she had spoken to staff about getting a urine sample. Mrs X says her granddaughter asked staff to call an ambulance, but they would not do so. The care home did not record the granddaughter’s visit or the conversations she had with staff.
20. During the night of 13/14 February, staff checked Mrs Y at 22.13 (sleeping), 22.56 (declined repositioning) and 00.07 (sleeping).
21. Staff checked Mrs Y again at 01.04, as Mrs X had contacted NHS 999 over her concerns for her mother and to request an ambulance take her to hospital. She says NHS 999 told her it could not send an ambulance for Mrs Y, as Mrs X was not at the care home (so could not know what Mrs Y’s current condition was). However, NHS 999 contacted the care home to check on Mrs Y. The care home told NHS 999 about the GP’s visit and the request for a urine sample and blood tests. NHS 999 said it would tell Mrs Y’s GP about the call and Mrs X’s concerns.
22. Staff checked on Mrs Y again at 02.17/18 (sleeping, declined repositioning), 04.13 (sleeping), 05.05/06 (pad changed, offered water), 05.20 (declined repositioning) and 06.08 (sleeping). Staff checked Mrs Y again at 07.33 and she was “settled” and asleep.
23. By 09.47 Mrs Y was not responding. Her temperature was 39 (high), pulse 102 (slightly high), oxygen 73 (very low) and blood pressure 103/44 (normal). The care home called NHS 999 as sepsis was suspected.
24. Mrs Y went to hospital in an ambulance around 09.54, accompanied by Mrs X. Mrs Y died in hospital.
25. Mrs X complained to the care provider in April.
26. When the care provider replied to Mrs X’s first complaint on 13 May, it said:
• Its records for 12 February said staff checked Mrs Y more than two hourly during the night and they encouraged her to drink. There was no record of her complaining about pain or discomfort. She woke at 05.00 on 13 February and complained about cramps in her leg. Staff noted Mrs Y was not well. She was encouraged to drink. Staff used a stand aid (for people with some degree of mobility) to transfer Mrs Y. She said she did not want help with her breakfast, but staff encouraged her to eat. The care leader called the GP, who went to see Mrs Y as soon as they arrived for their weekly visit to the care home. The GP asked staff to obtain a urine sample and referred her to the district nurse for a blood test. All interactions had been documented in Mrs Y’s records.
• Staff recorded no concerns about Mrs Y’s mobility until she was unwell on 12 February. A GP saw her the following day. Staff acted in line with the care provider’s policies and procedures.
• Mrs Y wore incontinences pads, which made it difficult for staff to get a urine sample. They made several attempts in the evening of 13 February but the samples were contaminated, so could not be used. On 14 February Mrs Y’s condition declined further, so staff called for an ambulance, which took her to hospital.
• Mrs Y’s records said she wore pads due to urinary incontinence. She also had a condition which could have affected her bowels. Its records showed she occasionally fluctuated between constipation and incontinence. It did not know why no one told Mrs X staff had not been able to get a urine sample.
• Its records said Mrs Y had declined breakfast on 13 February, but ate around 12.05 and 14.51, despite Mrs Y having told her daughter she had been off her food all day.
• A care worker had recorded supporting Mrs Y with personal care and continence at 21.51 on 13 February, but this had happened at 21.00, after which the care worker attended other residents. Case notes should be completed as soon as possible after each interaction, but this had to take account of the support needs of other residents. It would seek advice on best practice when recording retrospective interactions.
• The care home contacted the GP on 13 February as soon as staff recognised Mrs Y was not herself. The GP did not assess her condition as urgent and did not prescribe antibiotics, but asked for urine and blood samples.
• Mrs Y’s appetite had never been large while at the care home. She often fell asleep at the table with staff rousing her and encouraging her to eat. She sometimes needed help with food. She had been referred for support with weight loss, but had not lost weight since October 2023.
• The care leader did not recall being asked to call an ambulance on 13 February. Not all conversations with family members were documented.
• Staff checked on Mrs Y almost hourly during the night of 13 to 14 February. On two occasions she asked staff not to disturb her. At 09.47 Mrs Y seemed sleepy and was not responding well. An ambulance took Mrs Y to hospital with suspected sepsis.
• The paramedics did not raise concerns with staff about Mrs Y’s room being hot. There was nothing in the records about Mrs Y having felt cold or having asked for extra blankets. Mrs X had reported the paramedics commenting on the heat in her room and said her mother had three blankets.
• Its records showed staff documented changes in Mrs Y’s condition, and got advice from the GP.
• It could not comment on the information which had been passed to the GP, as that would have been recorded in the GP’s records.
• It would hold a meeting with staff to address the lessons learned.
27. Mrs X was not satisfied with the response, so she took her complaint to the next stage of the care provider’s complaints procedure. She said there had been no accountability for refusing to call an ambulance on 13 February.
28. When the care provider replied on 19 June, it said it was sorry Mrs X was disappointed by the lack of accountability. It said it had thoroughly investigated the issue and there was no further evidence to prove or disprove what happened. But the GP had been contacted on 13 February and actions were taken in line with the GP’s advice. It said it had sought advice on best practice with recording retrospective actions and had held a meeting with staff to address the lessons learned. But it did not say what the outcome of either action had been.
29. The care provider says the care leader is now “adamant that the claim made about the request to call an ambulance didn’t happen”. Ms X’s daughter has confirmed what she told her mother, that she asked the care leader to call an ambulance but was told her grandmother had perked up that day and was absolutely fine.

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

30. The care home’s records do not support all that the care provider said to Mrs X when responding to her complaint:
• It did not record pushing fluids, or Mrs Y being unwell on 12 February.
• It did not record Mrs Y refusing breakfast on 13 February, just refusing the offer of assistance.
31. The care home did not record the granddaughter’s visit on 13 February. It is clear the family were concerned about Mrs Y’s condition and by 13 February she was obviously not herself. The video, which Mrs X shared with the care provider, shows the granddaughter had spoken to staff and was concerned about Mrs Y’s condition. While the care provider was right to say there would be no need to record all conversations with relatives, the granddaughter’s visit and the questions she asked warranted recording, particularly if she asked the care home to call an ambulance.
32. While these failings amount to fault, for which the Council is accountable, there is not enough evidence to say they had an impact on the care Mrs Y received. The care home consulted the GP on 13 February. The GP asked the care home to obtain a urine sample (and requested blood samples from a district nurse). Unfortunately the care home could not get an uncontaminated sample of urine, as Mrs Y was incontinent of both urine and faeces. Sadly Mrs Y declined rapidly, which is common with sepsis, and therefore went to hospital the next day. When paramedics contacted the care home in the early hours of 14 February, they must have been satisfied that the decline in Mrs Y’s health was being addressed. There is no reason to assume Mrs Y would have been taken to hospital if an ambulance had been requested on 13 February.
33. Nevertheless, the mismatch between what the care provider said to Mrs X and what is reflected in the care home’s records, including the failure to record the granddaughter’s visit on 13 February, warrant an apology for the distress caused.

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Action

34. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions. Where we find fault with the actions of the service provider, we can make recommendations to the council alone. Here we have found fault with the actions of the care provider and make the following recommendations to the Council.
35. I recommended the Council:
• Within four weeks writes to Mrs X apologising for the distress caused by the mismatch between what the care provider said when responding to her complaint and what it says in its records, and the failure to record the granddaughter’s visit and the conversation she had with staff.
• Within eight weeks, work with the care provider to improve its records keeping, including the need to record significant conversations with family members and to help it understand the need to provide accurate information when responding to complaints.
36. The Council has agreed to do this. It should provide us with evidence it has complied with the above actions.
37. Under the terms of our Memorandum of Understanding with the Care Quality Commission and information sharing protocol, I will send it a copy of my final decision statement.

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Decision

38. I find fault causing injustice. The Council has agreed to take actions to remedy the injustice.

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Investigator's decision on behalf of the Ombudsman