Summary: We have found fault with St Augustine’s Care Home’s (owned by The Sisters Hospitallers of the Sacred Heart of Jesus) record keeping, communication around Mrs P’s end of life care, its visiting arrangements, and its complaint handling. CSH Surrey also missed the opportunity to assess Mrs P for fast-track NHS continuing healthcare. Those faults caused Mrs P’s daughters, Mrs M and Ms N, a personal injustice. The Home and CSH Surrey should apologise and carry out improvements to remedy their injustice.

The complaint

1. Mrs M and Ms N complain on behalf of their deceased mother, Mrs P, about the actions of St Augustine’s Care Home (the Home - owned by The Sisters Hospitallers of the Sacred Heart of Jesus), Woking and Sam Beare Hospice and Wellbeing Care (the Hospice), The Crouch Oak Family Practice (the Practice) and CSH Surrey. They say poor communication between the organisations on 19 and 20 December 2020 meant Mrs P unnecessarily suffered in pain before she died. Specifically, they say:
• There was confusion around what pain relief Mrs P needed and when to administer it. Mrs M and Ms N said the Home should have started anticipatory medications.
• Some staff at the Home were not aware the Hospice was supporting Mrs P. The Hospice missed the opportunity to refer Mrs P for fast-track continuing healthcare. Also, the Hospice has played down its role during the complaints process.
• The Practice did not check Mrs P after stopping her constipation treatment.
• The Home could not arrange for Mrs M to see her mother before she died.
2. Mrs M and Ms N say it was distressing to witness Mrs P in pain before she died.
3. They also say the Home has not responded to their complaint. That worsened the distress they have both suffered.
4. Mrs M and Ms N would like the organisations to carry out service improvements to improve communication and ensure similar fault does not happen to others.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. We decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. Where something has gone wrong we refer to those actions as ‘fault’. (Local Government Act 1974, sections 34B, and 34C, as amended)
7. The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services. If there has been fault, the Health Service Ombudsman considers whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1))
8. If the actions of a health and social care provider have caused injustice, the Ombudsmen 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 takes action to stop the same mistakes happening again.
9. 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

10. I considered the information Mrs M, Ms N and the organisations sent to me, including their responses to my enquiries. I also considered the relevant national guidance and legislation.
11. Mrs M, Ms N and the organisations had an opportunity to comment on two versions of my draft decision. I considered any comments received before making a final decision.

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What I found

Key facts

12. Mrs P lived in the Home. She suffered with dementia and lung cancer.
13. From September 2020, the Home, a Hospice Clinical Nurse Specialist (CNS) and Practice worked to provide end of life care and support. By that time, Mrs P’s health had deteriorated.
14. On 11 September, the Hospice CNS emailed CSH Surrey, and said: “Could you consider whether [Mrs P] is CHC [NHS continuing healthcare] Fast Track appropriate when you visit? Her family are asking about this”. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’. CHC funding can be provided in any setting. CSH Surrey did not assess Mrs P for CHC after that email.
15. On 22 October, the Hospice CNS recommended the GP prescribe anticipatory medications to Mrs P. That was because she was worsening, and needed those medications to control her pain in the last weeks and days of her life.
16. On 23 October, the Practice confirmed the anticipatory medication prescription was to be given when required either subcutaneously (under the skin) or by syringe driver (a pump that delivers medication at a constant rate throughout the day and night). That was in place at the Home.
17. On 16 December, the Practice reviewed Mrs P’s medications. It stopped her constipation treatment due to the problem with Mrs P’s swallow. She could not take the amount of water needed to mix with the powder. It felt the risk outweighed the benefit. The Practice continued with Mrs P’s Oramorph (liquid morphine) but decided it needed to be thickened to the required consistency. The Practice told the Home of the changes the same day.
18. On 19 December, Mrs M visited Mrs P. Mrs M told a Senior Carer her mother was in pain. The Senior Carer spoke to the Hospice CNS. The Senior Carer said the Hospice advised it was most likely constipation and recommended giving Mrs P prune juice and to contact the GP. The Home noted “I have done it”. However, the Home did not contact the Practice. The Hospice CNS said it was the Home who suggested Mrs P was constipated.
19. On 20 December, Mrs M said she called the Home to request a visit that day. Mrs M said the Home told her Mrs P’s heart rate seemed to be slowing. But because the Home Manager was not present, they could not agree for Mrs M to visit. Mrs M asked the Home to start the anticipatory medication, but the Home refused because Mrs M was eating yoghurt. The Home had no record of that conversation in Mrs P’s records. But later that day, in an internal email, the Home said: “”[Mrs M] was here on Saturday [19 December], concerned that her mom is pain and uncomfortable, maybe is time to start the end of life medication, I have contacted palliative team, asked for advice, the [Hospice CNS] said, because she is still eating and drinking it is too early to start end of life medication, they assume she is constipated, asked me to send an email to GP, they will do the same [sic]. And to start prunes juice. But today, [Mrs P] is very weak, her hart [sic] rate was sometimes under 40, her oxygen level was still 92. I have called [Mrs M] a couple of times to update her. [Mrs P] unfortunately cannot communicate already but I managed to have get [sic] some answers from her regarding her pain and other issues. She could give some yes and no for me. Please, [Home staff member], contact the GP regarding [Mrs P].
20. The next day, Mrs M called the Home to ask how Mrs P was and to request a visit that day. The Home said Mrs P’s condition had not changed but Mrs M could not visit due to the presence of COVID-19 in the Home. Later that morning, the Home asked Mrs M to come and see her mother as she was most likely dying. Mrs M arrived five minutes after her mother died.

Analysis

Pain relief before Mrs P died

21. First, I will explain what each organisation was responsible for:
• The Practice prescribed the pain relief to Mrs P.
• The Home gave liquid paracetamol and Oramorph to Mrs P. But it could not administer the anticipatory medications.
• CSH Surrey would have been responsible for giving the anticipatory medications to Mrs P; but it was not asked to. It only provided community nursing support to Mrs P.
• The Hospice acted in an advisory capacity to support Mrs P.
22. Overall, I am satisfied the Practice’s instruction about pain relief was clear. The Home was to administer liquid paracetamol and Oramorph four times a day. Also, the Home’s Medication Administration Record (MAR) charts noted it should ask CSH Surrey to start the anticipatory medications to manage Mrs P’s pain, if necessary. MAR charts list a patient’s medication, the quantity of tablets received, the dose, frequency and time of administration over a four-week period. Home staff sign it acknowledge receipt of medication, to record when they administer it or to record if, for any reason, it is not given.
23. The Home’s MAR charts show staff gave Mrs P liquid paracetamol and Oramorph four times a day from 17 December until she died. In the late afternoon on 19 December staff noted Mrs P refused the paracetamol. Overall, the Home’s records show Mrs P received regular pain relief up to the morning she died.
24. While the Home administered pain relief to Mrs P on 19 and 20 December, I cannot say if that was managing her pain. There is evidence Mrs P was still in pain on 19 December, when Mrs M visited. The Home and Hospice later attributed that pain to constipation, which I consider later in this statement.
25. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below. Specifically, Regulation 17: Good Governance users’ states that service records must be “complete, legible, indelible, accurate and up to date…”.
26. There is no information about Mrs P on 20 December in the Home’s daily care record. That was poor record keeping, which was not in line with the CQC’s Fundamental Standards. Mrs P was most likely at the end of her life, so it was important the Home recorded if Mrs P was in pain. I consider that was fault.
27. I have considered if the Home missed the opportunity to start the anticipatory medications on 19 December. By then, the Home was unsure if Mrs P needed it. The Home’s MAR chart clearly said the anticipatory medications should be started “By District Nurses”. It should have understood that was a reference to CSH Surrey as they were already supporting Mrs P. The Home should have either called CSH Surrey, the Practice (or their out of hours service) or even 111 (for advice). Those organisations were best placed to review and/or manage Mrs P’s pain and decide to start the anticipatory medications or not. Despite the Home agreeing to contact the Practice (after speaking with the Hospice CNS), I cannot see it did. That was a missed opportunity, which was fault.
28. The Home told me it would have expected CSH Surrey to have escalated concerns about pain management when it reviewed Mrs P for other issues. I disagree. I consider the Home was responsible for escalating concerns about Mrs P’s pain on 19 December.
29. Mrs M and Ms N said the Home told them it could not start the anticipatory medications because Mrs P was still eating. The Home’s internal email on 20 December indicated it received that advice from the Hospice CNS.
30. The Home’s food intake charts have no record for 19 December. I cannot say if that was due to poor record keeping, or if Mrs P did not have any food. That was fault. The next day, the Home recorded Mrs P had prune juice (to help her constipation). I consider, on the balance of probabilities, Mrs M was not eating by 19 December. By then, CSH Surrey were treating her poor swallow and the food intake charts show she could not tolerate solid foods.
31. I also consider the Home should have updated Mrs P’s care plan to include changes to Mrs P’s care and support at the end of her life. That was fault. I agree with Mrs M and Ms N’s view that this was important considering she was not in a nursing home and relied on coordinated medical support.
32. Overall, the Home’s poor record keeping means I cannot say if Mrs P was in pain the day before she died. Also, the Home missed the opportunity to refer Mrs P to the Practice and/or CSH Surrey to review her pain and decide if it was necessary to begin the anticipatory medications. That leaves Mrs M and Ms N uncertain if their mother was in pain the day before she died. Also, if she should have received the anticipatory medications after 19 December.
33. The Home should take further action to remedy the personal injustice to Mrs M and Ms N.

The Hospice’s role in Mrs P’s care

34. Mrs M and Ms N said some staff at the Home were not aware the Hospice was supporting Mrs P.
35. As I have said before the Hospice acted in an advisory capacity to support Mrs P at the end of her life. The Hospice told me it frequently communicated with the Home about Mrs P. It cannot say why some staff were unaware of the Hospice.
36. I do not doubt Mrs M and Ms N’s version of events, but I consider, on the balance of probabilities, staff at the Home were aware of the Hospice. The Home and Hospice’s records showed frequent communication between the two organisations when supporting Mrs P. I do not consider that was fault.
37. Mrs M and Ms N said the Hospice CNS missed the opportunity to consider Mrs P for fast-track NHS continuing health care (CHC).
38. I have considered the Hospice and CSH Surrey’s care records for Mrs P.
39. Following discussion with Mrs M and Ms N, the Hospice CNS appropriately referred the query to CSH Surrey, who would have responsible for making the decision about fast-track CSH Surrey.
40. CSH Surrey told me it cannot say why its district nurses did not follow up that request. It said the district nurses could have decided she was not eligible, and due to the pressures of COVID-19, may have missed recording that in Mrs P’s records. I consider CSH Surrey most likely did not follow up the Hospice CNS’s email. That was a missed opportunity, which was fault. I cannot say what the outcome of any assessment for fast-track CHC would have been. However, CSH Surrey’s fault now leaves Mrs M and Ms N uncertain if their mother would have received different support towards the end of her life.
41. CSH Surrey should take further action to remedy the personal injustice Mrs M and Ms N have suffered.
42. Mrs M and Ms N said the Hospice played down its role in its complaint response.
43. In its response, the Hospice clarified that its support to Mrs P was different to what the Hospice’s ‘Hospice at Home Team’ would provide. The Hospice did not provide 24-hour support to Mrs P because she already received that from the Home. Rather it acted in an advisory capacity at the end of Mrs P’s life. However, it apologised for any confusion on that point.
44. I am not persuaded the Hospice played down its role in the complaint response. The Hospice explained its role and apologised if it gave a different impression. I do not consider that was fault.

The Practice’s support for Mrs P’s constipation

45. Mrs M and Ms N say the Oramorph caused Mrs P’s constipation. When the Practice stopped the Laxido sheets, Mrs P’s constipation got worse. They say the Practice should have monitored Mrs P’s constipation.
46. Firstly, I do not consider the Practice acted with fault when it stopped Mrs P’s constipation treatment on 16 December. The Practice said because of Mrs P’s poor swallow, the risk of taking the laxative treatment outweighed the benefit. I consider the Practice appropriately balanced the impact of continuing the laxative treatment despite continuing with the Oramorph.
47. The Home gave Mrs P prune juice to treat her constipation, following advice from the CNS Nurse. The Home agreed to contact the Practice about Mrs P but it did not. As I have said already, that was fault. The Practice were best placed to consider treatment for Mrs P’s constipation then.
48. If the Home had escalated Mrs P, the Practice said it could have prescribed an alternative laxative treatment to be mixed with a thicker solution. However, I cannot say, even on the balance of probabilities, if any alternative laxative treatment would have been recommended by the Practice and/or effective. But the Home still missed an opportunity to escalate concerns to the Practice. That leaves Mrs M and Ms N uncertain if Mrs P could have received support for her constipation after 19 December.
49. The Home should take further action to remedy the personal injustice to Mrs M and Ms N.

Visiting arrangements for Mrs M

50. In December 2020, visiting arrangements in care homes changed due to COVID‑19 lockdown restrictions. This led to care homes introducing restricted visiting arrangements.
51. The Home’s Re-opening to Visitors During COVID-19 Policy and Procedure states: “All visits must be pre-booked by an allocated member of staff and will be by appointment only”. Also, it says: “Visits in exceptional circumstances such as end of life should always be supported and enabled. Families and Service Users should be supported to plan end of life more deliberately, with the assumption that visiting will be enabled to happen not just towards the end of life”.
52. I consider the Home’s Re-opening to Visitors During COVID-19 Policy and Procedure was in line with the Government guidance for care homes – COVID‑19: our actions plan for adult social care. The Government guidance states: “While we have recommended that care homes limit unnecessary visits, we are clear that visits at the end of life are important both for the individual and their loved ones and should continue”. The Home’s guidance appropriately reflected the importance of continuing end-of-life visits despite the impact of COVID-19.
53. Mrs M told me that on 19 December 2020 she could not arrange to visit her mother the next day. She said staff told her the Home Manager was not available to agree a visit.
54. I have considered if the Home followed its own guidance when Mrs M could not arrange a visit to see Mrs P.
55. Firstly, I do not consider, even during COVID-19, it was unreasonable Mrs M wanted to visit Mrs P over consecutive days. Mrs P was toward the end of her life and Mrs M wanted to see her more then. The Home should have tried to accommodate that request.
56. The Home told me it could not explain why Mrs M could not arrange a home visit. I consider, on the balance of probabilities, there was no one present on 19 December to approve a visit for the next day. There should have been someone present on 19 December to agree home visits. Also, I have also not seen any evidence the Home recorded Mrs M’s request or agreed to escalate it. That was poor recording keeping. Overall, I consider the Home acted with fault. That fault meant that Mrs M and Ms N (via video call) most likely missed the opportunity to see their mother the day before she died. While Mrs M saw Mrs P two days before she died, there is no doubt Mrs M and Ms N suffered distress at not seeing their mother the day before she died.
57. The Home should take further action to remedy the personal injustice to Mrs M and Ms N.

The Home’s complaint response

58. The Home received Mrs M and Ms N’s complaint in July 2021. The Home confirmed it had received their complaint a month later. Mrs M and Ms N chased a response in September but the Home never formally responded to their complaint.
59. I consider the Home acted with fault, which would have worsened the distress Mrs M and Ms N had already suffered. The Home has accepted this fault, but it should take action to remedy Mrs M and Ms N’s distress.

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Agreed actions

60. Within four weeks of this decision, the Sisters Hospitallers of the Sacred Heart of Jesus should ensure the Home:
• Apologise to Mrs M and Ms N for the uncertainty caused by not escalating concerns about Mrs P’s pain and constipation to the right organisations.
• Apologise to Mrs M and Ms N for the distress they suffered at not being able to see their mother on 20 December 2020.
• Apologise to Mrs M and Ms N for compounding the distress they suffered during the complaints process.
61. Within eight weeks of this decision, the Sisters Hospitallers of the Sacred Heart of Jesus should ensure the Home:
• Reminds relevant staff of the importance of record keeping and effective communication with other organisations, particularly for service users receiving end of life care.
• Reviews its Re-opening to Visitors During COVID-19 Policy and Procedure to ensure there is always someone present at the Home with authority to consider visit requests from families and service users.
• Reviews its complaints policy to ensure similar mistakes during the complaints process does not happen to others.
62. Within four weeks of this decision, CSH Surrey should apologise to Mrs M and Ms N for the uncertainty caused by not responding to the Hospice’s request to assess Mrs P for fast-track CHC.
63. Within eight weeks of this decision, CSH Surrey should ensure the relevant staff are aware of the importance in following up requests from other professionals.
64. Sisters Hospitallers of the Sacred Heart of Jesus and CSH Surrey should provide evidence they taken the above actions.

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Final decision

65. I have found fault with Sisters Hospitallers of the Sacred Heart of Jesus and CSH Surrey which caused Mrs M and Ms N a personal injustice. I consider the above actions are suitable to remedy their injustice and have now completed my investigation and closed the complaint.
66. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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Investigator's decision on behalf of the Ombudsman