Summary: Miss E complains about the care her father received in a nursing home. She says poor care led to his avoidable death. We do not find any fault. Mr E was approaching the end of his life. The care provider gave him appropriate end of life care, including following instructions from other organisations. So we do not uphold the complaint.

The complaint

1. The complainant (whom I shall describe as Miss E) complains about the care her late father (Mr E) received. She complains:

• Mr E was constantly unwell while at the Nursing Home;
• Mr E developed a mouth infection, due to a lack of oral hygiene care;
• the care provider did not keep fluid charts; and
• Mr E died of dehydration and could have been saved by fluids.

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The Ombudsman’s role and powers

2. 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. We refer to this as ‘injustice’. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We have powers to investigate adult social care complaints. Where local councils arrange or commission care services from social care providers, we can treat the actions of the care provider as if they were the actions of the council. (Part 3 Local Government Act 1974; section 25(6) & (7) of the Act)
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)

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How I considered this complaint

5. As part of the investigation, I have:
• considered the complaint and the documents provided by Miss E;
• made enquiries of the Council and considered its response;
• considered the response of the care provider, and looked at its records, including the fluid charts it kept for Mr E;
• spoken to Miss E;
• sent my draft decision to Miss E, the Council and the care provider and considered their responses.

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What I found

What should have happened

Standards in care provision

6. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers which is assesses against ‘fundamental standards of care’. These standards are set out in the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Registered providers of care services are expected to achieve those standards.
7. Included in the fundamental standards are that:
• care and treatment must be appropriate and reflect service users’ needs and preferences;
• service users must be treated with dignity and respect;
• service users’ nutritional and hydration needs must be met.

The ReSPECT process

8. The Resuscitation Council UK is the body responsible for setting standards in the processes of cardiac resuscitation and related issues. It has developed the ‘Recommended Summary Plan for Emergency Care and Treatment’ (ReSPECT) process.
9. The organisation’s information about ReSPECT says it ‘…will have increasing relevance for people who have complex health needs, people who are likely to be nearing the end of their lives, and people who are at risk of sudden deterioration or cardiac arrest.’

What happened

10. Mr E had several health problems, including dementia, Subdural Haematoma, type 2 diabetes, poor renal function, acute kidney injury and swallowing problems. He did not have the mental capacity to make his own decisions. He had been a resident in care homes for some time. Miss E and her brother were court appointed attorneys, responsible for managing Mr E’s affairs.
11. Miss E and her brother moved Mr E to a new Nursing Home in early 2019, run by Cedar Care Homes Limited (which I shall refer to as the care provider). The Council funded the care. Before the move, the Council carried out a review of Mr E’s care and support plan. This noted Mr E:
• needed twenty four hours a day dementia care;
• had increased care needs since his previous move in 2016. His mobility had declined, he had had sepsis and a unitary tract infection, he was doubly incontinent and his behaviour had changed.
12. At the end of November 2019, Mr E was admitted to hospital. Miss E says this was for a mouth infection; she says due to poor oral hygiene. The care provider says Mr E was admitted because he had MRSA, sepsis secondary to Parotitis (which is an infection of the glands). It said contributing factors to this condition include diabetic control and poor renal function.
13. The 24 December 2019 hospital discharge letter noted Mr E’s poor diabetic control in its diagnosis. It also noted his ‘severe frailty’. It advised Mr E’s GP:

‘[Mr E] will become unwell again with poor renal function and sepsis due to his frailty and severe dementia…Medical best interests for quality of life reasons would be to try to optimise [Mr E’s] quality of life in his care home.’

14. The care provider has sent copies of letters in its files from various parts of the NHS. These includes a note that, at the end of 2019, a doctor advised the care provider that Mr E was at high risk of dehydration.
15. Mr E had three further hospital stays in the early part of 2020. The last discharge was at the end of February. The hospital’s view was that, due to Mr E’s dementia, resuscitation attempts were not appropriate; nor were further hospital admissions. Mr E’s comfort and dignity were the priority. It advised the care provider it had completed the ReSPECT form and had consulted Miss E. It discharged Mr E back to the Nursing Home with anticipatory medication for end-of-life care.
16. Miss E wanted Mr E readmitted to hospital, should he fall ill again. Her view was this is what Mr E would have wanted, although she had not had the chance to discuss this with him.
17. The care provider has sent me fluid charts from the end of December 2020 (that is the date I requested them from). They show that, from his discharge from hospital, until the first weeks in April, Mr E was taking fluids reasonably well and consistently. From April, the Nursing Home also started to keep food intake charts.
18. The first record in the food and fluid charts of Mr E not eating or drinking was from 23 April. Mr E’s food and fluid intake in the days after was poor. On 24 April Mr E’s GP reviewed his health. She advised the care provider that Mr E was approaching the end of his life. By 27 April Mr E was not eating and drinking and had a very poor swallow. The last record of Mr E eating or drinking was on the 29 April.
19. By 1 May the Nursing Home had stopped Mr E’s oral medication because he had lost his ability to swallow. The Home’s staff kept in regular contact with Miss E. She was worried Mr E was dehydrated. She could not visit him because of the COVID-19 lockdown. The Nursing Home staff assured Miss E that Mr E was peaceful, with no signs that he was in pain or distressed. Its contemporaneous care records confirm that Mr E was peaceful.
20. On 3 May paramedics visited the care home twice, on Miss E’s request. Mr E’s GP and the paramedics spoke to Miss E and advised her Mr E would not benefit from hospital admission and it could be detrimental to him. The GP advised the care provider not to call 999.
21. Mr E passed away on 4 May. The care home’s records note he died peacefully in the presence of staff. The care provider let Miss E know.
22. Mr E’s death certificate says his cause of death was dementia. Miss E says her view is people do not die of dementia, so that is inadequate. Miss E was unhappy about the care Mr E received in his last weeks of life. So she complained, including to the Ombudsman after the care provider had responded to her complaint.
23. Miss E has advised me that she has now received Mr E’s blood test results from his doctor. She says these show Mr E had low sodium levels in his blood. Miss E says this shows he was dehydrated. Her view is his life could have been saved if the care provider had pushed fluids.

Analysis

24. As would be expected, Mr E’s passing was a distressing time for Miss E. This was no doubt exacerbated by the restrictions introduced during the COVID-19 lockdown. She was understandably concerned for Mr E’s welfare.
25. But looking at the evidence available, I cannot see evidence of significant fault by the care provider. Mr E had multiple longstanding health conditions. Records from medical professionals, from as far back as the end of 2019, noted Mr E was frail, prone to becoming unwell again and likely to be nearing the end of his life. Hospital staff followed the ReSPECT process. So, while Mr E did have several periods of illness while at the Nursing Home, I cannot conclude this was because of any fault by the care provider.
26. Miss E specifically complains about poor oral hygiene as the reason for Mr E’s first hospitalisation. The care provider has a different account of the reason for the hospitalisation. The discharge documents from the hospital do not raise the concerns Miss E had. So, on balance, I cannot uphold this part of the complaint.
27. After this, the view of medical professionals from the health service was that the primary goal for Mr E’s care in 2020 was to maintain his comfort and dignity. The care provider’s records demonstrate it did care for Mr E in line with these goals, and provided care that met the CQC’s fundamental standards.
28. I know Miss E wanted more active intervention – for example hospital admission and more active rehydration measures. But having considered the evidence, this was not what the medical professionals were recommending. Indeed, the view of Mr E’s GP was that this might actually be detrimental to him.
29. Miss E has been concerned that the care provider did not keep fluid charts. I asked the care provider about this. It has sent me records going back to the date I asked for them. I am unclear why Miss E has not been able to obtain these before now. But I am satisfied the care provider was keeping records that were largely adequate.
30. Miss E also raises the results of a blood test – low sodium in his blood, as proof Mr E died of dehydration. But I will not investigate this further. We cannot make a finding of Mr E’s cause of death. Nor can was say whether Miss E’s conclusions are consistent with the results. So it is unlikely any further investigation by the Ombudsman could resolve this issue.

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Final decision

31. I do not uphold this complaint as I find no fault by the Council or the care provider acting on its behalf. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman