Summary: Mrs P complained that after she asked a care home to call a GP to see her mother Mrs D, a GP did not visit and Mrs D died prematurely as a result. The Ombudsmen find that the care home failed to monitor Mrs D’s condition and seek medical attention as it should have done. The GP practice failed to respond properly to contacts from the care home about Mrs D. The Ombudsmen cannot say what impact this had on Mrs D, but the distress and uncertainty caused by this are an injustice to Mrs P. They recommend action to put this right.

The complaint

1. Mrs P complained about the care provided to her late mother Mrs D by St Thomas Care Home (the Home), which is owned by Barchester Healthcare Homes Ltd (Barchester), and by Crown Heights Medical Centre (the Practice). She complained that:
2. On 22 and 28 March and 4, 6, 7, 9 April 2017 she asked the Home to call a GP to see Mrs D after she had a bad fall and her breathing deteriorated, but a GP did not visit her. As a result, Mrs D sadly died prematurely from pneumonia. Further, she suffered unduly in the final three weeks of her life. This caused immense distress to Mrs P. Mrs P wants the organisation responsible for this to acknowledge what went wrong and put processes in place to stop this happening again.
3. Mrs P believes the Home’ records are incorrect because the Home’s records say they checked on Mrs D between 14:30 and 16:00 on 10 April 2017. Mrs P says she was there at the time, and they did not.
4. Mrs P also says the Home recorded that Mrs D’s fluid and food intake was good, but this was not the case. She says when Mrs D was admitted to hospital a nurse said she was severely dehydrated. She says Mrs D could not eat or drink without assistance from carers, therefore she often did not eat or drink.
5. Mrs P seeks an apology, service improvements so that similar problems do not happen to others, and a refund of the £7200 fees they paid to the Home to donate to charity.

Back to top

The Ombudsmen’s role and powers

6. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. We decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. Where something has gone wrong we refer to those actions as ‘fault’. (Local Government Act 1974, sections 34B, and 34C, as amended)
7. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services. We use the word ‘fault’ to refer to these. If there has been fault, the Health Service Ombudsman considers whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1))
8. If the actions of a health and social care provider have caused injustice, the Ombudsmen may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
9. 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, as amended, and Health Service Commissioners Act 1993, section 18ZA)
10. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

11. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
12. 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)

Back to top

How I considered this complaint

13. I considered information provided by the parties to the complaint, including relevant health and social care records provided by the Home and the Practice. I took clinical advice from a senior nurse with expertise in the care of older people, and from a senior GP. I took account of relevant policy, law and guidance.
14. I shared a draft of this decision with the parties to the complaint and considered their comments.

Back to top

What I found

15. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
16. We normally expect someone to complain to the Care Quality Commission about possible breaches of standards. However, we may decide to investigate if we think there are good reasons to do so. (Local Government Act 1974, section 34B(8), as amended)
17. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
18. Regulation 9 says care must meet a person’s needs, involve relevant persons in decisions about a person’s care, and meet a person’s nutritional and hydrational needs.
19. Regulation 12 says care must be delivered safely. Providers must minimise risks to a person as much as reasonably practicable. People providing care must have the appropriate skills.

Good Medical Practice

20. The General Medical Council (GMC – the organisation responsible for the professional regulation of doctors) has published ‘Good Medical Practice’, which sets out the standards that the GMC expects doctors to meet. It lists the duties and responsibilities of doctors and describes the principles of good medical practice and standards of competence, care and conduct expected of doctors in all areas of their work.

The Code for Nurses and Midwives

21. The Nursing and Midwifery (NMC) issued The Code in 2009 (updated 2015). This sets out standards of conduct, performance and ethics for nurses and midwives. It says clear and accurate records should be kept of discussions, assessments, treatment and medicines given, along with how effective these have been. Nurses and midwives must “accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care”. They must promptly refer a person to another practitioner when necessary for care or treatment.

What happened

22. Mrs D was an elderly lady with medical conditions including dementia and heart failure. She had to move into a care home in March 2017. The Home recorded that Mrs D was on antibiotics when she arrived because of an infected toe and an inflamed leg. It noted that she had no diagnosed breathing problems but that she “gets puffy. Regular rest periods if walking”.
23. In the morning of 22 March, Mrs P emailed the Home to say she had concerns about Mrs D’s health, following her visit the previous evening. She said she felt Mrs D may need more antibiotics. She also raised other concerns about Mrs D’s care. She asked the Home to arrange for a GP to visit to look at Mrs D’s legs and overall health. She said she would like to be present at the GP’s visit.
24. The Home replied in the late morning. It said it would ask for a GP to see Mrs D because it usually did this within the first 2-3 weeks of a new resident’s admission.
25. Mrs P replied that afternoon. She repeated that she felt Mrs D may need more antibiotics. She asked whether the lead nurse at the Home (the Nurse) could decide whether these were needed in advance of the doctor’s visit, and request them if so. She felt that without more antibiotics Mrs D would be susceptible to falls, since she had fallen previously when she had problems with her leg ulcers. She also felt Mrs D’s diuretic tablets may need increasing because her legs were more swollen.
26. Later that day, a carer at the Home recorded that Mrs D had fallen and bruised her head and knees. The Nurse contacted the Practice and said Mrs D had a raised temperature and probably needed more antibiotics. She did not tell the Practice that Mrs D had fallen. The Practice said it would arrange for the duty doctor to call back. The GP records say only that the Nurse called to ask for antibiotics and the GP issued a prescription.
27. In the morning of 27 March, a member of staff from the Home called the Practice. The Home said it was calling about two patients, one of whom it wanted to be seen by a doctor. It said one of the two patients was Mrs D, who was getting very short of breath when moving around, and who needed a review of her medication. The Practice did not provide the rest of the transcript of this call because it says it contains information about another patient. It is not clear from the transcript whether Mrs D was the patient the Home wanted to be seen by the doctor.
28. Later that morning, the Practice’s community paramedic (the Paramedic) called the Home about Mrs D. The Home said Mrs D was short of breath when moving around, but otherwise well, and needed a review of her medications. The Paramedic said Mrs D needed to be seen but it did not sound urgent. The Home agreed that it could be “tomorrow or whenever”. The Paramedic said she would ask the Practice’s Community Matron whether she could visit on any of the following three days and would let the Home know.
29. On 29 March, the Nurse spoke with the Community Matron by phone. The Community Matron wrote in the Practice’s records that the Nurse asked whether a GP could increase Mrs D’s diuretic medication because she was more short of breath when moving around. The Community Matron wrote that she would discuss this with a GP.
30. On 3 April, the Home recorded that it discussed Mrs D’s care with the Community Matron. Mrs D’s medication needed to be reviewed. The Community Matron would discuss Mrs D’s blood test results with a GP with a view to increasing her diuretic medication.
31. The Community Matron recorded that Mrs D had settled well, she was mobile, and eating and drinking well. She was at risk of falls and infection. They were to “treat as appropriate for [Mrs D’s] needs, trying to avoid any acute admissions”.
32. Mrs P said she was so concerned about Mrs D that she rang her former GP on 4 April for advice. The GP said to keep pushing for a doctor to visit because it sounded as though Mrs D had a new infection.
33. Mrs P said she discussed her concerns about Mrs D again with the Nurse in the morning of 6 April. She said Mrs D’s health had got much worse, she probably had a new infection, and she begged the Nurse to call a doctor to see her. She said the Home called that evening to say they could not get through to the Practice but would try again the following day. The Home recorded that the Nurse told Mrs P that Mrs D would be seen by a GP. Mrs P said she wanted to be present when the GP visited.
34. Mrs P said that from 7 to 10 April Mrs D was very unwell and could not eat and drink. She said she spoke with the Nurse again on 9 April and asked her to call a doctor.
35. On 10 April, a GP recorded that the Community Matron spoke with them about visiting Mrs D. The GP tried to speak with a nurse at the Home, but none was available so they left a message.
36. Mrs P said Mrs D was left alone severely distressed from then until 16:00 with no one checking her. The doctor did not come, but the Paramedic arrived at 16:30 and immediately called an ambulance to take her to hospital.
37. The hospital recorded that Mrs P said Mrs D had been unwell for a week and got much worse in the last two days. It noted that Mrs D was dehydrated. It gave her antibiotics to treat a chest infection. Sadly, Mrs D’s condition got worse, with her heart and kidneys failing. She died on 13 April.

Complaint responses

From Barchester

38. Barchester’s response to Mrs P’s complaint said:

• It contacted the Practice on 22 March about Mrs D’s fall.
• It appears that it contacted the Practice on 30 March about Mrs D’s condition, but the Practice did not feel she needed an urgent visit and said it would arrange a review.
• It contacted the Practice on 4 April and said Mrs D was short of breath when moving around. As a result, the Community Matron visited to review Mrs D’s medication and condition, and said she would feedback to the GP.
• The records indicate Mrs D had “consistent food and fluid intake”.
• It believes the Home contacted the Practice on 6 and 7 April but it has no record of this.
• It contacted the Practice on 10 April about Mrs D’s condition, and the Practice said the Community Matron would visit her.
• The nurse on duty on 10 April says Mrs D was checked between 14:40 and 16:00.

