Summary: Mrs X complained the care home failed to provide adequate care for an illness her mother Mrs Y was suffering from, during her respite stay. Mrs X said Mrs Y suffered unnecessarily during her stay and subsequently died. We do not find fault with the care providers actions.

The complaint

1. Mrs X complained the care home failed to provide adequate care for her mother Mrs Y, during her respite stay for 3 weeks in 2021. Mrs X said the care provider failed to identify an illness Mrs Y was suffering from. Mrs X states Mrs Y suffered unnecessarily during her stay and subsequently died. Mrs X would like the care home to review its procedures.

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The Ombudsman’s role and powers

2. 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. (Local Government Act 1974, sections 34B and 34C)
3. We may investigate complaints from a person affected by the matter in the complaint, or from someone the person has authorised in writing to act for him or her. If the person has died or cannot authorise someone to act, we may investigate a complaint from a personal representative or from someone we consider suitable to represent the person affected. (section 26A or 34C, Local Government Act 1974)
4. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
5. 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

6. I have considered:
• the information Mrs X provided, including digital messages between her and other family members and discussed the complaint with her on the telephone;
• the care providers comments about the complaint and the supporting documents including records from the care provider in response to my enquiries; and
• relevant law and guidance.
7. Mrs X and the care provider had the opportunity to comment on the draft decision. We considered their comments before making a final decision.

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What I found

Relevant law and guidance

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 provides fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
9. Regulation 12 states care and treatment must be provided in a safe way and prevent avoidable harm or risks. It states the care provider must assess health and safety risks and do all they can to mitigate any risks. This also includes management of medicines.
10. Regulation 14 sets out people must have adequate nutrition and hydration to sustain good health. It states people must be provided with appropriate food and drink and any support they may need to achieve adequate nutrition.

Urinary Tract Infection

11. The NHS states a urinary tract infection (UTI) is an infection of the urinary tract including bladder, urethra or kidneys. The symptoms of a UTI may include blood in the urine, increased incontinence, a high temperature or low temperature and changes in behaviour such as agitation.

What happened

12. In 2021, Mrs X arranged respite care for Mrs Y at the care provider’s care home for three weeks. Prior to this Mrs Y had been living at home with her husband who looked after her.
13. Mrs X provided information to the care provider as part of Mrs Y’s pre-admission assessment. The pre-admission assessment recorded Mrs Y:
• was prone to urine infections if she did not drink enough fluid and staff would need to be mindful of a change in behaviour;
• wore incontinence pads day and night;
• had mobility problems; and
• had a decline in short term memory and confusion.
14. The care provider produced Mrs Y’s care plan. It outlined Mrs Y’s needs and how it would meet those needs. The documents outlined Mrs Y:
• had no diagnosis of a cognitive impairment but had increased confusion and decline in short term memory;
• could make simple day to day decisions;
• needed full help with her personal care needs;
• was prone to urine infections. Mrs Y was reluctant to drink and worried about her poor mobility and her ability to get to the toilet. Mrs Y required encouragement to drink fluids;
• had a fluid target 1500 millilitres in a 24 hour period; and
• had a poor appetite and needed encouragement to eat;
15. The care provider’s records show Mrs Y’s weight and temperature remained stable during her 3 week stay at the care home.
16. The care provider’s fluid intake chart showed Mrs Y drank between 1300 millilitres and 1800 millilitres of fluid each day. Although on one day she drank less at 880ml.
17. Mrs Y’s daily care records showed throughout her stay Mrs Y was generally in a good mood with agitation recorded on one occasion when she was upset and asked for her husband. She ate and drank well.
18. The care provider’s food intake chart showed on most days Mrs Y ate her breakfast, a small lunch and small tea, she rarely had supper or snacks.
19. Three days after Mrs X entered the care home the family messaged each other and said:
• 'she is getting more and more confused but I also believe that she has another water infection, which could be causing her shouty, sweary manner. Late on Sunday she said her wee was hot and burning, it looked dark and smelled very strongly'; and
• 'spoke to one of the carers about water infection, GP going in there tomorrow so going to take a sample'.
20. Mrs Y was discharged from the care home by her family after eight days. Mrs Y’s husband looked after her for 24 hours but could not cope due to his own health problems. Mrs Y returned to the care home the day after she was discharged.
21. In the first two weeks of Mrs Y’s respite stay Mrs X said she and other family members raised concerns three times with the care home manager about Mrs Y’s confused state. They asked the care home to take a urine sample.
22. The care provider said it held no record of any conversation with Mrs Y’s family about their concerns over a urine infection in the first two weeks of her stay.
23. In early October 2021 a family member said to Mrs X in a digital message: ‘been asking about water infection ever since she went in, they better not put if off any longer’.
24. The care provider said in the third week of Mrs Y’s stay it recorded a telephone conversation with Mrs X. It said Mrs X asked the care home manager to take a urine sample. The same day the care home took a urine sample. The next day the urine sample was hand delivered to the GP surgery. The day after the care home received antibiotics. The medication administration records logged Mrs Y took the one dose sachet of antibiotics the following day.
25. Two days after Mrs Y had the antibiotics, Mrs X and her family were very concerned about Mrs Y’s health including increased confusion and tiredness. They took Mrs Y out of the care home and back to her own home. The following day the family called an ambulance and Mrs Y was admitted to hospital. Three days later Mrs Y passed away.
26. Two weeks after Mrs Y passed away, Mrs X made a formal complaint to the care provider. She complained:
• the death certificate confirmed Mrs Y had died of sepsis caused by a urine infection;
• during the first week of Mrs Y’s stay her family raised concerns with the care home manager about Mrs Y’s confusion which was often a sign of a urine infection. Mrs X asked the care provider to take a urine sample. This concern was raised on later visits by other family members;
• the GP did not visit Mrs Y about a possible urine infection;
• the urine sample was not taken for another two weeks; and
• Mrs Y took the antibiotics and was extremely confused. Six days later she died.
27. The care provider asked staff to complete a questionnaire in response to the complaint. The questionnaires filled in by care home staff showed no staff recalled any comments Mrs X or other family members had about concerns over a urine infection or Mrs Y’s increased confusion.
28. The care provider responded to the concerns raised by Mrs X. It said:
• the care home did not have any records of Mrs X or other family members raising concerns of a urine infection in the first two weeks of her stay;
• in the third week of Mrs Y’s stay the care home manager spoke to Mrs X on the telephone. Mrs X raised concerns of a urine infection. The care home noted the conversation, took a urine sample from Mrs Y, acquired and administered the antibiotics within a four day period;
• there were no recordings of behavioural change whilst Mrs Y was at the care home;
• the care home could not measure Mrs Y’s tiredness retrospectively but said she was often sleepy during the day which also occurred before admission to the care home; and
• the antibiotics had been prescribed so Mrs Y was not seen by a health care practitioner or doctor.
29. A day after receiving the care provider’s response Mrs X requested her complaint be escalated. Mrs X was not satisfied with the response received to the following points:
• delay in getting the urine sample and antibiotics;
• no records of conversations raising concerns in the first two weeks about a urine infection and Mrs Y’s increased confusion; and
• Mrs Y was confused and in a sleepy state at the end of her stay.
30. The care provider responded two weeks later. The care provider said:
• they had nothing further to add about the delay in getting the urine sample and antibiotics;
• they gave a summary of Mrs Y’s diet, fluid intake, engagement and temperature records in Mrs Y’s final week at the care home; and
• there was no evidence of increased confusion or tiredness above the levels on admission.
31. Mrs X then complained to the Ombudsman. Mrs X said it was not true Mrs Y was happy and settled for her respite stay.

My findings

32. The care home records show a thorough assessment was undertaken when Mrs Y entered the care home. The care provider was aware of Mrs Y being prone to urine infections, which could cause a change in her behaviour. This was also recorded in Mrs Y’s care plan.
33. The care plan recorded Mrs Y had a decline in short term memory and was confused. The care provider said Mrs Y was confused and suffered from tiredness from her admission but she was generally content with agitated behaviour recorded only once in her care notes. The fluid charts show Mrs Y was drinking an appropriate amount of fluid and was passing urine, without blood. The food charts showed Mrs Y ate regularly and her weight remained stable during her stay. The care plan showed Mrs Y had a temperature between 35.1 and 36.3 degrees Celsius during her stay which remained stable throughout.
34. The records of Mrs Y’s diet, symptoms and behaviour do not suggest the care provider should have acted differently in the first two weeks of her stay. The care provider did take a urine sample and administered the prescribed antibiotics in the third week after concerns were raised by Mrs X and recorded by the care provider. There is no evidence of fault by the care provider.
35. Mrs X provided digital messages to indicate she and other family members spoke to care home staff early in Mrs Y’s stay regarding her confusion and the need to take a urine sample. The care provider does not have any record of these conversations. Staff also completed questionnaires in response to the complaint and did not recall this being raised. I cannot resolve the conflict between what the care provider’s records say and the messages exchanged between Mrs X’s family members. I do not know exactly what was said to staff and who it was said to. So I cannot, even on the balance of probabilities, make a finding on whether care staff should have taken action sooner.

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Final decision

36. I have completed my investigation finding no fault by the care provider’s actions.

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Investigator's decision on behalf of the Ombudsman