Summary: The Care Provider has acknowledged that it did not always communicate key information, so the complainant did not know his father was receiving end of life care. It has apologised and refunded the care fees. The Care Provider also did not do enough to get the complainant’s father medical treatment when he was ill, and had refused food and water. Its actions have caused the family distress and it should apologise, remind its staff of its processes and pay the family in recognition of this.

The complaint

1. Mr B complains that BUPA (the Provider) failed to give adequate care to his father, Mr Y while he lived in their residential home. In particular it:

• Allowed him to become dehydrated, used dip tests to check for infection when this is inadequate and failed to ensure he was examined by a GP or seek treatment for a chest infection, sepsis or dehydration.
• Failed to consult the family about Mr Y’s care or tell them that he was receiving end of life care.

2. Mr Y was admitted to hospital. His son says the medical staff told him that his father was severely dehydrated and suffering from sepsis. Mr Y sadly died in hospital.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

5. In the course of my investigation I have considered
• the information provided by Mr B and discussed the issues to him.
• the information provided by the Provider including the qualification and training details of its staff, Mr Y’s daily care notes, the Provider’s policies and correspondence between the parties.
• The recording of the Provider’s call to the ambulance service and its records of the care Mr Y received from paramedics.
• The response of Kent County Council, the authority responsible for investigating safeguarding issues.
• the Care Quality Commission (CQC) Fundamental Standards of Care.

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What I found

Law and guidance

6. 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 CQC has issued guidance on how to meet the fundamental standards below which care must never fall. Relevant to this complaint is:
• Care and treatment must be provided in a safe and effective way. Providers should do all reasonably practicable to minimise risk to health and safety; ensure that staff have qualifications, competence, skills and experience to do so safely, assess the risk or and prevent spread of infection; and where responsibility for care is shared or transferred to others, ensure that timely planning takes place to ensure the health, safety and welfare of the service user. (Regulation 12)
• The Provider must ensure that service users have adequate nutrition and hydration to sustain life and good health and to reduce the risk of malnutrition. The Guidance says the Provider should assess the needs of the service user and make sure that these are met. The assessment should be carried out by someone with the required skills and knowledge. The assessment should follow recognised standards. Needs should be regularly reviewed. (Regulation 14)
• The Provider must have arrangements to take appropriate action if there is a clinical or medical emergency. (Regulation 12)

What happened

7. Mr Y lived in a residential care home. Mr Y had signed a Do Not Attempt Resuscitation Form and an end of life palliative care plan was made with him when he moved in.
8. Mr Y had an internal catheter which put him at risk of infection. The catheter was noted on Mr Y’s care plan. Mr Y told his family that staff were sometimes unable to deal with or change it. Hi catheter became blocked on several occasions and once this meant he had to be hospitalised. The staff performed dipstick tests, which Mr B says is not sufficient to properly diagnose the type of infection or treatment.

Mr Y’s care and the Provider’s requests for medical examination and assessment

9. The Provider’s home gives nursing care, will call for a GP to visit if needed and has a weekly visit from a GP who see several residents. Mr Y’s notes say he was seen by the GP on 8 January and 30 January. Mr Y had suffered from recurrent urinary and chest infections requiring antibiotics. However, Mr Y’s health began to deteriorate.
10. On 5 February 2019, the Provider’s records say that Mr Y had not drunk much and he was sleepy. The next day, staff encouraged Mr Y to drink more. They found he had a urine infection and faxed the GP. By 8 February, Mr Y was not eating well at all, and the next day notes that he was not eating or drinking. The Provider telephoned the NHS 111 service and was referred to the GP surgery who advised to make Mr Y comfortable and administer antibiotics.
11. The Provider keeps detailed food and fluid intake charts that record how much is offered and how much is taken. Mr Y continued to eat and drink very little throughout the next few days. He was very sleepy and spitting out or refusing water. The notes show the GP prescribed crisis medication on 11 February. By 14 February, Mr Y had completed the course of antibiotics for the urinary infection, but the care notes say he is still ill and needs to see the GP on the weekly round which was scheduled for the next day. The Provider told the family that the GP would see Mr Y and if this was not possible it would call out paramedics.
12. The GP did not visit Mr Y on 15 February. The Provider faxed the GP surgery which advised that it had no available doctors. The notes say the surgery will try to get paramedics to visit Mr Y. He continued to eat and drink very little throughout the 16 and 17 February, the Saturday and Sunday. The Provider did not contact the surgery again or the emergency services to seek medical help or examination for Mr Y.
13. The family visited Mr Y on 18 February. They were not happy with Mr Y’s care, especially as the GP who does a round on the Friday did not see him and the home did not call an out of hours GP. The Provider’s nursing staff examined Mr Y on 18 February, she found him non-responsive to voice although he did respond to touch. The Provider faxed the GP who said to manage Mr Y with antibiotics. Mr B says the family asked the care staff if his father could have sepsis, but this is not recorded in the Provider’s notes.
14. The Providers use a Care Home Support Team (CHST) to ensure patients receive support with symptom control at the end of life. They do not provide hands on care but do provide support and advice to the Provider’s staff. The notes show that the Provider kept the CHST informed about Mr Y’s deterioration and followed its advice.
15. On 19 February, the CHST visited Mr Y at the Provider’s request. The CHST examined Mr Y and gave him an injection commonly used at the end of life. The Provider spoke to the doctor who had prescribed a thickener to add to Mr Y’s fluid to help him swallow. Mr B says the family had asked to be present at any meetings but was not told that the CHST was visiting.
16. By 20 February, Mr Y was agitated, pressing his call bell frequently and unable to eat or drink. The family told the care staff he needed medical assistance and to call a GP or ambulance. Mr B says the staff twice refused to call 999, but he insisted. This is not recorded in the notes. The notes do say the Provider telephoned the GP surgery, but a doctor could not visit. It telephoned the CHST which advised to call the surgery and if there was no GP available to call 999. A member of staff called 999.
17. I have listened to the audio recording of the call. During this the emergency call handler asks the staff member to move Mr Y onto his side to help with breathing. She says she cannot because that would take two people and she cannot summon anyone to help her.
18. Mr Y was admitted to hospital that day. Mr B says that the paramedic and hospital staff told him his father was severely dehydrated and suffering from sepsis and should not return to the Provider’s nursing home. Mr B told the home this but sadly, Mr Y died in hospital.
19. The Provider keeps detailed daily care notes and a record of contact with the GP surgery, medical services and the CHST. These show that although the Provider’s staff had close contact with the GP surgery and the CHST, it did not always ensure that it did enough to make sure that Mr Y was assessed by a doctor when needed.
20. The GP prescribed crisis medication on 11 February. Mr Y was not eating or drinking much at all. A doctor had not examined him since January. The Provider was on notice that the Mr Y had finished a course of antibiotics but was still very ill on 14 February. The Provider decided that Mr Y needed a doctor’s examination but did not make sure this happened. Mr Y was not examined by a doctor until his admission to hospital.
21. I appreciate that the surgery did not have the staff and had said it would try to arrange paramedics to visit, however, the Provider retains responsibility for making sure Mr Y’s care is safe and effective and to take appropriate action when his health was deteriorating. It should have escalated its requests when the surgery could not respond.
22. As part of taking appropriate action in an emergency, the Provider’s staff should be able to follow the 999 emergency call handler’s instructions. In this case, the Provider could not turn Mr Y onto his side as instructed.
23. I cannot say the Provider missed signs of dehydration and sepsis, but it knew Mr Y had not recovered from the infection, that his fluid and food intake were extremely low and that he was very sleepy and not responding easily. Its shortcomings have left the family uncertain as to whether Mr Y would have suffered less and has caused them a great deal of distress.

Communication with the family

24. The Provider has acknowledged that it had failed to tell the family that Mr Y was receiving end of life care. The CHST notes query why the Provider has not done this. The family also did not know that the doctor had prescribed crisis medication. The family was in contact with the Provider by telephone and in person and there was plenty of opportunities to communicate properly with them about this. The Provider has apologised and refunded the care fees. It has also reminded staff in supervision sessions that communication about a residents’ end of life treatment is key, and has reviewed the services it offers to family at this time.

Other issues

25. Mr Y had recurrent urine infections and his catheter became blocked regularly. Mr B says that his father told them he was often left alone for hours and sometimes all day in agony because there was nobody available to give the needed catheter care. However, the notes show that the Provider gave catheter care and always checked that it was draining properly. Although the catheter did get blocked, I cannot say that this was due to poor care.
26. Mr B says that he has been advised that while a dip test will indicate whether there is an infection it is not sufficient to establish the type of infection or which medication is needed. The Provider has explained that the GP will rely on a dip test and that the care home cannot wait for a laboratory to analyse a sample before antibiotics are prescribed. I am satisfied that the Provider has followed the practice as directed by the GP and there was no fault in how the Provider tested for urinary infections.
27. As part of my investigation, the Provider has shared the daily care records and the charts tracking how much food and fluid it offered Mr Y, and how much he managed to take. Mr B says that these notes do not match what was happening and he is concerned that the notes were made retrospectively. He has given me specific examples where the notes appear wrong to him and one example where the notes are inconsistent. I have considered Mr B’s concerns.
28. I have mentioned above that the notes do not reflect well the communication with the family. The daily care records of 14 February suggest that Mr B took 200mls of tea and of soup when in fact this is what he was offered and not what he actually managed to take. Mr B also points out that he doubts his father could have always consented to being changed and washed as he could not always speak or respond.
29. I cannot tell whether the care notes were written retrospectively; they do not give this impression and show notes by a variety of staff. However, the notes should be accurate and consistent, and the example given by Mr B shows that this was not always the case.

Agreed action

30. The Provider has acknowledged that there was a communication problem and has waived the care fees for the period of time in question (from the 1 February to the date Mr B told the home that his father would not return there). Mr B feels that this is not compensation as the fees were waived because he refused to pay these on the basis that his father had not received the service.
31. Sadly, we cannot recommend compensation where the person it would be paid to has died. Instead we consider whether the person received the service and whether fees should be refunded to his estate or waived. This means I have decided that this part of the remedy is appropriate.
32. The Provider has reminded staff in supervision sessions that communication about a residents’ end of life treatment is key and has reviewed services it offers to family at this time so that the family is very much more involved. The Provider has also carried out a lot of reflective practice with staff about seeking medical attention. The Provider says this was acknowledged during the recent CQC inspection.
33. The Provider has agreed to also:
• Remind staff that medical treatment should be sought more promptly and followed up when the GP is unable to visit but the resident is not recovering.
• Review how staff operate to provide safe care as it cannot be right that the staff member could not summon help to turn Mr Y.
• Apologise to Mr B and pay £300 to him in recognition of the distress it caused the family and that they had to pursue this matter with the Ombudsman because the Provider did not accept that it had not sought medical help soon enough.
34. The Provider should do this within one month of this decision.

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Final decision

35. I have completed my investigation. The Care Provider’s actions caused injustice to Mr Y and Mr B. It has agreed to remedy this.
36. I have shared the final decision statement with the CQC.

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Investigator's decision on behalf of the Ombudsman