Summary: Mrs B complained about the actions of a care home in respect of her mother’s end of life care and storage of her belongings. The Council had placed her mother (Mrs C) at the care home following a discharge from hospital. We found the care home should have informed the family about Mrs C’s end-of-life care plan and kept better storage. The Council has agreed to pay Mrs B £250 and improve its storage procedures.

The complaint

1. Miss B complains that Farm Lane Care Home:
• failed to tell her on 1 April 2020 that Mrs C was receiving end of life care; and
• failed to accept it damaged Mrs C’s television set: the stand was missing when she came to collect it in September 2019.
2. These issues caused Miss B distress and frustration at a difficult time.

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The Ombudsman’s role and powers

3. 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)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. 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

6. I have considered the complaint and the documents provided by the complainant, made enquiries of the Council and considered the comments and documents the Council provided. Miss B, the Council 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

7. Mrs B’s mother, Mrs C was placed by the Council in Farm Lane Care Home (the Home) after a stay in hospital. She had a number of health conditions and was receiving a variety of medication, some in tablet form. The hospital had spoken to Mrs C and agreed she was not suitable for resuscitation. She was able to eat and drink independently and was prescribed nutritional supplements to counteract some weight loss.
8. Mrs C’s care plan said that when her medical conditions deteriorated the Home would inform her next of kin, discuss end of life care with her family and refer her to the palliative team.
9. The care records show that Mrs C was comfortable in the Home until the end of March 2020. On the evening of 31 March 2020, the Home noted her temperature was raised. Mrs C refused, medication, food and drink. The notes record she was stable but weak and unable to communicate. The night nurse was advised to monitor her closely. Staff raised no concerns over night. The notes record Mrs B took all her medication in the morning. But during the day she deteriorated and was breathless.
10. On 1 April 2020 the doctor visited and noted Mrs C was breathing rapidly and was not opening her eyes in response to voice or touch. The doctor noted Mrs C may have COVID and was in respiratory distress. She prescribed end of life injectable medication for breathlessness and agitation and noted Mrs C should not be resuscitated or transferred to hospital. She prescribed antibiotics in tablet form while awaiting the injectable medication from the pharmacy.
11. Mrs B says the Home informed her on 2 April 2020 that Mrs C was not well. She visited that day. She said Mrs C was very unwell. Mrs B says she spoke to the doctor who denied Mrs C had COVID and said she was on antibiotics. But Mrs B noted Mrs C was unable to swallow the tablet. By this time the doctor had left. The Home called 111 and when Mrs B spoke to them, she was told that Mrs C was on end-of-life care. Mrs B called an ambulance herself and Mrs C went to hospital later that day. She died on 4 April 2020.
12. Due to the COVID lockdown Mrs B was unable to collect Mrs C’s belongings. the Home cleared the room and stored the belongings in black bags. It did not take an inventory or any photographs. Mrs B contacted the Home in August 2020 asking to collect the items. Mrs B collected them on 7 September 2020.
13. When she got home, she noticed that the TV stand was missing. On 15 September 2020 she emailed the Home to complain that the television had been damaged. She did not receive a reply, so she made a formal complaint in October 2020, including the failure to tell the family Mrs C was on end-of-life care, giving her an antibiotic in tablet rather than liquid form, lack of support and condolence and failure to take responsibility for the broken television.
14. The Care Provider responded in November 2020. It said Mrs C had been referred to the GP on 1 April 2020 due to reduced oral intake and rapid breathing. The GP prescribed oral antibiotics for a chest infection and as Mrs C had been able to swallow solids, there was no reason to believe she would not be able to take the antibiotics. The GP had also ordered injectable medication for breathlessness and agitation. The Care Provider said Mrs B was informed of the situation on 1 April 2020 and that the Home did not have testing kits for the residents at that time. It noted Mrs B visited on 2 April 2020 and called an ambulance. The Care Provider said it was satisfied that its staff had followed the GP’s instructions and care plan.
15. In respect of the television the Care Provider said the maintenance person noted the television was missing some screws and was not firmly mounted on the wall. It said as Mrs B had not raised concerns until late October 2020 it was difficult to conclude how the TV had been damaged.
16. The Care Provider offered its sincere condolences for Mrs C’s death.
17. Mrs B was unhappy with aspects of the response and escalated her complaint. She queried why the GP had not noticed problems earlier with Mrs C, said the Home called her on 2 not 1 April 2020, queried why they were not told about the GP’s instruction that Mrs C should not be admitted to hospital and why the paramedics then did take her to hospital. She also questioned why tablet antibiotics had been given because when Mrs B saw Mrs C she could not swallow and why the Home had not informed them that Mrs C was on end-of-life care. She also pointed out she had contacted the Home on 15 September 2020 shortly after she had collected the television but did not receive a reply.
18. The Care Provider replied in January 2021. It said Mrs C’s swallowing difficulties could have started suddenly, she had been eating and drinking fine prior to that point and the doctor prescribed the antibiotic tablet. The Care Provider agreed the family should have been informed Mrs C was on end-of-life care. It explained that the end-of-life medication had been prescribed on 1 April 2020 but had not arrived by the time Mrs C went to hospital the next day. It said staff were very busy focussing on the pandemic and the high number of unwell residents.
19. It said it was not aware that a piece of the television was missing, only that it had been damaged. It repeated its view that it felt it had happened in transit. It explained that due to the pandemic staff were under pressure to clear and disinfect the rooms and could only use storage items within the home, so they did not have access to boxes.
20. Mrs C then complained to the Ombudsman.
21. In responding to my enquiries, the Council said it would expect the Home to have discussed the end-of-life care with the family. It noted since the complaint, the Home has reviewed all residents who have an end-of-life care plan and ensured that the GP visiting the Home has discussed the plan with the families. In respect of the television, it said it expected the Home to have a clear system in place when looking after resident’s belongings including an inventory and photographs. As there were no records it was not possible to establish how the stand went missing. It recommended a symbolic payment to Mrs B in recognition of the fault.

Analysis

End-of-life care

22. The Home should have informed Mrs B on 1 April 2020 that the GP had prescribed end-of-life treatment for Mrs C, for possible COVID and advised that she should not be transferred to hospital. The Home said she had been prescribed antibiotics for a chest infection which was not full and complete information. This was fault, which meant Mrs B missed vital hours with her mother towards the end of her life and was caused confusion and distress at a difficult time. It must have been a shock to have been informed over the telephone by 111 advisers that Mrs C was receiving end-of-life care. I welcome the fact that the Care Provider has taken action since then to improve its procedures, but Mrs B was still caused avoidable distress. This was exacerbated by the incorrect information in the stage one response, saying that the Home had informed Mrs B on 1 April 2020.

Television

23. I understand it was a very pressured time at the start of the COVID pandemic, but the Home should have made an inventory and taken photographs of the stored items. The failure to do so means it is impossible to conclude how the stand went missing and has caused Mrs B additional frustration. The frustration was exacerbated by the Home’s refusal to acknowledge it could be at fault and by its insistence that Mrs B had damaged it and that she had not reported the problem promptly.

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Agreed action

24. In recognition of the injustice caused to Mrs B, I recommended that (within one month of my final decision) the Council:
• pays Mrs B £250; and
• ensures the Care Provider implements a system for storing residents’ belongings including an inventory and photographs.
25. The Council has agreed to my recommendations

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Final decision

26. I consider this is a proportionate way of putting right the injustice caused to Mrs B and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman