The Ombudsman's final decision:
Summary: Ms X has complained about the care her mother received from the home before she went in to hospital. There is evidence of fault with some aspects of Mrs Y’s care and with how the home communicated with her family. The home has already given a suitable remedy for the injustice caused.
- Ms X has complained about the care her mother, Mrs Y, received from the care home shortly before she went in to hospital. Ms X says the home should have arranged for her mother to go in to hospital sooner and believes the delay contributed to Mrs Y’s death.
- Ms X has also said the home failed to properly tell her about her mother’s condition or the doctor’s visits and treatment she received.
The Ombudsman’s role and powers
- 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)
- If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
How I considered this complaint
- I have considered all the information from Ms X and the care home, including the home’s response to my enquires.
- A copy of this decision was sent in draft to Ms X and the care home. I have considered any comments received in response.
- Ms X has complained about the standard of care her late mother received from the home in the weeks before she went in to hospital. Ms X says the home should have taken her mother to hospital sooner and the lack of urgency contributed towards Mrs Y’s death. Ms X has also raised concerns about the communication she received from the home. She says it did not keep her properly informed about her mother’s medical condition and did not enquire about Mrs Y after she was taken to hospital.
- On the 19 May 2017, Ms X visited her mother in the care home and found that she was unwell and seemed very confused. The nurse on duty told Ms X that a doctor had visited and they were awaiting the results of a urine sample. Ms X says the nurse also told her that the doctor had not prescribed any antibiotics. Two days later, Ms X visited again. Mrs Y was still unwell and uncomfortable as the staff on duty had not emptied her catheter bag for some time. During the visit, the home also told Ms X that her mother had suffered a leg injury following an accident with a wheelchair.
- On 30 May 2017 Ms X received a call from the home saying Mrs Y did not have a ‘Do Not Resuscitate’ form with her records and as such an ambulance had been called to take her to hospital. Once in hospital, the doctor told Ms X that her mother’s kidney function was dangerously low. Following treatment Mrs Y’s condition started to improve. However, Mrs Y later became worse and she sadly died on 23 June 2017. Ms X says the home should have taken Mrs Y to hospital on 19 May. The home does not agree and says it was working under the guidance of the doctors that visited Mrs Y.
What I found
- The care home has provided copies of its records. These show that Mrs Y was visited by a doctor on 12 May. During the visit, a urine sample was taken and antibiotics prescribed. A second doctor’s visit took place on 19 May. At the time Mrs Y was already on a course of antibiotics and the results from a further urine test was due a few days later. The doctor visited again on 23 May and changes were made to Mrs Y’s medication. The doctor also told the home to test Mrs Y’s urine again in three days. On 30 May the doctor visited and after consulting with the hospital, called an ambulance.
- Based on the evidence, I cannot say the home contributed to Mrs Y’s death or that it should have taken her to hospital sooner. Mrs Y was being seen by the doctor and the home was administering the prescribed medication. It also ordered the necessary tests requested by the doctor. I understand Ms X has said that when she visited the home to collect her mother’s belongings, the nurse on duty acknowledged that Mrs Y should have been taken to hospital sooner. The home says it has spoken to the staff on duty at the time and they cannot recall making these comments. In circumstances such as these, it will never be possible to know for certain what happened when Ms X collected her mother’s belongings or what the duty nurse said. However, based on the information available I cannot say there is evidence to show the home is at fault in this regard.
- Ms X has also raised other concerns about her mother’s care. In particular, Ms X has said;
- She is unhappy with how staff at the home told her that her mother had been taken to hospital;
- the home failed to keep in contact or ask about Mrs Y’s condition after she went in to hospital;
- when she visited the home, she found Mrs Y’s catheter bag full and causing her discomfort. It had not been emptied for some time and the staff on duty only agreed to empty it after she insisted;
- she told the home that her mother had died before collecting her belongings. But she was still asked by staff on three separate occasions how her mother was, which was very upsetting.
- she has concerns about an injury her mother suffered following an incident with a wheelchair. She has questioned if the wheelchair was in good condition or if the incident was down to a lack of care from the staff member involved.
Ms X also says the home failed to keep her informed about her mother’s condition and the doctor’s visits. She says if she had been properly informed she would have intervened and ensured that her mother went to hospital sooner.
- I have first considered the concerns Ms X raised about the leg injury her mother suffered following the incident with a wheelchair. The home told Ms X that Mrs Y’s leg was cut when the footplates on the chair swung back in the shower room. The home says the wheelchair was in working order at the time and while this was an unfortunate accident it has reminded staff of the relevant procedures for transferring residents from wheelchairs.
- I have reviewed the details about the incident including the accident forms completed at the time and records to show the home regularly check and maintain the wheelchairs. While I cannot know exactly what happened, the evidence available suggests the injury was more likely than not an accident. I am also satisfied the home took appropriate steps following the incident.
- However, it is clear there has been some fault by the home, particularly with how it communicated with Ms X. The home seems to accept it could have kept Ms X better informed regarding Mrs Y’s doctor’s visits and medication. It also says the way it told Ms X about her mother’s hospital admission was unacceptable and it should have kept in contact while Mrs Y was in hospital. The home has also acknowledged that Mrs Y’s catheter should have been emptied straight away and it should not wait for a resident’s visitors to leave before it does this.
- The home has apologised for these issues, implemented new procedures and provided training to its staff. It has also refunded the fees paid for Mrs Y’s care from 19 May 2017. I consider this a suitable remedy for the injustice caused.
- There is evidence of fault with some aspects of Mrs Y’s care. The care home has already arranged a suitable remedy for the injustice caused.
Investigator's decision on behalf of the Ombudsman