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London Borough of Tower Hamlets (16 011 254)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 29 Mar 2018

The Ombudsman's final decision:

Summary: The Ombudsman found the Home, on behalf of the Council and the CCG, had managed a patient’s nutrition adequately and made the correct referrals when swallowing difficulties arose. We also found there was not fault in the Home’s record keeping, communication and managing of residents’ finances.

The complaint

  1. In this draft decision I refer to the complainant as ‘Mr D’ and his late sister as ‘Miss E’. Murrayfield Care Home (the Home) was caring for Miss E under s.117 of the Mental Health Act (MHA). London Borough of Tower Hamlets (the Council) and London Borough of Tower Hamlets Clinical Commissioning Group (the CCG) jointly funded her care.
  2. Mr D complained the Home treated his sister’s refusal to eat over several months as being due to her mental health rather than a physical issue. By the time she attended the hospital that identified her throat cancer, it was too late for effective treatment and she sadly died. Mr D also complained about a lack of acceptable record keeping, communication failures and the management of patients’ finances at the Home.

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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, 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)).
  3. 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

  1. During this investigation I considered the following evidence:
    • Papers and emails provided by Mr D about his complaint
    • Relevant papers provided by the Council, the Home and the CCG
    • I took account of relevant statutory guidance and national policy.
    • I have also sought professional advice from a registered nurse (our Nursing Adviser).

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  1. Miss E was 69 and had a history of schizophrenia, with persistent auditory hallucinations. She had entered the Home in August 2014. Miss E was sectioned in October 2014 due to concerns about her refusing medication and nutrition. Following this stay in a mental health unit, she returned to the Home in December 2014. She attended hospital in April 2015 because of difficulties in swallowing. Doctors diagnosed a throat tumour and she sadly died on 26 June 2015.

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What I found

  1. Mr D said staff at the Home interpreted his sister not eating solid food as a refusal rather than a physical inability to swallow. He said as a result, there was no urgency in referring her for examination, despite monthly recordings of considerable weight loss. He also pointed to a SALT referral form which said ‘created Dec 2014’ at the bottom of the page. This form outlined swallowing difficulties and weight loss which he said proved Miss E was suffering these problems months earlier than the Home had originally stated.
  2. Mr D complained that if the Home had acted sooner his sister’s throat tumour may have been smaller and so treatable.
  3. The Home said it offered Miss E a full balanced diet during her stay in question and it recorded her nutritional intake and any refusals daily.
  4. The Home pointed out that during the last few months before her hospital admission in April 2015, various health care professionals visited Miss E and provided support. These included a GP, community matron (The Matron) and a geriatrician.
  5. The Matron from Enfield Care Home Assessment Team (CHAT) provided a response to Mr D to further explain Miss E’s care and treatment. The Matron said following in-patient mental health treatment in October 2014, Miss E had improved.
  6. The Matron said on 4 March 2015 the Home contacted her again because Miss E was suffering delusions and refusing medication. She was, however, still eating and drinking. The Matron contacted Mile End Mental Health Team for an urgent assessment but the team refused this as Miss E was now a patient of Enfield. A consultant geriatrician saw her on 6 March 2015 and found no underlying medical cause for a deterioration in her mental health.
  7. There was no mental health review for the rest of March but a geriatrician saw her again on 15 April. The geriatrician carried out a full medical review and all Miss E’s observations were normal. The geriatrician was unsure about an admission as the hospital could simply assess then discharge Miss E due to her observations being normal. However due to the swallowing concerns the geriatrician arranged for an urgent gastrointestinal investigation in two weeks. In the meantime, a SALT practitioner visited. They classed Miss E as Nil By Mouth (NBM) and this led to an immediate hospital admission on 22 April 2015. This was when the hospital diagnosed throat cancer.
  8. There is evidence in the care home records of assessment and care planning. This follows national guidance (NICE 2006 CG 32 Nutritional support in adults, pages 8 and 11). Nursing staff did at times have difficulty meeting her nutritional needs because Miss E declined medication and food.
  9. The geriatrician on 9 October 2014, following review, considered Miss E to be physically stable but considered that her mental health issues needed urgent intervention to prevent her physical health suffering. Following her admission to the mental health unit in October 2014 there is evidence that her food intake and compliance with medication improved.
  10. Despite the lack of food charts in September and October 2014, it is evident throughout the records that Miss E’s overall nutritional care was reasonable. There was some weight loss noted from January to April 2015. However , this on its own would not be of concern as her BMI remained high (31).
  11. The Geriatrician who reviewed Miss E on 9 October 2014 found no evidence her refusal to eat and drink was due to any swallowing difficulties.
  12. People with any signs of swallowing difficulties should be referred to healthcare professionals with relevant skills and training in diagnosis, assessment and swallowing disorders (NICE 2006 CG32 Nutrition support in Adults: oral nutrition support, enteral tube feeding and parenteral nutrition. Quick reference guide page 7).
  13. It is apparent from the records when Miss E did experience swallowing difficulties a referral for a SALT (speech and language therapy) assessment on 7 April 2015. There is no convincing evidence she was suffering these difficulties before April 2015.
  14. Mr D pointed to the SALT referral which he said was from December 2014. However this referral had a fax cover sheet in front of it dated 7 April 2015. In addition there is no reference in the care home records in December 2014 of a SALT referral. After weighing the evidence, I believe the Home made the referral on 7 April 2015. The actual referral form master version used for all SALT referrals was created in December 2014 which is why it says ‘created December 2014’ at the bottom of the page. The Home then filled the form in by hand on 7 April 2015 to make the referral.
  1. The Home involved a community matron in Miss E’s care throughout her stay. It also made geriatrician referrals appropriately when required in October 2014 and March and April 2015. It made appropriate referrals for her mental health and for swallowing when this became a difficulty and this led to a diagnosis of her throat cancer. I have not found persuasive evidence to support Miss E suffering from swallowing difficulties before April 2015 which would have warranted a SALT referral. In addition there is evidence that the Home managed her nutrition adequately during the period in question.

