Summary: Mrs B complains North East Care Homes’ Stainton Lodge Care Centre provided incomplete information to the NHS about her father’s medical circumstances resulting in a delay in him receiving correct medical treatment and his untimely death. It did not tell an out of hours GP that her father was taking antibiotics for a suspected water infection. We cannot say that caused his death. Nevertheless, North East Care Homes needs to apologise and pay financial redress for the distress it has caused.

The complaint

1. The complainant, whom I shall refer to as Mrs B, complains Stainton Lodge Care Centre (Stainton Lodge), which is run by North East Care Homes (the Care Provider), failed to look after her father properly.

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The Ombudsman’s role and powers

2. 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 34B, 34C and 34H(4), as amended)

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How I considered this complaint

3. I have:
• considered the complaint and the documents provided by Mrs B;
• discussed the complaint with Mrs B;
• shared a draft of this statement with Mrs B and the Care Provider and taken account of the comments received.

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What I found

Key facts

4. Mrs B’s father, Mr C, went to live at Stainton Lodge on 22 October 2018 after leaving hospital. He had gone into hospital with increased confusion and reduced oral intake. He had spent some time on a rehabilitation unit but did not improve.
5. Mrs B has provided recordings of two telephone calls on 3 November 2018, one Stainton Lodge made to NHS 111 at 02.48 and one an out of hours GP made to Stainton Lodge at 03.19. She has also provided other medical records for her father and copies of Stainton Lodge’s records.
6. Stainton Lodge’s record dated 27 October (a Saturday) appears to relate to 28 October as it refers to Sunday morning. It says Mr C had a small pot in his room which he used to spit into, but asked staff to remove it.
7. Stainton Lodge’s record for 29 October says it called a GP who prescribed an antibiotic for an infection “for 3 days to see how he goes on with that”. The GP’s records say Mr C had a suspected urinary tract infection (“dark concentrated urine and more confused. Incontinent”). The GP prescribed an antibiotic (to take one capsule twice a day, 14 capsules altogether). Stainton Lodge’s medication administration records say the antibiotic arrived on 30 October. Mr C took his first tablet at tea-time. They suggest he took the full course of antibiotics.
8. Stainton Lodge’s records say a Carer called NHS 111 at 02.47 for advice, as Mr C was complaining of pain in his lower back on the right side. He said it felt the same as when he had a collapsed lung. The records say they advised Mr C to take paracetamol, and for carers to “push fluids” and take a urine sample. Mr C refused to take paracetamol.
9. In the recording of the call with NHS 111, a Carer:
• says it was not possible for NHS 111 to speak to Mr C;
• asks Mr C NHS 111’s questions and relays his answers back to NHS 111, which does not speak to him directly;
• says Mr C had been going to the toilet, using his walker, but was doubled over;
• says Mr C had vascular dementia;
• says Mr C had stopped all his usual activities and could not settle;
• says Mr C had new pain and swelling in a knee;
• says Mr C was not suddenly confused or more confused than usual.
10. NHS 111 referred Mr C to the out of hours GP service. It advised making sure he kept taking fluids and recommended taking paracetamol for the pain.
11. The Carer was not with Mr C when the out of hours GP called:
• when asked about Mr C’s medication the Carer did not mention antibiotics;
• she said he had vascular dementia and suffered TIAs but did not mention the water infection;
• at first she said he was not confused but later confirmed he was not more confused than usual;
• she said his urine was not smelly or a dark colour;
• she said he had a chesty cough which made the pain worse and was more noticeable that night, but then said he was only coughing that night.

The GP decided a home visit was not necessary, as the pain had only come on the evening before. She said to continue with paracetamol but to get in contact if the symptoms got worse (e.g. pain, temperature or coughing up green phlegm). The GP suggested dipping his urine to test for a urine infection.

12. On 4 November Stainton Lodge told his family Mr C had been distressed and agitated. It said he became agitated due to his illness and was being treated for a urinary tract infection.
13. On 5 November Stainton Lodge contacted a GP about swelling to Mr C’s right ankle. The GP said to bring him to the surgery the next morning.
14. The GP’s record for 6 November says Mr C was agitated, not sleeping, confused and distressed, but could not explain what was going on. It says he had taken antibiotics but had not improved. His chest was clear. The GP sent Mr C to hospital. The hospital’ records say he had “increased confusion, agitation, and a productive cough”. He received treatment for chest sepsis and delirium. He improved at first. But he had a further episode of pneumonia and, despite treatment, continued to decline and was placed on end of life care. He died in hospital on 3 December. The cause of death was aspiration pneumonia (contributory factors: vascular dementia, emphysema and bronchiectasis).
15. When the Care Provider responded to Mrs B’s complaint on 22 February 2019, it said:
• the deprivation of liberty safeguard (DoLS) in place for Mr C when he was in hospital could not transfer to Stainton Lodge, so it had applied to the local authority for a new DoLS;
• a Doctor visited Mr C on 24 October and diagnosed him with vascular dementia;
• a GP prescribed antibiotics on 30 October following a conversation with a senior staff member and Mr C took the full course of medication;
• Stainton Lodge called NHS 111 twice on 3 November and it advised taking paracetamol for pain. Staff said they had first spoken to NHS 111 after which NHS 111 spoke with Mr C in the presence of staff;
• staff made the call to NHS 111 and sat with Mr C when NHS 111 spoke to him. Staff made NHS 111 aware of Mr C’s dementia, medical conditions and deafness;
• Stainton Lodge can ask a GP to visit but it is for the GP to decide whether to do a home visit.
16. Mrs B says the records conflict with what the Care Provider said in its response to her complaint as the Carer:
• said it was not possible to speak to Mr C;
• said he was active, but he needed help walking and two carers to attend to his daily needs;
• said he was no more confused than usual, but on 27 October Stainton Lodge called a GP as he was confused;
• said a chesty cough had only just started but on 27 October Mr C was given a sick bowl to cough up phlegm;
• told neither 111 nor the GP Mr C was on antibiotics for a suspected water infection.
17. Mrs B says her father did not take all his antibiotics as on several occasions he either refused to take his medication or could not swallow them.

Did the care provider’s actions cause injustice?

Saying NHS 111 spoke to Mr C

18. The Care Provider was wrong to say NHS 111 had spoken to Mr C when that did not happen. It is unclear why it provided inaccurate information, as it gained nothing from this. The recording shows the Carer relayed NHS 111’s questions to Mr C and passed his responses to NHS 111.

Saying Mr C was active

19. The Carer was not wrong to say Mr C was still active. That he needed help did not alter the fact he was still making his way to the toilet. Besides, the Carer told NHS 111 Mr C had stopped his usual activities and could not settle.

Saying Mr C was no more confused than usual

20. Stainton Lodge’s records show Mr C suffered from confusion when he arrived. It called a GP on 29 October because of his confusion and he started taking antibiotics. It contacted NHS 111 on 3 November because he complained of pain in his lower back, rather than because his confusion was getting worse. While Mr C’s voice is indistinct on the recording of the call with NHS 111, it is clear he understood the questions being relayed to him and could answer them.

Mr C’s cough

21. It is not clear when Mr C started to cough. The Carer said his cough was more noticeable on the night of 3 November and there is no evidence to suggest that was not correct.

Antibiotics

22. Despite the GP asking what medication Mr C was taking on 3 November, the Carer did not say he was still taking antibiotics for a suspected UTI. That was a significant omission. Stainton Lodge’s records say it had been advised to see how Mr C got on with the antibiotics for three days. That it had to contact the NHS again after three days meant this was something it should have mentioned.
23. This failure prevented the GP from considering all the relevant information. Had the GP had all the information, she may have decided to visit Mr C. Whether this would have resulted in any different treatment for Mr C we cannot say, as a GP did not visit on 3 November. Nor can I draw a causal link between the failure to share all the information with the GP and Mr C’s death. Nevertheless, it has caused avoidable distress to Mrs B by creating doubt over what might have happened. It has also put her to the time and trouble of pursuing her complaint, some of which may have been avoided if the Care Provider had provided accurate information when responding to her complaint.

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Recommended action

24. I recommend North East Care Homes within four weeks:
• writes to Mrs B apologising for the failure to provide accurate information about her father’s medical circumstances to the out of hours GP and the failure to provide accurate information when responding to her complaint; and
• pays her £400 for the distress it has caused and the time and trouble it has put her to in pursuing her complaint;
• identifies the action it needs to take to ensure staff share complete and accurate information with medical professionals.
25. Under the terms of our Memorandum of Understanding and information sharing agreement with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

26. I have completed my investigation on the basis North East Care Homes will take the action I have recommended.

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Investigator's decision on behalf of the Ombudsman