Summary: We investigated a complaint about the care provided to Mrs D. We found fault with the Trust, who did not arrange mental health support for Mrs D while she was in the Queen Elizabeth Care Centre (QECC). The Trust accepted it was at fault. The Trust has agreed to apologise to Miss C and send the Ombudsmen evidence of what steps it has taken to ensure it doesn’t happen again. We found no fault with the Council, the QECC or the Integrated Care Board (ICB).

The complaint

1. Miss C complains about the care and treatment her mother, Mrs D, received from Ealing Local Borough Council (the Council), the QECC and West London NHS Trust (the Trust). Mrs D received s117 aftercare funding from NHS North West London ICB. Specifically, Miss C complains;
• The Trust did not include the family when it did a mental capacity assessment on Mrs D in October 2019.
• The Queen Elizabeth Care Centre (QECC) was too far from Mrs D’s family.
• Mrs D received poor care at the QECC. She did not have her hair washed, lost weight, staff did not help her move out of bed or arrange physiotherapy. Mrs D was also attacked by another resident.
• Mrs D did not have enough access to the mental health team during her 12 months in the QECC.
• The Council did not tell Mrs D’s family her placement at the QECC was ending. Miss C feels the move to a new care home was inappropriate as she was unwell.
2. Miss C says these events were damaging to Mrs D’s health and caused distress to the family while she was alive. Since Mrs D’s death, Miss C experienced severe panic attacks, and anxiety; she needs medication, therapy and struggled to do her job.
3. Miss C wants an apology and service improvements to prevent other families experiencing what she has.

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The Ombudsmen’s role and powers

4. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation acts to stop the same mistakes happening again.
7. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I considered the complaint Miss C made to the Ombudsmen and information she provided by email. I also considered the information the Council, the Trust and the QECC provided in response to my enquiries. I also made enquiries to the Integrated Care Board (ICB) because Mrs D received S117 aftercare funding.
10. I shared a confidential draft with Miss C, the Council, the Trust, the QECC and the ICB to explain my provisional findings and invited their comments. I considered their comments before making a final decision.

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What I found

Background

11. Mrs D had schizoaffective disorder, a mental health condition marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania. She was detained under Section 3 of the Mental Health Act 1983 (the MHA) in 2010 and again in early 2019. The Trust managed her mental health, she had a care plan and care coordinator to help her. Mrs D was eligible to receive S117 aftercare services.
12. Section 117 of the MHA states a person may be eligible for aftercare services, if they are intended to meet a need that arises from or relates to a mental health problem and reduces the risk of the person’s mental health condition getting worse.
13. S117 of the MHA imposes a duty on health and social services to meet the health and or social care needs arising from, or related to, the persons mental disorder. This is known as S117 aftercare.
14. S117 does not define what aftercare services are. Section 33.3 of The Mental Health Code of Practice 2015 (the MHA Code) explains “after-care services mean services which have the purposes of meeting a need arising from or related to the patient’s mental disorder and reducing the risk of a deterioration of the patient’s mental condition (and, accordingly, reducing the risk of the patient requiring admission to hospital again for treatment for mental disorder)”. Section 33.4 adds aftercare can “encompass healthcare, social care and employment services, supported accommodation and services to meet the person’s wider social, cultural and spiritual needs”.
15. Section 33.7 of the MHA Code states Councils and CCGs (Clinical Commissioning Group, since replaced by ICB) should “maintain a record of people for whom they provide or commission aftercare and what aftercare services are provided.”
16. The ICB shares a statutory duty with the Council to provide, or arrange, S117 aftercare services for eligible service users in the area.
17. After release from section 3 in May 2019, Mrs D had a care plan which included S117 aftercare services.
18. In July 2019, Mrs D had a fall at home which caused a brain haemorrhage, and she needed a craniotomy (temporary removal of bone to expose the brain). While in hospital, professionals decided Mrs D could no longer decide about her own care and treatment.

Complaint about capacity assessment

19. Miss C complains the Trust conducted a capacity assessment on Mrs D in October 2019 without the family’s knowledge or involvement.
20. The Mental Capacity Act 2005 (MCA) Code of Practice 2007 explains “the person who assesses an individual’s capacity to make a decision will usually be the person who is directly concerned with the individual at the time the decision needs to be made.”
21. Mrs D was in hospital, and Trust doctors assessed her. The Trust explained it did the assessment because the Council were looking for a placement for Mrs D, and it needed to know who should be involved in the decision. Mrs D could not decide about her own care, so her family would decide for her.
22. A family member does not need to be present at a capacity assessment. There was no fault by the Trust.

Complaint about move to QECC

23. Miss C complains about the choice of QECC for her mother. She explains it was too far from Mrs D’s family, and it was not the right decision to move her there.
24. Mrs D had specific needs and needed a specialist care placement. She was well enough to leave hospital in September 2019. Doctors wanted Mrs D to leave hospital as soon as possible. There are risks to elderly patients associated with prolonged hospital stays and the Trust wanted to ensure Mrs D’s safety by moving her to a Care Home.
25. The Council’s placement team contacted suitable homes in Mrs D’s local area. This included homes in Greenford, Ealing and the surrounding boroughs. All responses told the Council they could not meet her needs or had no vacancy. This forced the Council to widen the search for a placement for her.
26. The Council found the QECC, who assessed Mrs D, said it could meet her needs and accepted the referral.
27. The Council spoke to Mrs D’s family. The MCA Code of Practice 2007 says “any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests.”
28. The family were unhappy with how far away this was and considered if Mrs D could return to her home with changes which made a safe environment for her. This was not possible.
29. The MCA Code of Practice 2007 states “multi-disciplinary meetings are often the best way to decide on a person’s best interests. They bring together healthcare and social care staff with different skills to discuss the person’s options and may involve those who are closest to the person concerned. But final responsibility for deciding what is in a person’s best interest lies with the member of healthcare staff responsible for the person’s treatment”
30. I asked the organisations if they held a best interest meeting with Mrs D’s family, they confirmed they did not. However, I have seen evidence of many discussions with Miss C and Mrs D’s husband (Mr D) about their concerns and their reservations about the move.
31. One concern the family raised was the QECC did not have a Care Quality Commission (CQC) rating because it was new. A CQC rating is only awarded after an inspection, which normally takes place within 12 months of opening. The Council asked the QECC for evidence it was registered with the CQC, it also checked safeguarding issues, insurance and visited the home. Everything passed their checks. I have seen evidence of these actions and I am satisfied the Council acted to ensure Mrs D would be safe before she moved.
32. The Council also considered the family concerns, even as an interim placement the QECC was away from their local area, and this would make visiting difficult. All members of the family explained socialising was important to Mrs D’s wellbeing. This is also mentioned in Mrs D’s care and support plan. The Council agreed to pay for taxis monthly so the family could visit. Miss C has explained this was difficult to arrange, and the Council confirmed it only received two requests for payment of a taxi fayre.
33. After working through their concerns, the family consented to Mrs D moving to the QECC on the basis it was short term until the Council could find somewhere closer to their home.
34. I can understand why Miss C and her family were unhappy Mrs D was moved out of her local area because it was difficult for her family to visit. However, the Council intended this to be a short term placement and felt it was safer for her than staying in hospital.
35. I am satisfied the organisations took suitable action to help Mrs D’s family to visit her, by paying for taxis, and continued to search for a placement closer to her home. Unfortunately, the COVID-19 pandemic began soon after her move which was outside the organisations’ control. I find no fault.

Complaint about care Mrs D received at QECC

36. Miss C complains Mrs D received poor care at the QECC. She did not have her hair washed, she lost weight, staff did not help her to move out of bed and the QECC did not arrange physiotherapy. Mrs D was also attacked by another resident.