39. Barchester said “actions have been carried out and learning has happened as a result of your concerns”. However, it provided no detail of this.
40. Based on the records I have seen, it appears that some of the information in Barchester’s response is incorrect.

From the Practice

41. The Practice’s response to the complaint said:

• The Home asked for repeat antibiotics for Mrs D on 22 March because she had a high temperature, but it has no record it was told she fell that day.
• The Paramedic spoke with the Home in the morning of 27 March and they agreed Mrs D did not need an urgent visit. If the Home had not been happy to wait until at least 29 March, they would have visited that day.
• The home visit took place on 29 March when the Community Matron visited, but there is no record the Home felt Mrs D’s breathing was noticeably worse. The Home did not request another visit from a doctor, suggesting it was satisfied with the input from the Community Matron.
• The Home requested home visits for other residents on 6 and 7 April but not for Mrs D.
• The Home requested a visit for Mrs D at 14:08 on 10 April. The Paramedic visited about 16:30 and phoned an ambulance.
• It would raise a “significant event” to reflect on these events and invite the Home to attend.

42. The Practice’s response appears to incorrectly state that the Community Matron visited the Home on 29 March, since the Practice’s records say this was a telephone consultation and the Home’s records do not suggest the Community Matron visited that day.
43. NHS England also wrote to Mrs P, having reviewed the Practice’s records. It said the Practice should have reviewed Mrs D when she registered as a new patient. It said it would have been appropriate for a GP to visit Mrs D after she fell on 22 March, but the fall was not reported to the Practice and the Home did not request a visit. It also said shortness of breath when moving around is potentially serious and it would have been appropriate for a GP to visit. But when the Home requested a visit, it said Mrs D was well and the visit could be done on a routine basis. It said there seemed to be a difference between Mrs P’s recollection of Mrs D’s condition and what the Home recorded. The Practice did not know about the seriousness of Mrs P’s concerns.
44. The Practice completed a significant event analysis. This says its phone call records show that the Home gave it different information from what Mrs P thought was happening, and the Practice did not know that Mrs D needed an urgent visit. The Community Matron usually visits new patients in care homes, but when Mrs D arrived at the Home she was on leave and could not catch up straight away. The record keeping by the Community Matron, the Paramedic, and the GP who prescribed antibiotics on 22 March was insufficient. The Practice said it was due to start a new care home programme, and the Community Matron and Paramedic’s record keeping would improve. The Home did not take part in the analysis, and the Practice noted that key staff involved no longer worked at the Home.

Findings about a GP not visiting after Mrs P asked the Home to call one to see her

45. On 22 March, Mrs P asked the Home twice to arrange for a GP to visit Mrs D because she was concerned about her. The Home should therefore have asked for a GP to visit. It should also have reported Mrs D’s fall to the Practice.
46. Given the concern about an infection in Mrs D’s leg, the Home and the Community Matron should have made sure a swab was taken from the leg, to make sure the right antibiotics were being used. The Home should have monitored Mrs D’s temperature. This did not happen.
47. The Nurse did speak with a GP, but there is no evidence she asked a GP to visit. However, GPs are required by ‘Good Medical Practice’ to adequately assess a patient’s condition, including examining them where necessary. The GP who spoke with the Nurse on 22 March should have asked the Nurse questions about Mrs D’s condition, and then decided whether they needed to visit the Home to examine her. There is no evidence the GP did so.
48. On 27 March, the Home told the Practice that Mrs D was well apart from increased breathlessness. But the Home had not monitored Mrs D’s physiological observations, which it should have done to establish that she was well apart from her increased breathlessness.
49. It was for the Practice to adequately assess Mrs D’s condition to decide whether she needed an urgent visit. It should have done this by asking the Home questions, including how short of breath Mrs D was, how quickly the breathlessness had come on, and whether she had other symptoms such as chest pain or a fever. The Practice did not properly assess Mrs D’s condition to decide how soon she needed to be seen.
50. Further, the Practice decided that the Community Matron would see Mrs D over the following few days, but this did not happen. There was only a phone call with the Community Matron on 29 March. The Community Matron said she would speak with a GP about Mrs D’s medication, but there is no evidence she did so.
51. The Community Matron did see Mrs D on 3 April, and her notes that Mrs D was settled, eating, drinking, and mobile, do not indicate a cause for concern. This is at odds with Mrs P’s report of 1 April that Mrs D was struggling to eat and drink and too tired to move around, but without independent evidence I cannot account for this. The Home recorded on 3 April that Mrs D’s medication needed to be reviewed because she was short of breath when moving around, and that the Community Matron would discuss Mrs D’s blood test results with a GP with a view to increasing her diuretic medication. There is no evidence this happened.
52. There is evidence in the Home’s records that it agreed to call the Practice on 6 April to request a GP visit. Though the Home told Mrs P it could not get through to the Practice that day, it did not call the out of hours service, and there is no evidence it considered this. It made no record of any attempts to seek a visit from a GP between then and 10 April. Nor did the Home record any physiological observations for Mrs D, in response to Mrs P’s concerns.
53. I find that throughout this period, the Home failed to appropriately respond to Mrs P’s concerns. It failed to ask a GP to review her as and when it should have done. It failed to monitor Mrs D’s condition through physiological observations. Therefore, I consider that there was fault in the care provided by the Home, which was not in line with the NMC Code, and appears to be a potential breach of CQC’s fundamental standards of care. The Practice failed to appropriately respond to the Home’s contacts of 22 March and 27 March by assessing Mrs D’s condition and deciding whether it needed to see her. It also failed to take a swab of her leg wound, and to follow the Community Matron’s plan to discuss Mrs D’s medication and condition with a GP. Therefore, I consider that the Practice did not provide care in line with Good Medical Practice and The Code. This is fault.
54. Unfortunately, it is not possible to determine with any degree of certainty what effect these failures had on the outcome for Mrs D, because of the absence of assessment findings and physiological observations. We do not know when Mrs D’s chest infection developed, or whether Mrs D could have been successfully treated if seen sooner. The information in the hospital records suggests that Mrs D’s condition got worse from 8 to 10 April. Given her poor health before these events and how unwell she became in hospital, with multi-organ failure, I find it more likely than not that her death was not preventable. However, the uncertainty around this, and the distress caused by the Home’s failure to properly respond to her requests for a GP to see Mrs D, was an injustice to Mrs P.
55. Neither organisation fully identified what went wrong in their responses to Mrs P’s complaints. Both their complaint responses contained incorrect information. The Home said it had learned from Mrs P’s concerns, but did not explain how. The Practice’s significant event analysis was inadequate. It did not contain a thorough review of what happened, fully identify what went wrong on the part of the Practice, or adequately identify improvements it needs to make. It should have addressed ensuring it adequately assesses the needs of patients on receipt of phone calls from care homes, the record keeping of GPs, the Community Matron completing management plans, and the Practice providing cover for the Community Matron’s leave.

Complaint that the Home did not check on Mrs D in the afternoon of 10 April

56. The Home’s records of 10 April are not clear about the times at which staff saw Mrs D in the afternoon. The Home’s response to Mrs P’s complaint said a nurse checked her during the afternoon. Mrs P said they did not. In the absence of further evidence I cannot resolve this, therefore I do not find fault here.

Complaint about Mrs D’s food and fluid intake

57. The Home’s care plan for Mrs D’s nutrition and hydration says she had a good appetite but needed prompting with food and fluids. The records indicate that she ate and drank up to 9 April, but refused food and drink offered to her on 10 April.
58. That Mrs D was dehydrated when she was admitted to hospital is not evidence that the Home failed to support her with nutrition and hydration. Dehydration would be expected given that she was very unwell and refusing food and drink. It is not possible to know whether Mrs D was more dehydrated than would be expected for the circumstances. Therefore, I do not find fault with the Home here.

Back to top

Agreed action

59. Within one month of this decision:
1. Barchester and the Practice will each write to Mrs P to acknowledge what went wrong and apologise for the impact of this on her;
2. Barchester will review the Home’s practice and procedures for acting on the concerns of relatives, monitoring the condition of patients who are unwell, or who may be unwell, seeking medical attention, and record keeping. It will produce an action plan setting out how it will ensure that similar faults are prevented in future. It will share a copy of this with Ms P and the Ombudsmen.
3. Barchester will share a copy of this decision statement and its action plan with CQC and the commissioning organisation(s) for the Home. It will provide evidence to the Ombudsmen that it has done this.
4. The Practice will complete a further significant event analysis, taking account of my findings, and produce an action plan setting out how it will avoid similar faults in future. It will share a copy of this with Mrs P and the Ombudsmen.
5. The Practice will share a copy of this decision statement, its new significant event analysis and its action plan with NHS England. It will provide evidence to the Ombudsmen that it has done this.
6. Barchester will pay Mrs P £600 to acknowledge the distress and uncertainty she was caused by the faults in Mrs D’s care. The Practice will pay Mrs P £400 to acknowledge the distress and uncertainty she was caused by the faults in Mrs D’s care. I have recommended that Barchester pay a higher amount because I consider that the faults by Barchester had a greater contribution to the injustice.

Back to top

Decision

60. I find that there were faults in the care provided by Barchester and the Practice to Mrs D, and these caused injustice to Mrs P.
61. As Barchester and the Practice have agreed to my recommendations to remedy the injustice, I have completed my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman