Summary: We uphold two of Ms A’s complaints about her late father Mr B’s care: there was poor record keeping around injuries to Mr B and a failure to speak to her about the decision to stop funding a nursing home placement. This was fault and caused Ms A avoidable distress. We have not upheld the rest of Ms A’s complaints. To remedy the injustice, the Council has accepted our recommendation to apologise and make a symbolic payment of £250.

The complaint

1. Ms A complains about her late father Mr B’s care, arranged and funded by Devon County Council (the Council.) She complains:
1. A social worker provided incorrect information about Mr B to other professionals involved in his care and attempted to have him placed in a nursing home against the family’s wishes.
2. The social worker failed to respond to requests for information from a Clinical Commissioning Group as part of the Continuing Healthcare funding assessment process.
3. The Council placed Mr B in a nursing home (Camelot House, the Nursing Home) that was not suitable for him and that could not meet his needs. This contributed to Mr B’s escalating behaviour and detention under the Mental Health Act 1983.
4. The Nursing Home failed to provide appropriate care. Mr B lost weight and sustained unexplained injuries to his chest, hands and feet which Ms A feels may have been a result of restraint. The Nursing Home failed to administer Mr B’s prescribed medication appropriately.
5. An Approved Mental Health Practitioner (AMHP) from the Council failed to take the effects of Mr B’s medication into account as part of his Mental Health Act Assessment and did not involve Ms A.
2. Ms A says the failure of the Council and Nursing Home to provide Mr B with appropriate care caused her significant distress.

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The Ombudsman’s role and powers

3. 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with a council’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)
5. 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, section 25(7), as amended)
6. The Council commissioned the Nursing Home to provide Mr B’s care. The Council remains responsible for Mr B’s care. Any fault by the Nursing Home is fault by the Council.

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How I considered this complaint

7. I considered Ms A’s complaint, the Council’s response to her complaint, information from Ms A and documents from the Council described below. The parties received a draft of this statement and I took comments into account. Relevant comments are included in this statement.

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What I found

Relevant law and guidance

8. Under the Mental Health Act 1983, when someone has a mental disorder and is putting their safety or someone else’s at risk they can be detained (’sectioned’) in hospital against their wishes. Usually three professionals need to agree that the person needs to be detained in hospital. These are an Approved Mental Health Professional (AMHP), plus a doctor who has been specially approved in Mental Health Act detentions and another doctor. The AMHP is responsible for making the application to detain the person once the two doctors have made medical recommendations. The AMHP must consider whether detention would be the best way of getting the care and treatment the person requires.
9. The AMHP has to make reasonable efforts to contact the nearest relative to inform them of the application and to invite their views about the patient’s needs and the nearest relative’s needs. They must tell the nearest relative their rights. (Code of Practice to the Mental Health Act 1983, 14.64)
10. AMHPs should take reasonable steps to contact the person’s attorney for health and welfare and seek their opinion. They should also be given the opportunity to talk directly to the doctors assessing the patient, where practicable. (Code of Practice to the Mental Health Act 1983, 14.70)
11. People are detained under section two of the Mental Health Act 1983 for assessment of their mental health for up to 28 days. A person can only be detained if they are suffering from a mental disorder which warrants detention in hospital for assessment and they need to be detained in the interests of their own health or safety or with a view to the protection of others. (Code of Practice, Mental Health Act 1983, 14.4)
12. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity. If a person’s mental capacity to make a particular decision, is in question, there should be an assessment of their capacity.
13. A Lasting Power of Attorney (LPA) is a legal document which allows people to choose one person (or several) to make decisions, when they become unable to do so for themselves. The decision must be in the person’s best interests. There are two types of LPA, property and finance and health and welfare. A health and welfare LPA gives the attorney(s) the power to make decisions about the person's health and personal welfare, such as day-to-day care, medical treatment, or where they should live.
14. Continuing healthcare (CHC) is a package of ongoing care arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist. The threshold for meeting the CHC Checklist is low. If the completed CHC Checklist indicates the person may be eligible for CHC, the next step is a full multidisciplinary assessment which is usually completed by the person’s local Clinical Commissioning Group (CCG).
15. If a council decides a person needs care and support, it should prepare a care and support plan which specifies the needs identified, says whether they meet any eligibility criteria and sets out how the council is going to meet them. It should give a copy of the care and support plan to the person. (Care Act 2014, sections 24 and 25)
16. Statutory Guidance explains a council should review a care and support plan at least every year, on request and where circumstances have changed. (Care and Support Statutory Guidance, Paragraph 13.32)
17. A council can arrange a person’s care for them if they wish, or, the person or their representative can have a direct payment, which is money to organise care themselves.
18. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
19. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Ombudsman considers the 2014 Regulations when determining complaints about poor standards of care. Those relevant to this complaint are:
• Regulation 9 requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should design a care plan to meet needs and preferences.
• Regulation 12(i) says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.
• Regulation 17 requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
• Regulation 14 says the nutrition and hydration needs of residents must be met. They must receive suitable nutritious food and fluid to sustain life and good health, with support to eat and drink if needed.

What happened

20. Information in this section is taken from the Council and Nursing Home’s records, unless otherwise stated. Where Ms A denies making comments and information that have been attributed to her in those records, or disputes the accuracy or truth of incidents which are recorded as having happened, I have reflected this.
21. Mr B lived at home with his wife Mrs B before the events of this complaint. He had vascular dementia and heart problems. Mr B received social care funding from the Council. He had a care and support plan drawn up in April 2017 which set out his needs and outcomes and a personal budget to meet his needs. Ms A had an LPA for health and welfare and managed Mr B’s care for him, including supporting him to take prescribed medication. Ms A used a direct payment from the Council to employ personal assistants to support and care for Mr B in his home.
22. Mr B had a psychiatrist and an occupational therapist from the local NHS community mental health team for older people (‘the mental health team’). The mental health team in Devon is an NHS service and is not run by the Council. There was close liaison between the Council’s social care and team and the mental health team.
23. On 3 July 2017, a social worker emailed Ms A asking if she had received a copy of a completed CHC checklist. Ms A said she had not. The social worker posted a further copy and a stamped addressed envelope to Ms A on 20 July. Information from the CCG that Ms A provided in response to a draft of this statement indicates the CCG received the completed checklist in August and declined it as it was dated April 2017. The CCG told Ms A it advised the Council it had declined the checklist by email. However, there is nothing in the Council’s records to suggest it received an email from the CCG in August.
24. At the start of September, Ms A told the social care team, she thought Mr B may need respite care in a nursing home. The case was allocated to a social worker and the social care team started to look for suitable nursing homes with vacancies, noting Mr B would need one to one care for the settling in period. The social worker wrote to Mrs B asking if she could visit the family at home. The records indicate Mrs B was not keen for a home visit and wanted workers to visit them at Ms A’s home. Ms A told us she decided on 28 September, having discussed Mr B’s case in consultation with a private psychiatrist, that Mr B needed respite care to withdraw from quetiapine (a drug to treat mood disorders, sometimes used for dementia).
25. The Council’s records say Ms A told the social worker she did not think Mr B had dementia and believed his behaviour was due to medication toxicity and one of Mr B’s tablets (quetiapine) had caused her father’s heart problem. Ms A told us that she never queried her father’s diagnosis of dementia, but she queried the type of dementia with Mr B’s GP. The Council’s records note there was a concern from the mental health team that Ms A was seeking an alternative diagnosis for her father and may not be giving Mr B his medicine as prescribed because she felt her father was being over-sedated.
26. Ms A took Mr B to see a private cardiologist, who stopped his heart drugs and recommended to the GP that the quetiapine be reduced and replaced with a different type of drug due to possible unwanted side effects (a slow heart rate). Mr B also saw a private psychiatrist who, Ms A said, recommended Mr B stop taking quetiapine prescribed by his NHS psychiatrist. The Council’s records indicate the social worker spoke to the mental health team, which advised her Mr B’s GP was responsible for implementing any changes to Mr B’s prescribed medicine. The social worker then spoke to Mr B’s GP who told her they had received a letter from the private psychiatrist advising to give Mr B two doses of quetiapine a day (I have seen copies of both letters from the private cardiologist and private psychiatrist: the latter recommended quetiapine twice daily, the former recommended quetiapine be reduced and then replaced with an alternative. Ms A told us Mr B’s regular GP could not change the drugs as his records had been sent to the new GP surgery he had registered with due to being in the Nursing Home).
27. The records indicate the Council was considering starting a safeguarding investigation to address the medication issues. It did not do this for reasons which are not recorded.
28. A social worker carried out an assessment of Mr B’s mental capacity to decide to go into a nursing home. The outcome was he lacked capacity.
29. Mr B became increasingly unsettled in September, with reports of him assaulting a neighbour and becoming more difficult for the family and personal assistants to care for. Ms A denies her father assaulted a neighbour.
