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Sheffield City Council (19 002 255)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 17 Dec 2019

The Ombudsman's final decision:

Summary: Mrs X complained a care home failed to seek appropriate medical advice after her mother became unwell during a Council-arranged respite stay. She says this caused her mother unnecessary suffering and has caused her distress. The care provider has accepted it should have been more proactive in seeking medical advice and has taken action to improve its services. The Council will now ask the care home provider to apologise to Mrs X and acknowledge the distress caused. I also found evidence of poor record keeping and the Council has agreed action to improve this.

The complaint

  1. Mrs X complained a care home failed to seek appropriate medical advice after her mother became unwell during a Council-arranged respite stay. She says this caused her mother unnecessary suffering and caused her distress. The Council says the care home have accepted that staff should have been more proactive in seeking medical advice. Mrs X wants the care home to admit it made a mistake, apologise and improve its procedures to ensure it proactively seeks medical advice for residents when required in the future.

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The Ombudsman’s role and powers

  1. 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)
  2. 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)

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How I considered this complaint

  1. I read Mrs X’s complaint and spoke with her about it on the phone.
  2. I made enquiries of the Council and considered the information it sent me.
  3. Mrs X and the Council had the opportunity to comment on the draft decision. I considered their comments before making my final decision.

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What I found

Legal and administrative background

  1. Section 42 of the Care Act 2014 places a duty on a council to make enquiries, or ask others to do so, if it believes an adult is experiencing or is at risk of abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect, and if so, by whom.
  2. If a council asks others to make enquiries on its behalf, it should consider the enquiry report. It should then decide whether it is satisfied the Council has met its Section 42 duty to prevent or stop abuse or neglect or if further enquiries or actions are needed.
  3. Sheffield Clinical Commissioning Group has produced written guidance for care homes in its area. This guidance includes advice on what do in different situations when staff are worried about a resident, and who to contact for further advice or help. It also contains information and advice about caring for residents with a range of different medical conditions.

What happened

  1. In 2018, Mrs X’s mother, Mrs Y, had regular respite care organised by the Council. One Monday in November, Mrs Y began a week’s respite stay at a care home where she had stayed previously. Care home staff completed a respite care plan detailing Mrs Y’s care needs and started daily care notes to record details of her stay.
  2. On Tuesday, care staff noticed Mrs Y appeared sleepy during the day and recorded this in the daily care notes.
  3. On Wednesday, care staff updated the respite care plan to say Mrs Y appeared more sleepy than usual. It said staff were having to wake her up and encourage her to eat meals and drink fluids. It said staff should continue to observe. The daily care notes also recorded she had been very sleepy during the day.
  4. On Thursday and Friday, the daily care notes said Mrs Y had been very sleepy on both days.
  5. On Saturday, Mrs Y vomited. Staff recorded this in the daily care notes and started a fluid chart to document how much fluid Mrs Y was drinking. When Mrs X visited her mother that day, staff told her what had happened. They said staff would monitor Mrs Y for 24 hours. If Mrs Y was still vomiting the next morning, they would call out the emergency GP. Mrs X accepted this and said she would call Sunday morning for an update. Staff recorded this conversation with Mrs X on the respite care plan.
  6. On Sunday morning, Mrs X phoned the care home for an update. Staff told Mrs X that Mrs Y had not vomited again, was sat out in her chair, drinking some fluids and eating a small diet. It said that based on this improvement in her condition, it would not be calling out the emergency doctor. Mrs X told staff her brother would be visiting later that morning. Staff recorded in the daily care notes that Mrs Y had not vomited Sunday but had eaten a very small diet and had been assisted with her food. It said staff had needed to encourage her to drink throughout the day, and she had been very sleepy.
  7. On Monday, Mrs X and her brother arrived to collect Mrs Y and take her home. Mrs X said her mother was slumped in the wheelchair and could not stand. She said she had to book a wheelchair taxi to get her home, and then carry Mrs Y up the steps to her house. Mrs X called the GP for Mrs Y and the GP visited later that day. The GP said Mrs Y was severely dehydrated and arranged her immediate admission to hospital.
  8. The next day Mrs Y’s grandson contacted the care home to make a complaint. He told the care home Mrs Y was now in hospital and the GP and hospital staff had said she was severely dehydrated. He said it had upset and distressed the family to find Mrs Y in such a poor state when Mrs X and her brother had arrived to collect her the previous day.
  9. The care home told the Council about the complaint. The Council started an investigation under Section 42 of the Care Act 2014. It instructed the care provider to investigate the complaint and submit its findings to the Council.
  10. The care provider completed its investigation. The investigation panel consisted of a senior manager within the organisation and a registered manager from another care home. The panel reviewed records and spoke to the staff on duty during Mrs Y’s stay. It said it was satisfied staff had actively encouraged and assisted Mrs Y to eat and drink throughout her stay. However, it said records showed Mrs Y had been far sleepier and needed more assistance than in previous stays and staff should have been more proactive and sought advice from the GP. It said it had identified learning outcomes to prevent similar incidents reoccurring in the future.
  11. In December 2018, the care provider wrote to Mrs Y’s grandson and explained what it had found. It apologised to him for not being more proactive in seeking medical advice from the GP. It said it had taken action to identify learning outcomes and to ensure this did not happen again.
  12. Later that month, Mrs Y passed away.
  13. The care provider submitted its investigation report and findings to the Council. The paperwork included a section where the Council should document its consideration of the report and decision regarding whether it needed to act further. This section was incomplete.
  14. Mrs X was dissatisfied with the complaint response and brought the complaint to us. She said the incident had caused Mrs Y unnecessary suffering and if the care home had sought medical advice when she became unwell, Mrs Y may still have been alive today.
  15. In its response to our enquiries, the Council said staff only reported small amounts of vomiting on the Saturday. They put in a fluid chart, encouraged fluid intake and advised Mrs Y’s family. Care staff decided to monitor her for 24 hours and said Mrs X appeared happy with this approach. By Sunday, she was starting to improve. She was drinking more and there was no further episodes of vomiting. Because of this, care staff did not feel a GP was required.
  16. The Council said care staff’s account of Mrs Y’s presentation on the Monday she went home differed from Mrs X’s. It said care staff did not say Mrs Y was slumped in her wheelchair, but that when Mrs X arrived, staff were assisting her to drink a cup of tea. They said Mrs Y did appear sleepy but had taken her medication earlier and staff had not reported concerns. The fluid chart showed she had drunk three drinks that morning. Care staff said there was no clear rationale to call the GP at that time.
  17. The Council says since the complaint the care provider has taken action to improve its practice. It has held meetings with staff members to look at how to respond when they note a significant decline in a resident’s health, particularly for respite clients. It said it has also reminded staff of the information and guidance in the Clinical Commissioning Group care home guidance. It said staff are now clear they must communicate with relatives and seek medical advice as appropriate. It said the Council’s quality and performance team continues to review care homes twice a year to review incidents and make recommendations on quality improvements.
  18. It says the care provider has already acknowledged staff should have been more proactive in contacting a GP and has apologised to Mrs Y’s grandson for this. It says the care provider is happy to write a letter of apology to Mrs X if considered appropriate.


  1. When Mrs Y vomited on the Saturday, the care home staff acted appropriately by updating the respite care plan, informing Mrs Y’s family and starting a fluid chart. Staff decided to monitor Mrs Y for 24 hours rather than immediately contacting the GP. They considered the situation before coming to a decision as I would expect them to do, and this was not fault. Staff informed Mrs X of this decision and there is no evidence Mrs X questioned this decision at the time.
  2. By the Sunday, Mrs Y had not vomited again and had started to take small amounts of food and drink. Staff decided not to call the GP and informed Mrs X of this decision. Staff made a decision based on the circumstances and again this is not fault. Mrs X’s brother visited Mrs Y that day and there is no evidence either he or Mrs X expressed concerns or asked the care home to call the GP for Mrs Y on the Sunday.
  3. Mrs X says her mother was slumped in her wheelchair and barely responsive when she came to collect her on the Monday. The Council says care home staff’s report of that morning does not support this view. There is no written record of what she ate that morning, but the fluid chart did record Mrs X drank some fluids. Although acknowledging the differing views, the conflict of evidence means I cannot comment further on how Mrs Y presented that morning. However, there is no evidence that staff expressed any concern about her presentation at that time. I cannot say care staff were at fault for not contacting the GP.
  4. When Mrs X first arrived at the care home, staff noted that her presentation was different than on previous stays. There are multiple entries saying she was sleepier than on previous stays and was only taking small amounts of food and fluid. The care home should have considered seeking medical advice. It did not do so and this is fault.
  5. The care provider has acknowledged staff should have been more proactive in seeking advice from a GP. It apologised to Mrs Y’s grandson for this in its complaint response letter. It says it has since held meetings with staff members to share learning from the complaint and improve understanding of how to respond if they notice a significant decline in a resident’s condition, particularly with respite clients. I have seen evidence of meetings when staff are reminded of the need to closely monitor respite clients, in particular their food and fluid intake, and to discuss with family any concerns they have had in the period prior to admission. It has also reminded staff of information and advice in the Clinical Commissioning Groups Guidance for care home staff. The care provider has taken appropriate actions to improve its service and learn from the complaint.
  6. Even if the care home had sought medical advice, I cannot know what advice it would have received or whether this would have had any impact on the course of events. I cannot say the fault contributed to Mrs Y’s death.
  7. Mrs X wants the care provider to apologise to her and improve its procedures. The care provider has already taken appropriate action to improve its services. It has agreed to write an apology letter to Mrs X. This is an appropriate action to acknowledge the distress caused.
  8. After completing its investigation, the care provider submitted its investigation report to the Council. The Council’s Section 42 enquiries paperwork is incomplete. Because of this, there is no record of the Council’s consideration of the report or decision that it was satisfied no further action was needed. The failure to keep accurate and complete records is fault.

Agreed action

  1. Within one month of the final decision the Council has agreed to:
    • Instruct the care provider to write a letter of apology to Mrs X to acknowledge the fault and the distress caused to her;
    • Remind relevant staff of the importance of keeping accurate and complete records of investigations and decision making when conducting enquiries under Section 24 of the Care Act 2014.

It should provide evidence to the Ombudsman that it has completed these actions.

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Final decision

  1. I have completed my investigation. I have found fault and the Council has agreed actions to remedy the injustice caused and to improve its services.

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Investigator's decision on behalf of the Ombudsman

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