Summary: There was fault in the way the Home communicated with Mrs B and provided her with updates. The Home has agreed to apologise to Mrs B and pay her a small sum to reflect the distress caused.

The complaint

1. Mrs B complains on behalf of her mother, Mrs C, who has sadly passed away. Her complaint relates to Digby Court care home in Bourne.
2. Mrs B says the Home failed to inform Mrs C about her right to attendance allowance when she became a permanent resident in 2014 and says the Home delayed until 2018 to provide Mrs C with the larger room she had been promised.
3. Mrs B says the Home did not give her updates about Mrs C in recent years and its communication with her was poor.

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What I have investigated

4. I have investigated Mrs B’s complaint about the communication. Paragraph 32 explains why I have not investigated the other two complaints.

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The Ombudsman’s role and powers

5. 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. I have used the term fault to describe such actions. If they have caused an injustice we may suggest a remedy. (Local Government Act 1974, sections 34 B, 34C and 34 H(3 and 4) as amended)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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How I considered this complaint

7. I have discussed the complaint with Mrs B. I have considered the documents that she and the Home have sent and both sides’ comments on the draft decision.

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What I found

8. I have summarised the complaint correspondence from August 2020 to February 2021 insofar as it is relevant to the complaints I am investigating.
9. Mrs B complained on 27 August 2020 and said:
• The Home said it would provide her with monthly updates on Mrs C’s progress but failed to do so. She received emails in June and July 2020 and then they stopped.
• The hospital contacted her on 26 August 2020 to let her know that Mrs C had been admitted to hospital. The Home had not contacted Mrs B to let her know that Mrs C was in hospital and this was the second time that this had happened.
• The hospital asked Mrs B whether a DNAR (do not attempt resuscitation) resuscitate) form was in place for Mrs C. The Home had told the hospital that there was no DNAR.
• She did not receive any updates from the Home after Mrs C was discharged from hospital.
10. The Home replied on 16 September 2020 and said:
• The Home suggested the monthly updates in July 2018. It admitted that this had not always been completed. However, following a conversation earlier in the year, the manager had been reminded of this task and monthly updates had been provided, except in March 2020, because of the Covid pandemic.
• A copy of the DNAR form should be given to the paramedics when they attend the Home. In Mrs C’s case the Home confirmed that the manager had shown the form to the paramedics.
• The records showed that the Home called Mrs B on 26 August 2020 to inform her of Mrs C’s admission to hospital.
• The Home admitted it had not called Mrs B after that initial call and admitted it should have done.
• The manager emailed Mrs B on 11 September 2020 in relation to Mrs C’s health status and admitted that this should have happened much sooner. It apologised for this oversight.
11. Mrs B wrote back in October 2020 and said:
• She had only received updates for April, June, July, August and September 2020.
• The Home did not call her on 26 August 2020. She called the Home after finding out from the hospital that Mrs C had been admitted.
• The nurse (from the hospital) who called Mrs B said she had contacted the Home to find out if there was a DNAR. The Home had told the nurse to contact Mrs B as the Home had no record of a DNAR.
• The Home did not appear to have any record of a call on 27 August 2020 when the manager rang Mrs B to inform her that Mrs C had had another fall.
• The Home did not contact her until 11 September 2020, 15 days later to say how Mrs C was progressing. The Home had explained what action it was taking in terms of lowering the bed and placing a sensor mat by the bed. Mrs B pointed out that Mrs C should already have a sensor mat by the bed because of her night-time activities.
12. The Home replied and said:
• The Home had obtained a deprivation of liberty safeguard (DOLS) consent for Mrs C because of her dementia. It proposed weekly emails of reassurance and monthly reviews. It admitted there had been no monthly updates on the DOLS.
• It admitted that its communications with Mrs B had been sporadic and accepted that this would have made things more difficult for Mrs B, particularly during a lockdown period and a lack of contact. It apologised for this.
• There had not been a need for an alert mat before August as Mrs C was at low risk of falls, but she was provided with the alert mat after the falls in August.
• The Home had sent the DNAR form with Mrs C when she went to hospital, so it was not clear why the hospital did not have the form. It could be that the ambulance crew did not pass on the form.
• The Head of the service was certain that she contacted Mrs B (about the hospital admission) but there was nothing on the documents to say either way.
13. Mrs B took the matter to the third stage of the Home’s complaint process as she was not satisfied with the lack of communication and documentation, but the Home’s position remained unchanged.
14. Sadly, Mrs C contracted Covid-19 in February 2021 and passed away in March 2021.
15. Mrs B took the matter to the Ombudsman. She said Mrs C was in hospital twice without the Home informing Mrs B. She only became aware of this when the hospital rang her to ask her about the DNAR form.
16. She said she was informed by text that Mrs C tested positive for Covid-19 and felt that this should have been done by phone. Also, when she rang to enquire how Mrs C was, after she had Covid-19, she was told she was fine and that the other residents with Covid-19 were also fine. Sadly, Mrs C and four residents died of Covid-19.

Further information

17. The Home has sent me its records relating to the incidents and falls.
18. The incident report dated 7 August 2020 said Mrs C was taken to hospital after a fall. The form said the incident happened at 08:15 and Mrs B was informed of the incident by email at 09:05.
19. The incident report dated 26 August 2020 says:
• Has the next of kin been advised of the incident? ‘No’.
• Under the heading ‘actions taken’, the document says: ‘Paramedics attended the home at 09:15, decision made to take [Mrs C] to hospital. [Mrs C] left Digby at 09:40 – DNAR and photocopied MAR (medical administration record) sent also.’
20. I also asked the Home to send me the monthly updates it sent to Mrs B since August 2018.
21. The Home sent me emails to Mrs B dated 14 August 2018, 1 October 2018, 3 January 2019, 3 June 2020, 6 July 2020 and 16 September 2020.
22. I asked the Home to send me copies of any communications after Mrs C was diagnosed with Covid-19, but the Home was unable to send me any emails or notes of conversations relating to that time-period.

Analysis

23. I have investigated the complaint that the Home failed to contact Mrs B on two occasions when she was taken to hospital.
24. I could only find one record relating to an incident before 26 August 2020, which was the incident which occurred on 7 August 2020. It appears that the Home did inform Mrs B of the fact that Mrs C was taken to hospital, but did so by email. I am of the view that it would have been good practice, where an emergency has taken place, to inform the relative by phone, rather than email.
25. In terms of the incident on 26 August, the records show that the Home did not contact Mrs B so this was fault.
26. The records show that the Home provided Mrs C with her DNAR form when she went to hospital on 26 August 2020. I appreciate that the hospital then rang Mrs B about the form, but it could be that the form was lost somewhere in the transportation to the hospital or at the hospital. Therefore, I cannot say, on the balance of probabilities that there was definitely fault in the Home’s actions in that respect. However, it is concerning that the hospital told Mrs B that they contacted the Home about the DNAR first and the Home did not know whether Mrs C had a DNAR.
27. I uphold the complaint that the Home did not provide Mrs B with the monthly updates which it said it would provide. The Home agreed to provide the monthly updates in July 2018. There were 32 months between July 2018 and March 2021 when Mrs C passed away. The Home only provided me with evidence of six updates during this entire time so clearly the Home failed to provide the updates, even after the Home had been reminded to do so.
28. There was also fault in the communication after Mrs C caught Covid-19. I agree with Mrs B that she should not have been informed by text message that her mother had tested positive for Covid-19. This news should have been delivered by telephone and a text message was not sufficient. I appreciate that the Home would have been under significant pressure at the time but, nevertheless, it had a duty to keep Mrs C’s relatives informed of what was happening and to update them regularly after the diagnosis. It failed to do so and that was further fault.
29. Mrs B has suffered distress as a result of the poor communication. When the injustice suffered is distress, the Ombudsman normally recommends an apology and sometimes a small symbolic payment to reflect the distress a person has suffered. These sums are usually between £100 to £300 and exceptionally higher.

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Agreed action

30. The Home has agreed to take the following actions within one month of the final decision. The Home will:
• Apologise to Mrs B in writing for the fault.
• Pay Mrs B £150.

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Final decision

31. I have completed my investigation and have found that the Home’s actions have caused an injustice. The Home has agreed the remedy to address the injustice.

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Parts of the complaint that I did not investigate

32. I have not investigated the complaints relating to events from 2014 and 2018 as they happened too long ago. It would be difficult to have a meaningful investigation into these events and Mrs B could have complained about these matters earlier.

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Investigator's decision on behalf of the Ombudsman