Hair washing

37. Miss C feels the care workers did not help look after Mrs D. She says she did not have her hair washed which was important to her. She says her mother always liked to look her best and to see her in this state was distressing for everyone.
38. I have reviewed Mrs D’s care records. Her care plan from 8 February 2020 says “she likes to be clean and tidy at all times”. I cannot find any mention in her care records specifically about hair washing, equally I cannot see any mention of anyone raising concerns of her being unclean.
39. Miss C explained the family paid for a hairdresser to come to see Mrs D, but this did not happen. She also said her hair became so unmanageable a large amount had to be cut off by her.
40. I can understand why Miss C worried about her mother’s appearance if she knew it was important to her. As it is mentioned in her care plan, staff should have been aware it was important to Mrs D. However, it is not possible from the available evidence available to know if staff were washing Mrs D’s hair regularly.

Weight loss

41. Miss C saw Mrs D become thin and worried she was not receiving enough food. Staff at the QECC told Miss C her mother’s intake did vary, but they could not force her to eat if she refused her meals.
42. I have reviewed Mrs D’s care plan, nutrition and fluid charts, weight chart and her daily care records for the time she spent in the QECC. Mrs D’s care plan states she has a poor appetite.
43. On admission Mrs D weighed 53.3kg, and on discharge she weighed 53.2kg, this is a 0.1kg difference in weight overall. However, three months after her admission, her weight dropped to 50.8kg.
44. I can understand why Miss C was concerned her mother loss weight quickly. This may have been more noticeable to her because she could not visit her as often as she would have liked due to the distance and the QECC being in lockdown due to the pandemic. However, I am satisfied the care workers acted by accurately noting the weight loss and her nutritional intake to help Mrs D put the weight back on without forcing her to eat.

Physiotherapy

45. When Mrs D left hospital to move to the QECC, the Trust gave it a summary of her needs so staff knew what care she needed. The discharge summary does not mention Mrs D needed physiotherapy so there would be no reason for the QECC to arrange this for her. I have not seen any mention in Mrs D’s records of this as a concern.

Mobility

46. On admission to the QECC, staff assessed her mobility, her notes say she “needs to be hoisted” because she has “a history of falls”. This is different from Miss C’s view, which was that her mother could walk with the help of an aid, such as a zimmer frame. I cannot reconcile the difference in accounts, but I can understand why it would have been distressing to Miss C if she thought her mother could walk without help and wasn’t encouraged to do so.

Incident with another resident

47. In February 2020 while at the QECC, Mrs D and Mr D were attacked by another resident who was experiencing a mental health episode.
48. Mrs D and Mr D were not physically harmed, but both were distressed and traumatised by what happened.
49. Mr D told Miss C what happened the same day. She spoke to QECC staff who said they had phoned the police and told the Council what had happened. They explained the resident had been sedated so Mrs D was not at further risk. The QECC then worked with the other resident’s GP to stabilise them so a further episode would not take place.
50. Miss C worried for her mother’s safety and phoned the police herself, who told her it had no record of the incident. Miss C then contacted the Council, told them her concerns and wanted to know how the incident occurred and to make sure it would not happen again.
51. The Council contacted the QECC and asked staff for an account of what happened, the social worker also visited and spoke to Mrs D in person. The accounts provided by staff, Mrs D and Mr D amounted to the same events. QECC staff and the social worker did not see any of the alleged damage to Mrs D’s room.
52. In early March 2020, the Council had a meeting with Mrs D’s family to discuss the incident. The notes show the family were unhappy with what happened, but accepted Mrs D was no longer at risk because the other resident was carefully watched. The notes also show the family agreed for Mrs D to stay there until a placement closer to home could be found, as none were available.
53. The Council assured the family it was doing all it could to find Mrs D a placement closer to the family home. The Council also planned an assessment review which it could use in the new placement search.
54. The Council also reviewed the actions of the QECC staff and provided feedback. It gave learning to the QECC so it could improve should a similar incident happen in the future. The Council told the QECC its staff should have contacted the police straight away and should have called an ambulance for both Mrs D and Mr D. This is because even though neither had visible injuries, staff could not rule out internal injuries and Mrs D was visibly traumatised.
55. Miss C was understandably very distressed when she found out what happened to her mother while her father visited. The QECC took suitable steps to ensure Mrs D’s safety and to ensure there was not a repeat, but it could have done more to ensure Mrs D was well following the incident. The Council provided feedback to the QECC at the time to help it improve and I am satisfied this is enough.

Access to mental health services

56. Miss C complains Mrs D did not have enough access to the mental health team during her stay at the QECC.
57. Mrs D received S117 aftercare funding. Her Care and Support Review from October 2019 before admission to the QECC says “will require mental health reviews and prescriptions of her medications to ensure that her mental health remains stable.”
58. I asked the Trust to explain what support it provided to Mrs D while she was at the QECC. It explained the plan was to transfer Mrs D’s care to a new Local Community Mental Health team, and discussions were held in December 2019 to arrange this. The Trust has admitted it did not take any further action to support or transfer Mrs D until October 2020.
59. In October 2020, the Trust tried to transfer Mrs D’s mental health care to the local Community Health Care Team, where QECC is. This team refused to accept the referral because Mrs D was still registered and receiving prescriptions from a GP in another area. In November, the Trust asked the QECC to arrange a new GP local to it for Mrs D, so it could transfer her mental health care. The process of this transfer was started but not completed because the Council was able to move Mrs D to a new placement closer to her family.
60. Because of the COVID-19 pandemic, Mrs D was not receiving any face-to-face visits from mental health professionals, and her only form of support was prescriptions from her GP. The QECC had qualified nursing staff and from her contact records, I can see Mrs D was being monitored and was taking her medication. Miss C does not agree with this. She explains she saw
61. The Trust explained Mrs D was at lower risk because she was in a care placement. Miss C disputes she was being monitored closely because she saw her head begin to droop which was very distressing for her. However, it has acknowledged Mrs D should have been transferred to the local mental health services right away and told us it has taken learning from Miss C’s complaint.
62. I accept the Trust’s explanation she was at lower risk because she was in a care placement with staff who could monitor her behaviour. However, the Trust did not support Mrs D’s mental health as indicated in her care plan. This is fault.
63. Miss C explains she could see her mother’s mental health declining, she was often confused and dribbled from her mouth. The family were very worried about her because they could not visit as often as they liked. Miss C knew Mrs D was not being reviewed by mental health professionals and this added to their concern. This is an injustice to Miss C.

Move to a new care placement

64. Miss C complains the Council did not tell the family Mrs D’s placement at the QECC was coming to an end.
65. Mrs D went into hospital in early October 2020. The Council’s social worker spoke to the family about moving Mrs D closer to home, as they had been seeking. Mr D said he felt it was best she stayed in the QECC as this was familiar to her, until her health stabilised. Mrs D was discharged from hospital back to the QECC. In late October, the social worker again spoke to Mr D who said she should move in January.
66. Mrs D went back into hospital in early December. I have seen a note from the Council to the QECC which asks it to send the notice letter to Miss C. I have also seen a phone note which shows the social worker discussed this with Miss C who explained the search for a placement closer to home was already underway. Mr D recommended a home he liked to the Council. Four days later, the Council confirmed this home as the new placement for Mrs D, and she left hospital to go there several days after that.
67. While I can understand why it would have been distressing for Miss C to receive the notice letter, conversations with Mr D had been ongoing for several months about moving Mrs D closer to the family home. The Council contacted the home Mr D preferred for Mrs D and arranged the placement.
68. I provisionally find no fault with the actions of the Council, who were acting on the wishes of the family.

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Agreed actions

69. The Ombudsmen made and the Trust agreed to the following actions.
70. Within one month of the date of the final decision, the Trust should write to Miss C to apologise for the distress it caused by not arranging mental health support for Mrs D while she was at the QECC. It should send a copy of this letter to the Ombudsmen.
71. Within two months of the date of the final decision, the Trust should provide the Ombudsmen with a copy of what action it has taken following the learning it took from Miss C’s complaint so we can be assured it will not happen again.

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Final decision

72. I partly uphold this complaint. I found fault by the Trust which led to an avoidable injustice to Miss C and Mrs D. The agreed actions will provide a suitable remedy. I found no fault with the Council, the QECC or the ICB.

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Investigator's decision on behalf of the Ombudsman