Record keeping

  1. Mr D said when he examined his sister’s records the Home only had her daily dietary records for the last 16 days before hospitalisation in April 2015. They show she consumed no solid food for over a fortnight.  He said what was missing from the records was how long this had gone on before this period.
  2. There are no specific standards or guidelines about this issue. If there were concerns about a resident’s food intake it would be good practice to start and maintain food charts.
  3. Miss E was admitted to a Mental Health Unit in October 2014 due to concerns about her mental health and her refusal to eat or take medication. The Home did not maintain food charts in the time period leading up to this admission. However the lack of food charts did not impact on Miss E’s nutrition and medication as the Home’s intervention led to her admission to the mental health unit. During this time she began to eat and take her medication again.
  4. In the months following her discharge in December 2014 there were no documented concerns about eating and drinking or any swallowing difficulties. When staff noted swallowing difficulties in April 2015, they completed food charts.
  5. Although it would have been good practice to start food charts when Miss E refused food in October 2014, she was sectioned which led to her nutritional and medication needs being met. Considering this omission and its effect on Miss E, I would not class it as serious enough to amount to fault on the Home’s part. Furthermore it was reasonable not to have kept food charts from December 2014 to April 2015 when they were commenced. This was because there were no documented concerns about eating and drinking or swallowing difficulties during this time.


  1. Mr D said there is evidence from other official records that his sister reduced from eating solid food over a period of months to semi-solid and then only liquid intake. Yet the Home never told Mr D as next of kin and regular visitor of any problem.
  2. It would be good practice for staff to have told a resident’s relative of any significant health issues, if the resident was happy for this to take place. There are entries in the communication records, showing that communication did take place with Mr D. However there are no entries suggesting the Home discussed any difficulties with Miss E’s dietary intake with him. However, Miss E did not lack capacity for much of this period and so there was no actual duty to tell Mr D of any difficulties with feeding. In addition, the documented difficulties in nutrition and swallowing only occurred in April 2015 rather than over a course of months.


  1. Mr D criticised the way the Home managed his sister’s finances including how it stored her money and how it paid for and recorded services such as hairdressing.
  2. Mr D also complained that when he attended the Home to pick up his sister’s belongings her room was left open. He said this meant that her belongings were vulnerable to theft.
  3. The Home stated that Miss E’s money was stored in a bank account for her with only a small float kept in the safe in the Home. This is a reasonable approach to take by the Home so that it is not storing a large amount of residents’ money on site.
  4. When money was withdrawn or deposited it provided residents with a receipt however some lacked capacity or did not want to hold on to the receipt in which case it would be stored by the Home. Mr D has said this system is open to abuse as all three copies of the receipt could be held by the Home. I understand Mr D’s concern. However, a system such as this is based on trust and taking into account some residents reluctance or inability to keep receipts I would not recommend the Home change their system. Therefore I have not found fault with the Home‘s way of managing residents’ money.
  5. The Home said the services which were supplied were invoiced and signed for by a member of staff who confirmed the residents received the service. The records were checked and audited weekly by the home administrator and home manager. As this system has several checks and audits in place to prevent abuse I do not find fault with it.
  6. Regarding Miss E’s room being left open the Home admitted this was not normal procedure and was a shortfall on the part of the staff. The Home apologised and said the error was addressed in staff supervisions. This is a reasonable response to the failing that Mr D pointed out. We do not have sufficient evidence that any money was taken from Miss E’s room during this time and so would not recommend any compensation to Mr D.

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Final decision

  1. I do not uphold this complaint as I have not found fault with the Home, Council or CCG.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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