Summary: Mr A complains about the Avon Healthcare in relation to care provided to Mrs B which he said led to her death. We will not investigate the complaint as we would be unlikely to find fault or add to the work Avon Healthcare has already carried out.

The complaint

1. Mr A has complained about Avon Homecare (the Agency) in relation to the care of the late Mrs B.

Specifically, Mr A has complained:

• Mrs B’s oxygen was not managed properly,
• Mrs B fell which resulted in injuries causing her death; and
• staff attempted resuscitation against Mrs B’s wishes.

2. The impact of this has been distress for Mr A at the injuries and loss of Mrs B and at how she died.
3. Mr A wants the Agency to have properly qualified which meet the needs of the people it cares for, improved record keeping, better staff conditions and an open culture where lessons are learnt from previous failings.

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The Ombudsmen’s role and powers

4. We have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• the fault has not caused injustice to the person who complained, or
• it is unlikely we could add to any previous investigation by the bodies.

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

6. I considered evidence provided by Mr A and the Agency as well as relevant law, policy and guidance.
7. I also considered Mr A’s comments on my draft decision statement before making this final decision.

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What I found

Background

8. Mrs B lived at home and the Agency was providing her with palliative care. She had 24-hour live in waking care. This meant the carer lived at the property and had rest periods overnight but could respond to emergencies or if Mrs B required assistance. The family then asked for a 24-hour waking care package. This involved carers providing overnight care, undertaking regular checks and immediate responses if there was any change in Mrs B’s condition.
9. Mrs B also had oxygen managed by the Agency and had a request on record for carers not to attempt resuscitation in an emergency.
10. The Agency said on the Friday before Mrs B died, it agreed to the waking care package but could not put it in place over the weekend due to staff resources, so it was due to start on the Monday morning shift.
11. Mrs B fell on Monday morning, between 3am and 5am, before the Agency started the new package. She was found unresponsive and died after a carer found her, rang 999 and attempted resuscitation.

Oxygen

12. Mr A complained about incidents involving Mrs B’s oxygen, specifically a time when she contacted them saying her oxygen machine was beeping as it had run out and she was distressed.
13. Mr A said he spoke to the carer who did not seem to know how to use the machine and this meant he was worried whether the Agency was able to meet Mrs B’s needs.
14. The Agency said it investigated and found the carer acted correctly when switching to a different machine when a fault was detected with the first one. The problem was a kinked hose supplying the oxygen supply.
15. The Agency said the carer had completed the correct training and acted accordingly.
16. In relation to the oxygen management, an investigation would be unlikely to uncover if a carer error led to the oxygen running out or a kinked hose. In addition, the Agency retrained the staff in oxygen troubleshooting and so we would be unlikely to recommend any further action.

Falls and resuscitation

17. Mrs B fell in early May and Mr A raised concerns that this was not properly recorded. He also complaint about the second fall which led to Mrs B’s death.
18. Mr A said the Agency was supposed to provide 24-hour care, yet Mrs B fell and was not found for over two hours.
19. The carer also attempted resuscitation, despite it being clearly noted in her records not to do this.
20. The Agency said it received a request from the family to increase the package to 24 hours waking care on the Friday. Due to the timing of this confirmation at the end of the working week and staff availability, the Agency scheduled implementation for the Monday, commencing with the morning shift.
21. The Agency said unfortunately, Mrs B passed away before the formal transition to the full 24-hour waking care package could take effect. It also said that the falls were not recorded in the daily care notes.
22. Regarding the resuscitation, the Agency said the carer contacted emergency services immediately after finding Mrs B. During the 999 call, the call handler provided instructions to commence resuscitation. In the urgency of the situation and while following these instructions, the carer started resuscitation. The Agency said once the carer realised their mistake, resuscitation was stopped and paramedics attended and confirmed Mrs B’s death.
23. Regarding the falls, it appears there could be a fault in that they should have been recorded in Mrs B’s daily notes and the Agency has said it has reinforced its post fall procedures, including with record keeping.
24. The Agency’s explanation of the reason for the delay in putting in place the 24 hours waking care appears reasonable as it would be difficult to put in place over a weekend due to the short period of time and staff resources.
25. In addition, we could not say that any fault by the Agency led directly to Mrs B’s fall and death.
26. Therefore, an investigation would be unlikely to find that there was fault by the Agency leading to Mrs B’s death.
27. Regarding the resuscitation, this does appear that it could be a fault by the carer undertaking orders from a 999 call handler in an emergency situation.
28. The Agency said it would monitor and carry out reflective supervision with carers involved in serious incidents and this would appear to be a proportionate response to what could be a mistake and we would not recommend any further action.

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Decision

29. We will not investigate this complaint further because the Agency appears to have already accepted fault and has provided a suitable remedy.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman