Summary: The Care Provider’s complaint response was inaccurate and the Care Home failed to take appropriate action to escalate concerns when Mrs Y’s condition deteriorated. The Care Provider will apologise in writing to the family for the avoidable distress and confusion.

The complaint

1. Mrs X complained about her late mother Mrs Y’s care in one of the Care Provider’s care homes, Wellington Vale (the Care Home). She said the Care Home failed to recognise a serious decline in Mrs Y’s condition and failed to take action to ensure she received appropriate healthcare. Mrs Y also said the Care Provider’s complaint response was inaccurate.
2. Mrs X said the Care Provider’s failings meant she and her sister were unable to see their mother in her final days and that her mother was not able to have her family with her in familiar surroundings when she died.

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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 or others. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If we are satisfied with a care 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)

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How I considered this complaint

5. I considered Mrs X’s complaint to us, the Care Provider’s response and documents described later in this statement. I discussed the complaint with Mrs X.
6. Mrs X and the Care Provider had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

7. This complaint involves events during the COVID-19 pandemic. At the start of April 2020, the Government introduced new and frequently updated rules and guidance which we consider when relevant to our investigations.
8. During COVID-19, the Care Provider’s policy was to check all residents’ vital signs daily (vital signs are measurements of essential bodily functions) and use the NEWS 2 protocol (National Early Warning Score.) The NHS website and guidance from the Royal College of Physicians explains:
• NEWS is a tool to identify and respond to patients at risk of deteriorating, used in acute hospitals. It can also be used in other settings. For people in care homes, knowing their baseline scores may help a doctor who has to assess them acutely to decide whether they are baseline (normal for them) or not
• A score is allocated to 6 measurements:
1. Breathing rate
2. Oxygen levels
3. Temperature
4. Blood pressure
5. Pulse
6. Level of consciousness.
• The score for each measurement reflects how far from the normal level the patient is. The scores are added up. They help to identify a sick patient.
• The tool should not be used in isolation and is not a substitute for clinical judgement. Any concern about a patient’s clinical condition should prompt an urgent clinical review.
• A score of 0 to 4 is low clinical risk, 5 to 6 is medium, indicating the trigger for escalation and an urgent response. A score of 7 to 20 indicates a need for urgent action.
• If the patient is in hospital, a score of 5 or 6 means the patient needs hourly monitoring and for a clinician competent in assessing acutely ill patients to be involved and to assess within an hour. If the patient is in a community setting, thresholds for actions have not been determined but NEWS 2 scores may help the assessing clinician to determine actions.
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. The Care Quality Commission (CQC) issued guidance in March 2015 on meeting the regulations (the Guidance.) We consider the 2014 Regulations and the Guidance when determining complaints about poor standards of care.
10. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
11. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.

What happened

12. Mrs Y was in her eighties and lived in the residential unit of the Care Home. She arranged and paid for her care privately. The Care Home also had a nursing unit with qualified nurses able to offer clinical support to all residents, although Mrs Y did not require nursing care.
13. Before the incidents that led to this complaint and generally, Mrs Y was in good health given her age. She was very severely underweight according to weight charts and this was a long-term issue. She had a small appetite and took nutritional supplements. Mrs Y had no memory issues and was able to make all decisions, including those about her care and treatment. She needed little, or no help with personal care or toileting and she took her medication independently (staff ordered it for her). She walked using a frame. The care documents indicate Mrs Y valued her independence and privacy and liked to plan her day. The daily notes indicate she often asked staff not to check her during the night.
14. The Care Home kept care plans for Mrs Y which were reviewed regularly. She had minimal care needs. The care plan said Mrs Y wanted to be resuscitated and have active treatment including hospital admission if she became unwell and for staff to speak with her relatives as soon as possible. The care plan noted that she had told staff she did not want to speak about her preferred place of care at the end-of-life stage.
15. Staff recorded Mrs Y’s vital signs on an electronic chart. They did not take always take all six of the measurements to enable full NEWS calculations and they took some measurements like oxygen levels and temperature several times a day. I have calculated Mrs Y’s NEWS 2 scores where there were all 6 measurements available at a given time.
• 18 November at 10.22 pm: 6 (medium risk – threshold for urgent response)
• 19 November at 7.18 pm: 2 (low clinical risk)
• 21 November at 12.53 pm: 3 (low clinical risk)
16. The Care Home kept daily records of Mrs Y including her general presentation, notes of communication and the care which staff provided. These included clinical observations. I have summarised the entries below.
• On 18 November, in the morning there were no concerns about Mrs Y. Her oxygen level was 96% and temperature was 36.4. Staff spoke to Mrs X in the afternoon who was worried about Mrs Y because she was not her normal self. Staff checked on Mrs Y and she had a urine test which was negative. Her oxygen level was 93% and temperature 35.8. Later in the evening, Mrs Y told staff she was not feeling right; she was tired and unwell and was finding it hard to swallow food. A nurse took her blood pressure which was low (90 over 55), her temperature was 35.9, respiratory rate was 18 breaths a minute, pulse 92 and oxygen level was 94%.
• On 19 November, Mrs Y had a shower independently and spoke to her daughter on the phone. She declined most food that day, but she had a small lunch. She was noted to be low in mood and staff checked her oxygen levels twice. Mrs X called and said she was worried, staff explained Mrs Y’s vital signs were normal, but she had agreed to speak to the GP the following day. Mrs Y went to the toilet independently at night-time.
• On 20 November, Mrs Y had a good night’s rest. Staff updated her daughter early in the morning. Staff helped Mrs Y with morning personal care and took her vital signs. Her oxygen level was 89%, temperature 36.5, blood pressure was 110 over 73. Mrs Y and staff spoke to the medi-care telephone health service which arranged for a GP to call back later in the day. Mrs Y was weak, tired and chesty. Staff spoke to the GP on the phone, Mrs Y’s oxygen level was 83% at 3 pm. The doctor sent out a paramedic at just after 3 pm and staff arranged a COVID-19 test. The paramedic examined Mrs Y and was concerned about her low oxygen levels and breathing and wanted her to go to hospital, but she refused. He advised to treat Mrs Y as if she had COVID-19. Staff noted they would keep monitoring Mrs Y. The paramedic prescribed antibiotics and the records noted staff administered the first dose at 6.25 pm. Mrs Y’s vital signs were oxygen 94% and temperature 35.9.
• On 21 November, Mrs Y had regular night-time checks with no concerns; her breathing was regular. She became weak and breathless after washing in the morning. Her oxygen level was 91% and temperature 36.4 at 10 am. The nurse on duty saw Mrs Y at 11 am to discuss her treatment wishes - Mrs Y wanted full active treatment if her heart stopped including admission to hospital. The nurse took her vital signs: oxygen level was 98%, temperature 36.4 pulse 70, respiratory rate 18 breaths per minute. The Home Manager spoke to Mrs Y’s daughter after lunch to update her. Staff continued to monitor Mrs Y and took more vital signs. She was struggling to stand in the evening.
• On 22 November, Mrs Y needed two staff to help her with personal care. She spoke to the Home Manager at lunch time and said she was feeling better, but her mobility was noted not to be back to previous levels. The Home Manager spoke to Mrs Y’s daughter at lunch time. She ate most of her lunch. Mrs Y became breathless in the afternoon and her oxygen level was 91% at 6 pm. She ate most of her dinner and staff updated her daughter in the evening.
• On 23 November, Mrs Y was still weak, breathless and dizzy. She had been checked regularly overnight. Her oxygen level fell to 84% and so staff called an ambulance at 8.20 am. Mrs Y’s COVID-19 test returned a negative result and so her daughters had been able to see her in the car park before she went to hospital in the ambulance.
17. Mrs Y was admitted to hospital and died on 25 November. The daily records indicate Mrs Y’s daughter said Mrs Y developed pneumonia.
18. I have summarised the Care Provider’s response to the complaint below:
• On 18 November, Mrs Y was not her usual self, but there were no clinical signs of illness. She was having trouble swallowing and there was a hospital test booked to check her swallow on 25 November
• Her NEWS2 score was below 4 between 16 and 18 November and so she was low risk
• No-one called Mrs X back on the 18th, so Mrs X called back to speak to the Home Manager. The Care Services Manager rang her back because the Home Manager was finishing her shift. The Care Services Manager explained Mrs Y had a crackling sound at the back of her throat which was usual for her when she was eating and drinking. The Care Services Manager suggested Mrs Y see the GP, but she refused. Mrs Y’s urine was tested and there was no sign of an infection.
• The following day, the 19th, the Care Services Manager visited Mrs Y and she appeared well. Her vital signs had already been checked and were normal
• The team leader spoke to Mrs Y and she agreed to have regular checks at night and she agreed to be seen by the doctor the next day. She had a restful night, but had low blood oxygen levels from early evening to the following day which was a change in her condition
• The senior healthcare assistant persuaded Mrs Y to see a doctor and the online telephone health services was contacted. This service is for clinical assessments that are not emergencies. Following this call, a paramedic attended at 3 pm and noted low oxygen levels and breathlessness and recommended hospital. Mrs Y refused. The paramedic confirmed a respiratory infection, thought to be COVID-19 and prescribed antibiotics. Antibiotics arrived at the home and the first dose was given without delay. Mrs Y was placed in isolation.
• The antibiotics started within 5 hours which was in line with the agreement with the pharmacy (6 hours).
• The senior healthcare assistant spoke to the family several times about Mrs Y’s refusal to go to hospital
• Staff carried out frequent checks over the weekend. Mrs Y was breathless and weak at times, but calm at others, with normal vital signs.
• The Home Manager spoke with the family on Saturday 21 and then saw Mrs Y. The records indicate Mrs Y had eaten and drunk ok, she needed little to no help through the day and her observations were ok. Staff discussed Mrs Y’s wishes for the future with her and she said she wanted full treatment if her heart stopped.
• Mrs Y had a restful night on Saturday 21st, but in the early morning she was breathless and needed support from two staff to get up and ready.
• On Sunday 22nd, the Home Manager went to see Mrs Y who told her she was feeling better. This was in line with what the family put in the complaint, as they saw her through the window in the morning. By the early evening, the nurse on duty phoned the family as Mrs Y’s breathing was very bad. Mrs Y agreed to hospital admission if she did not improve and there would be regular checks
• On the 23rd, Staff checked Mrs Y and she was very breathless with a low oxygen level (84%). Staff wanted to call an ambulance, but Mrs Y wanted to speak to her family first. Emergency services were called. A chest infection was suspected and Mrs Y went to hospital. Her COVID-19 test results arrived at the home and were negative.

Findings

Complaint: Failure to act on a decline in Mrs Y’s condition

19. Mrs Y’s NEWS 2 score was 6 on the evening of 18 November. As this was a score requiring action, the Care Provider should have escalated the case by obtaining an urgent GP consultation or failing that urgent healthcare via emergency services. I find the Care Provider failed to act in line with the policy it had adopted for COVID-19 which was to apply the NEWS 2 protocol to trigger an urgent response and further action to enable an assessment of Mrs Y by a clinician competent in assessing acutely ill patients. Care to Mrs Y was also therefore not in line with Regulation 12(i) of the 2014 Regulations because the Care Home failed to work effectively with other healthcare professionals to ensure Mrs Y’s health and wellbeing in a timely manner. However, I cannot say on a balance of probability what would have happened had an assessment by a GP been sought on 18 November or that the course of events would have been any different. Taking into account that the following day’s NEWS 2 score was 2 – a low clinical risk, and that Mrs Y declined to go into hospital on 20 November against a paramedic’s advice, there is insufficient evidence of injustice to Mrs Y. However, Mrs X suffered avoidable distress as this was a matter she was aware of.

Complaint: Inaccuracies in the Care Provider’s complaint response

20. The Care Provider said in its complaint response that staff offered to contact the GP on 18 November, but there is no record of this in the care notes. The response also suggested Mrs Y needed little to no help on 21 November. I consider the response gave an inaccurate overall picture of Mrs Y on 21 November because the care records said Mrs Y and became weak and breathless when washing in the morning and struggled to stand in the evening. The complaint response gave a misleading impression of Mrs Y’s condition.
21. Aside from the failings identified in the previous two paragraphs, I am satisfied care to Mrs Y was in line with Regulation 12(i) of the 2014 Regulations because Mrs Y received regular checks and monitoring and when there was concern about her breathlessness, action was taken to offer to seek medical advice and to obtain medical support when Mrs Y consented. There is no evidence of any delay by the Care Provider in obtaining antibiotics and I am satisfied these were administered within 3 to 4 hours of the paramedic prescribing them.
22. I am also satisfied that staff sought Mrs Y’s views and wishes about what she wanted to happen should her health decline seriously and recorded those views in her care plan. This was in line with Regulation 9 of the 2014 Regulations. As Mrs Y wanted active hospital treatment, transfer to hospital happened in line with Mrs Y’s expressed wishes when she consented. Mrs Y did not want to discuss her wishes regarding where she wanted to die with care staff and so her preferences were not known to staff.
23. While it was a tragedy that Mrs Y was not able to die in familiar surroundings with her family around her, this was essentially due to her rapid and unforeseeable decline and due to COVID-19 restrictions which limited hospital visitors and transfer of patients back into the community. None of these were within the Care Provider’s control.

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Agreed action

24. Within one month, the Care Provider will apologise in writing to the family for the avoidable distress and confusion.

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Final decision

25. The Care Provider’s complaint response was inaccurate and the Care Home failed to take appropriate action to escalate concerns when Mrs Y’s condition deteriorated. The Care Provider will apologise in writing to the family for the avoidable distress and confusion.
26. I have completed the investigation and shared a copy of my final decision statement with the Care Quality Commission under our information sharing agreement.

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Investigator's decision on behalf of the Ombudsman