30. At the end of September 2017, Ms A contacted the social care team. The records note she said Mr B had urinated on an electric fire and the family could no longer cope with him. (Ms A told us her father did not urinate on an electric fire as her father had been trying to dry hankies on it and so the fire was removed at the start of August. She asked for an emergency placement in a nursing home). The social worker and mental health team visited Mr B at home and found him restless and agitated; they could not engage him in conversation. The social worker completed a review of Mr B’s care and support plan, updated this to reflect recent events and detailed that he required a short-term placement. The social worker updated Mr B’s personal budget which set out the cost of the placement to the Council.
31. The Council arranged for Mr B to go into the Nursing Home for one week beginning 29 September. The notes indicate Ms A had visited the Nursing Home previously and had spoken to the Nursing Home’s manager to enquire about a vacancy, suggesting her father needed placing urgently. The Council agreed funding for Mr B to receive one to one care.
32. The social worker noted Ms A told her, if the Nursing home got her father to take quetiapine, she wanted him to come home after two weeks. The social worker said there would be a review of the placement after one week. Ms A told the social worker she was not going to visit Mr B for two weeks and would keep in contact with her father by phone. Ms A told us she never said she wanted two weeks respite for her father, only one week and the family was told not to go to the home for fear of unsettling him. Ms A also told us she kept in phone contact with the Nursing Home and apart from one occasion, she was told he was fine.
33. The social worker told the Nursing Home’s manager that staff could not overrule Ms A’s instructions on what medication they could give Mr B because she had an LPA for health and welfare. The manager emailed the social worker on 29 September saying she had spoken to Ms A and the latter had agreed Mr B could have quetiapine twice a day and lorazepam (a drug to treat anxiety) as and when needed ‘in an emergency’, in line with Mr B’s NHS psychiatrist’s recommendation.
34. The Nursing Home drew up care plans for Mr B. His weight on admission was 96 kg. He had a body mass index of 31, meaning he was overweight. The care plans said:
• Mr B was to have one to one care and staff were to complete hourly charts of his behaviour
• He was to have medication as required and in line with what Ms A wanted him to take
• If restless, Mr B should be allowed to walk, given space and kept safe. He was mobile. There had been falls in the past.
• Mr B needed reminding to go to the toilet and supervision in the toilet
• Staff were to discuss care with Ms A when making decisions. Mr B could not retain information and lacked mental capacity to make decisions about his care
• Staff needed to monitor for triggers which could cause falls and try to avoid these
• Mr B needed supervision with eating and drinking, staff were to offer drinks and snacks from the normal menu and weigh him monthly
• Staff needed to ensure he was offered a daily wash and a shower or a bath at least weekly. To promote independence while giving assistant and instructions where needed.
• Mr B found putting things into words difficult and became agitated and could show aggression. Staff needed to divert him. He did not like loud noises and should be moved to a quieter area if other residents were loud
• He did not always take medication and so staff gave it covertly (mixed in with food or drink) with the GP’s approval.
• He was incontinent and used pads. Staff were to ensure he was clean and dry
• He could be disinhibited and may urinate in public
35. The Nursing Home kept detailed hourly recordings of Mr B’s behaviour and care interventions. The records noted:
• He had a sore on his left big toe with a broken nail
• He was aggressive to staff, including trying to bite them, and hold on to their arms very firmly; he was unsettled and needed diversions
• He needed a lot of encouragement to eat
• He often walked around, moved furniture
• He sometimes declined medication, even when it was given covertly in food
• He slept only for short periods and was not in a regular sleep pattern.
36. The Nursing Home also kept reports of incidents and injuries. One report noted Mr B had lost his balance and was about to fall so staff lowered him to the ground. They noted a small scab on his left elbow. He continued to walk around and was not in any pain when checked.
37. On the day of admission to the Nursing Home, the care records indicate Mr B hit windows, pushed chairs towards staff, bent their fingers back, punched and tried to bite staff. Staff tried to reassure him but were unsuccessful. The manager of the Nursing Home contacted the mental health team to ask for clarification about Mr B’s current medication. The manager spoke with Mr B’s psychiatrist from the mental health team and she advised staff to continue with quetiapine twice a day and lorazepam up to twice a day if needed and to document any falls. The psychiatrist asked the manager to speak to Ms A to ensure she was happy with the plan and if she declined, there would need to be a different plan. The manager did so and noted Ms A agreed with the plan. The social worker emailed the manager to say if Ms A ever stated Mr B could not be sedated, then she could not be overruled as she held a health and welfare LPA and the only action available then would be a Mental Health Act assessment. Mr B’s NHS psychiatrist also advised the Nursing Home that they could request a Mental Health Act assessment if they could not manage Mr B’s behaviour.
38. The Nursing Home’s medication charts show Mr B received quetiapine twice a day on 29, 30 and 31 September. This was then stopped. Mr B received lorazepam twice a day from 2 October.
39. On 30 September, Ms A spoke to a member of staff at the Nursing Home and said she was unhappy Mr B was being given quetiapine. The manager spoke to Ms A later on and told her if staff were not allowed to give Mr B medication then they would be considering a Mental Health Act assessment due to Mr B’s safety and the safety of others. Ms A agreed Mr B could have lorazepam and quetiapine only if he needed it. Ms A disagrees with this and told us she never consented to Mr B having quetiapine when he was at the Nursing Home.
40. On 2 October, the mental health team emailed the Nursing Home to say Ms A had agreed Mr B could have lorazepam twice a day and Ms A was going to speak to Mr B’s cardiologist about this.
41. On 2 October, the Nursing Home’s manager emailed the social worker to say Mr B had been aggressive to staff and residents and Ms A told her she did not want the mental health team involved in his care, only the private consultant. The manager said she did not want to go against Ms A’s wishes and wanted some advice. The mental health team spoke to the Nursing Home’s manager saying Mr B’s NHS psychiatrist prescribed lorazepam twice a day and Ms A agreed subject to what the cardiologist said. She did not agree to quetiapine.
42. The Nursing Home arranged for Mr B to see the GP’s nurse practitioner on 2 October. The GP prescribed antibiotics for an infection in his toe nail.
43. The manager emailed the social worker on 2 October to say Mr A had assaulted another resident. On 3 October, a member of staff from the Nursing Home told the social worker Mr A had not been sleeping and had hit a carer; Ms A had been ringing the Nursing Home several times a day anxious that the lorazepam was too high a dose.
44. A note in the Nursing Home’s records on 4 October said Ms A told staff Mr B’s heart medications had been stopped by the cardiologist. The Nursing Home had received medication from the GP surgery. Staff kept the cardiac medicine in the cupboard and did not give any to Mr B
45. Senior staff at the Nursing Home reviewed Mr B’s care plans on 4 October. He had been taking lorazepam twice a day, but was still agitated and volatile. A checklist for NHS funding had been completed. Mr B’s worker from the mental health team had asked for blood tests. A member of staff spoke to Ms A and explained Mr B had been unsettled during the night and was urinating in his room. Ms A told the member of staff that if Mr B became very aggressive, she should be contacted and would take him home before a Mental Health Act assessment could be arranged. Ms A denies the Nursing Home made any contact with her about any problems with her father.
46. A note in the Council’s records in October indicates the social worker had updated Mr A’s continuing healthcare checklist and he scored enough points for the CCG to complete a full assessment. The social worker noted the checklist had also been done in May, but had not been forwarded to the CCG because Ms A had not verified it. It is unclear what, if any action, the social worker took following the update to the CCG checklist.
47. Internal records at the Council indicate senior officers decided the Nursing Home was not able to meet Mr A’s needs even with one to one care. Officers liaised with the mental health team and the plan was to assess Mr A to see if he required an admission to hospital under the Mental Health Act as he was a risk to himself and others.
48. The Nursing Home’s senior manager spoke to the social worker on 5 October. The note of the call indicates the Council was stopping funding Mr B’s placement the following day as the Council considered the placement was not meeting Mr B’s needs. There was a problem with continuing the placement because Ms A said Mr B could not have one of his medications. Officers were considering an application to the Court of Protection or use of the Mental Health Act.
49. The Nursing Home’s manager said in a statement that:
• She had spoken to Ms A the day before he went into the Nursing Home and Ms A had said things were not going well with Mr B’s behaviour.
• Ms A had agreed Mr B could have quetiapine twice a day and lorazepam as and when needed. She then changed her mind
• She was aware Ms A had an LPA, but the Nursing Home needed a treatment plan for Mr B. The mental health team emailed her to say Ms A had agreed a trial of lorazepam twice daily.
50. An AMHP assessed Mr B at the Nursing Home on 6 October. The AMHP completed a report. The reason for the assessment was Mr B’s increase in aggression to himself and others. The AMHP considered information from staff, looked at Mr B’s records and spoke to the two assessing doctors. The AMHP met and spoke to Mr B, who was unable to give him more than a few words which were difficult to decipher. The AMHP observed Mr B being escorted back into the building and noted this required the support of three staff. The AHMP decided the criteria for an application were met based on the high number of incidents, the harm and risk to others posed by Mr B. The AMHP noted he had spoken to Mrs B, who was the nearest relative and had explained what was happening and her rights. Mrs B had asked the AMHP to speak to Ms A. The AMHP noted he explained the outcome of the assessment to Ms A. He noted Ms A wanted to discuss Mr B’s medication and the AMHP told her his involvement was limited to the assessment and consideration of the criteria to make an application.
51. Officers from Somerset Council’s safeguarding team (responsible for safeguarding enquiries as the Nursing Home was in Somerset) contacted the Council to say a police officer reported a safeguarding concern about Mr B: he had bruising on his torso. The report queried whether the bruising on the torso could have happened during transport to hospital.
52. A senior manager of the Nursing Home completed a report for Somerset Council’s safeguarding enquiry. This noted the Nursing Home had not completed body maps, but noted the incidents of challenging behaviour may have caused Mr B to get bruised. The report said the Nursing Home would make changes to practice, to ensure staff completed body maps on admission and discharge
53. A manager in the Council’s social care team apologised to Ms A for not speaking to her before Mr B left the Nursing Home. He explained that following a review (which Ms A did not attend as she wanted to stay away from her father for the first two weeks) professionals decided he needed a higher level of mental health care.
54. Mr B’s hospital records indicate he weighed 84.6 kg on the day of admission to hospital.
55. Officers arranged a best interests meeting, which was later cancelled due to Mr B’s ill-health and were looking into alternative placements, including at Nursing Home X for when Mr B was fit to leave hospital. This was not taken further than preliminary enquiries about vacancies, because Mr B became physically unwell and so was not ready for discharge. The case notes also indicate Ms A had contacted Nursing Home X and expressed interest in her father going there, but had told Nursing Home X that the placement would be private.
56. Mr B died in hospital on 10 November.
57. The Council responded to Ms A’s complaint in October and November 2018. The responses said:
• There was a safeguarding enquiry by Somerset Council which was inconclusive about physical abuse. Concerns of neglect were partly upheld because staff did not complete detailed records.
• The social worker held meetings with her, but should have agreed communication
• Lorazepam was given on the day of the Mental Health Act assessment to reduce Mr B’s agitation.
• The assessment said the AMHP made two calls to her at Mrs B’s request
• The CHC checklist was posted to Ms B on 22 June. The social worker resent it as Ms B did not receive it
• The Council did not contact the Court of Protection about removing the LPA. The Nursing Home were concerned she would not let them give Mr B his prescribed medication.
• Even with additional support Mr B behaviour was difficult to manage.

Was there fault?

Complaint (a): a social worker provided incorrect information about Mr B to other professionals involved in his care and attempted to have him placed in a nursing home against the family’s wishes.

58. The Councils records show Ms A agreed to the placement in the Nursing Home and that officers arranged it at her request. The records also show Ms A was looking at Nursing Home X for Mr B while he was in hospital and that council officers had also been considering Nursing Home X as a possible future placement. I do not consider either the Nursing Home or Nursing Home X were placements against the family’s wishes. So I do not uphold this complaint. Ms A also complains about the Council trying to arrange a placement several months before Mr B went into the Nursing Home. I do not regard there to be any fault or injustice in the Council’s actions at that time as the placement did not go ahead.
59. The issue about providing incorrect information is to do with the conflict between Ms A and the mental health team about whether Mr B had vascular dementia and if so whether the psychiatric drug prescribed to treat Mr B’s mood and behaviour was appropriate. Mr B’s diagnosis and prescriptions were not issues for the Council or Nursing Home, but for his doctors. I am satisfied the social worker explained to the Nursing Home’s manager that Ms A’s instructions about medication had to be followed (and trumped any instructions from health professionals) as she held LPA for health and welfare. I am also satisfied that the Nursing Home’s manager or other staff spoke to Ms A daily and followed her instructions about what medicine Mr B was to have. The records indicate Ms A changed her mind (though Ms A disputes ever changing her mind) and so this was difficult, but I am satisfied these conversations took place and the Nursing Home’s records were updated in line with her wishes. It was also difficult for staff at the Nursing Home because Mr B’s behaviour was escalating without staff being able to give Mr B the quetiapine that both his private and NHS psychiatrist had prescribed. I do not uphold the complaint about the social worker giving incorrect information, the information she gave was accurate and correct.

Complaint (c): The social worker failed to respond to requests for information from the Clinical Commissioning Group as part of the Continuing Healthcare funding assessment process.

60. There is no evidence the social worker failed to respond to any requests from the Clinical Commissioning Group. There is evidence the social worker completed a CHC checklist and posted a copy to Ms A twice. It is not in the records that the social worker received a signed copy back from Ms A. There is also no record of the Council receiving any request for an updated checklist from the CCG in August.
61. The records noted the social worker updated the CHC checklist in October. By this time, Mr B was in hospital and he died suddenly and so no further action was taken. I do not uphold Ms A’s complaints as the social worker did what was required of her to progress Mr B’s application for CHC funding while he was alive. There is no fault and I do not uphold this complaint.

Complaint (d): The Council placed Mr B in a nursing home that was not suitable for him and that could not meet his needs. This contributed to Mr B’s escalating behaviour and detention under the Mental Health Act 1983

62. The Council placed Mr B in the Nursing Home at Ms A’s request. Before doing so, it reviewed and updated his care and support plan in line with the responsibilities set out in the Care Act set out in paragraphs 15 and 16. It was a respite placement with the highest level of individual care. I am satisfied that at the time the placement was made, officers took appropriate steps to ensure it was suitable. There was no fault. I do not uphold this complaint.

Complaint (e): The Nursing Home failed to provide appropriate care. Mr B lost weight and sustained unexplained injuries to his chest, hands and feet which Ms A feels may have been a result of restraint. The nursing home failed to administer Mr B’s prescribed medication appropriately.

63. The Nursing Home has already accepted it should have completed body maps and the failure to do so was poor record keeping. Mr B’s care was not in line with Regulation 17 and this was fault. No-one can say who or what caused the bruising to Mr B’s torso. I note bruising could be consistent with Mr B’s reported episodes of challenging behaviour.
64. Mr B was overweight and took a normal diet. There was no requirement to log his food intake as he was not under weight and had no special dietary needs. He was weighed on admission to the Nursing Home and thereafter the intention was to weigh Mr B monthly had he remained there. This was an appropriate care plan given the low nutritional risk. I note the weight taken on admission to hospital a week later, indicates a loss of over 11 kg, which is a lot. But there was no fault by the Nursing Home which delivered care according to Mr B’s care plan and in line with Regulations 9 and 14.
65. I am satisfied the Nursing Home administered Mr B’s medicine in line with Ms A’s changing wishes and liaised with her frequently. Ms A told us she never agreed that her father could have quetiapine. But the records reflect a discussion with her to the contrary. I have relied on those records to conclude Mr B’s care was in line with Regulation 9 and there was no fault.

Complaint (f): An Approved Mental Health Practitioner (AMHP) from the Council failed to take the effects of Mr B’s medication into account as part of his Mental Health Act Assessment and did not involve Ms A in the assessment.

66. On the day of the assessment, Mr B was given his prescribed dose of lorazepam, which Ms A had previously agreed he could have. The AMHP spoke to staff and Mr B and looked at Mr B’s council and nursing home records which included his medication charts which showed the medicine he had received. The AMHP’s actions followed the law which says he could make an application on the basis of risk to Mr B and/or others if there was no other suitable care alternative. As the Nursing Home could not manage Mr B safely in the absence of Ms A’s consent to give him appropriate medication, there was no fault in the AMHP making the application as there were no other appropriate care settings for Mr B. This was in line with the Mental Health Act 1983.
67. The AMHP spoke to Ms A at the request of the nearest relative, Mr B’s wife and sought her views: Mrs B gave no view and deferred to Ms A. The AMHP informed Mrs B of the outcome of the assessment and informed Mrs B of her rights as nearest relative. This was in line with the Code of Practice to the Mental Health Act. The AMHP also spoke to Ms A as Mr B’s attorney. I note she did not agree with the decision to detain Mr B. But, as the AMHP sought her views as part of the decision, he acted in line with the Code of Practice to the Mental Health Act and there was no fault.
68. Although I do not regard the AMHP to be at fault for reasons given in the previous two paragraphs, I consider those managers at the Council who became aware that Mr B’s placement was in jeopardy and that further funding was not going to be approved, should have spoken to Ms A before the Mental Health Act assessment and before Mr B went into hospital. I accept there was a concern that Ms A may have removed Mr B from the Nursing Home. But, as the holder of an LPA for health and welfare), Ms A was the main person for the Council to consult with about Mr B’s care arrangements and so the failure to involve her in an urgent discussion about why the placement was breaking down and to explore all the options open to the parties was fault.

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Agreed action

69. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the service of the Nursing Home, my recommendations are for the Council.
70. The fault I have described caused Ms A avoidable distress. To remedy this, I recommend the Council apologises within one month of my final decision and makes her a symbolic payment of £250. The Council has accepted this recommendation.
71. The Nursing Home has already changed its procedures to ensure it keeps body maps. There is no need for me to make any further recommendations for procedural changes.

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Final decision

72. I uphold two of Ms A’s complaints: there was poor record keeping around injuries to Mr B and a failure to speak to her about the decision to stop funding the Nursing Home placement. This was fault and caused Ms A avoidable distress.
73. I do not uphold the rest of Ms A’s complaints.
74. To remedy the injustice, the Council will apologise and make a symbolic payment of £250 within one month.
75. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman