Summary: Mrs D complains about the standard of care provided to her mother following a fall in a care home. The Ombudsman has found no fault.

The complaint

1. Mrs D complains about the standard of care provided to her mother, Mrs J, in Beechwood House Care Home in November 2018. In particular, she complains that after Mrs J fell the provider did not properly assess her and failed to seek prompt medical care.
2. Mrs J was admitted to hospital a week later and found to have broken ribs and a thoracic haemorrhage. Mrs D says this caused severe distress to Mrs J and the family, as they had to take time off work and move Mrs J to a nursing home.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34H(3) and (4), as amended)
4. If we are satisfied with a provider’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 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)

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How I considered this complaint

6. I spoke to Mrs D about her complaint and considered the information she sent, the care provider’s response to my enquiries, and:
• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
• The care provider’s policy: Care of someone who has fallen in residential care
• NICE Quality statement 4: Checks for injury after an inpatient fall
7. I sent Mrs D and the care provider two draft decision statements and considered the comments I received.

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What I found

Fundamental Standards of Care

8. 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.
9. Regulation 12 requires care providers to give safe care and treatment and to prevent avoidable harm or risk of harm. In doing so, providers must:
• assess the risks to the health and safety of service users of receiving the care or treatment;
• do all that is reasonably practicable to mitigate any such risks;
• have arrangements to take appropriate action if there is a clinical or medical emergency

Dealing with falls

10. The care provider’s policy says if a resident has fallen staff should immediately assess the extent of their injuries. If there is no evident injury the resident should be allowed to get up and their condition monitored. The policy says staff should seek medical help if necessary. The incident should be recorded.
11. Guidance about falls in hospital from the National Institute for Health and Care Excellence, says: “When a person falls, it is important that they are assessed and examined promptly to see if they are injured. This will help to inform decisions about safe handling and ensure that any injuries are treated in a timely manner”. It says a post-fall protocol should include “checks by healthcare professionals for signs or symptoms of fracture and potential for spinal injury before the patient is moved”.

What happened

12. Mrs J is elderly, walks with a frame and has arthritis for which she takes paracetamol. In September 2018 Mrs J moved into Beechwood House Care Home (the Home), operated by Beechwood House Ltd (the care provider). The Home’s risk assessment says Mrs J was at high risk of falls and needed observation, support, and a call bell.
13. During the early hours of 8 November 2018, Mrs J fell upturning her walker and side table, smashing a glass. The fall was not witnessed by carers, who attended when Mrs J rang her bell. The daily care record says: “Was on the floor and had blood on her feet. ... There was glass all over the floor. Assisted into bed. Dressed cut. Gave glass of water.” The accident record says Mrs J had “a cut to her left middle toe and a cut on her right upper foot. Also a red mark on her left lower back.”
14. The manager assessed Mrs J later that morning. Mrs J said “she was in a lot of pain in her back”. The manager decided to give codeine twice a day, as well as paracetamol which Mrs J usually took. Mrs D was told about the fall and visited.
15. Mrs D says over the next few days Mrs J’s breathing deteriorated into shallow breaths and other residents said she was panting and her walking was slow and painful. There are no breathing problems recorded in the Home’s daily records.
16. On 10 November, the carer noted a red mark on Mrs J’s back. During that day paracetamol was given four times in addition to codeine. On the morning of 11 November, Mrs J said her back was very sore and paracetamol was again given four times, in addition to codeine. On 12 November Mrs J reported her back felt stiff.
17. The next day the record says Mrs J’s breathing was “a little strained”. The Home contacted the GP who asked Mrs J to attend the surgery. Mrs D spoke to the surgery and arranged a home visit for the next day.
18. On 14 November, the GP prescribed Furosemide for fluid on the lungs and arranged for Mrs J to have an x-ray. The provider says the GP did not mention a suspicion of broken ribs or punctured lung. Mrs J went to the hospital later that day for the x-ray and was found to have seven broken ribs and a thoracic haemorrhage. Mrs D says she “was rushed to the major trauma room in the ‘resus’ ward where 1.2 litres of blood were drained from her lung”. The doctor advised Mrs J would now require full time nursing care and Mrs J moved to a different home.
19. Mrs D complained to the Home on 20 November 2018. She considered it had been complacent in its handling of Mrs J’s fall, had not sought proper medical attention and that, if she had not intervened, Mrs J’s condition could have led to her death.
20. The care provider investigated the complaint, interviewing staff and looking at records. It wrote to Mrs D on 10 December 2018 expressing regret at the distress suffered by Mrs J. The provider was satisfied staff had acted in accordance with its policy and said there was no evidence Mrs J required medical assistance until 13 November 2018. Mrs D complained to the Ombudsman.
21. In response to my enquiries, the care provider said it had reviewed its falls policies and procedures and was working with an occupational therapist to reduce the risk of falls and improve outcomes following a fall.

My findings

22. After Mrs J fell, staff assessed her injuries, recorded the incident and informed the family. They gave pain relief and monitored Mrs J’s condition. This is in line with the provider’s policy and are the actions I would expect a care provider to take.
23. Mrs D says Mrs J’s breathing was shallow, but this is not recorded in the daily care logs and the provider says there were no breathing problems until 13 November.
24. The records show Mrs J continued to report she was in pain and was given paracetamol four times a day. In my first draft decision I considered this should have prompted the provider to speak to the family and contact the GP earlier than 13 November, probably by 10 November when Mrs J was asking for pain relief every few hours.
25. In response to my first draft decision, the care provider sent records showing Mrs J’s use of pain relief for her whole time at the Home. This shows she asked for four doses of pain medication on five days and three doses on nine days. I cannot therefore say that Mrs J’s need for pain relief increased significantly after the fall and that it was clear she required medical attention. I have therefore changed my view and do not find fault.
26. However, I consider the provider’s falls policy was vague. It said medical attention should be sought “if necessary”. This incident seems to indicate that judging this on how someone presents has masked some significant injuries. It may be there is a need for a nurse or first aider to assess someone after a fall to decide if there is a need for medical intervention. I therefore welcome the care provider’s review of its falls policy.

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Final decision

27. There was no fault by the care provider which caused injustice to Mrs J.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman