Summary: Mrs Y complains the care home failed to adequately look after her mother-in-law, Ms X, who fell out of bed and suffered an injury that led to her death. Ms X also had a valuable ring which went missing in the care home. We find fault with the care home for not having suitable safety measures in place. We have recommended remedies for the injustice suffered as a result.

The complaint

1. Ms X was staying at Abbeycrest Nursing Home. Her daughter-in-law, Mrs Y, complains Ms X fell out of bed and suffered an injury that led to her death. Mrs Y says when Ms X fell she was left unattended on the floor for five hours.
2. Mrs Y says the care home should have been aware she needed bed guards to prevent falls, or crash mats on the floor by the bed.
3. Mrs Y also says a valuable ring went missing while Ms X was in the care home.
4. Mrs Y wants the outstanding bill of £8,000.00 to be written off, and compensation for the missing ring.

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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 injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)
6. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

7. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
8. 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.
9. 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

10. I spoke with Mrs Y about her complaint and what she wanted to achieve. I asked Abbeycrest Nursing Home questions about the care provided. I considered -
• Ms X’s case records, care plans and risk assessments;
• Complaint correspondence;
• Correspondence relating to the subsequent investigation by Social Services and the Council;
• Relevant legislation and guidance.
11. Mrs Y and the home 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

Legislation and Guidance

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out the fundamental standards those registered to provide care services must achieve.
13. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. It also has power to enforce against breaches of fundamental care standards and prosecute offences.
14. The CQC has issued guidance on how to meet the fundamental standards below which care must never fall. The relevant regulations here are:
15. Regulation 9 on personalised care. The CQC’s guidance on the regulations says:
• “Providers must do everything reasonably practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences, whatever they might be”.
16. Regulation 10 is about dignity and respect. “When people receive care and treatment, all staff must treat them with dignity and respect at all times. This includes staff treating them in a caring and compassionate way.”
17. Regulation 12 is about safe care and treatment. The guidance says:
• “Providers must do all that is reasonably practicable to mitigate risks.
• Staff must follow plans and pathways.”
18. Regulation 15 is about premises and equipment. 15(1)(b) says “Security arrangements must make sure that people are safe while receiving care, including:

• Protecting personal safety, which includes restrictive protection required in relation to the Mental Capacity Act 2005 and Mental Health Act 1983. This includes the use of window restrictors or locks on doors, which are used in a way that protects people using the service when lawful and necessary, but which does not restrict the liberty of other people using the service.
• Protecting personal property and/or money.”

19. A person can have the capacity to make some decisions and not others. Some decisions require them to understand more complex information or weigh up more options than others. For example, a person with dementia may be able to choose between two meal options (fish or stew), but not understand what information is relevant to make a decision about different care and treatment options, such as where to live. 
20. The Deprivation of Liberty Safeguards (DoLS) provide legal protection for service users who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without the authorisation, the deprivation of liberty is unlawful. It is the responsibility of a care home to apply for authorisation.

What happened

Fall

21. Ms X went to Abbeycrest Nursing Home (the home) in February 2021 due to an increase in her care needs.
22. There had been a significant deterioration in Ms X’s health before admission in the home, along with evidence of short-term memory loss. There was a further rapid decline around May 2021.
23. Ms X had a fear of falling and slept in a recliner chair in her bedroom.
24. In early June Ms X developed a pressure ulcer, so the home agreed with the family she should start sleeping in her bed at night.
25. At first she was unhappy about having to sleep in her bed but Ms X did sleep after staff soothed her.
26. The staff would regularly turn her in her sleep to take the pressure off her pressure ulcer and to ensure she did not develop any more.
27. On 16 June 2021 around 1am Ms X was found on the floor next to her bed. The care notes say the emergency bell was pressed and they called an ambulance.
28. Ms X was awake and fully conscious and had a skin tear to the left of her forehead, bleeding to her nose, and a bruise on her thigh.
29. The staff applied a dressing to her forehead and made sure she was comfortable.
30. The ambulance was delayed and the staff were advised not to move Ms X from the floor. The case notes show they chased up the ambulance and kept Ms X warm.
31. The ambulance arrived at 6.36am. The paramedics spoke to Ms X’s daughter over the telephone.
32. Before the accident, both Ms X and her daughter had been clear that she did not want to go to hospital. Ms X’s daughter explained this to the paramedics after Ms X’s fall. The ambulance team explained that this injury may well be the cause of Ms X’s demise.
33. The day after the accident Ms X vomited a little after lunch. Staff told the nurse and called the GP. The GP recommended Ms X should go to hospital for a diagnostic test.
34. The GP said Ms X had the capacity to decide for herself as there was no formal dementia diagnosis in place. With Ms X’s daughter present, in front of the Manager and Deputy Manager of the home, they asked Ms X if she wanted to go to hospital as she was very poorly. She said no.
35. The GP noted this saying they agreed not to have Ms X admitted “as it would unlikely change her management. If she did have an intercranial bleed she would unlikely be a neurosurgical candidate and would be for palliative care anyway.”
36. Mrs Y says Ms X did not open her eyes or talk following the fall. She moaned in pain on their visits and the family asked for her to be given pain killers.
37. The records show that Ms X passed away peacefully in her sleep at 00:05 on 21 June 2021. The home told her family. The cause of death was an intracranial haemorrhage following the fall from her bed.

Ring

38. Ms X took a ring with her into the home as it had high sentimental value. She did not wear it all the time but wanted it with her.
39. The nurse in charge rang Ms X’s daughter to discuss removing the rings from Ms X’s fingers. She said no as this would cause distress to Ms X.
40. Ms X kept the ring in her bedroom in a jewellery box. Her daughter had noticed on her visit on 12 April that she had not seen the ring for some time.
41. Ms X’s daughter asked a member of staff to get the ring. The staff member gave her the box but the ring was not inside. The staff member told the nurse in charge and they both then went to look for the ring.
42. The Home Manager was made aware the ring had gone missing on 23 June. She assembled an urgent staff meeting and was told staff had been looking for the ring since it had been reported previously.
43. On the same day the Site Maintenance Officer conducted another search of Ms X’s room, and it was deep cleaned.
44. On 25 June the Deputy Manager called the police about the missing ring. The officer did not consider this a criminal matter so he did not give a reference number.

Analysis

Fall

45. The home carried out regular Risk Assessments and Care Plans. It was noted when she first moved in that Ms X was at high risk of falls whilst walking.
46. The Risk Assessment on 9 May said Ms X had no falls in the previous year. She had a walking aid, poor balance and fear of falling.
47. The Care Plan of 10 May said Ms X was frightened to sleep in her bed at night, and would get up several times in the night to sleep in her arm chair. The home would carry out monthly risk assessments for falls and hourly checks during the night. Ms X said “I don’t require the use of bed rails or a crash mat”.
48. Ms X had a further Falls Risk Assessment on 10 June. She was now receiving all care in bed. Her score was 8 which is high risk.
49. The Council and Social Services investigation say it was at this point that some measures should have been taken by the home to reduce the risk of falls.
50. After her fall out of bed Ms X had a Bed Rails Assessment on 16 June which said her general condition had declined and she had been nursed in bed for more than a month. Ms X verbally agreed to have the bed rails raised while she was in bed. Her son was visiting and signed the bed rail form.
51. A Mental Capacity Assessment was also carried out on 16 June and a request for DoLS was sent out on the same day.
52. In the complaint response the home says “bedrails are not, and should not, be used as standard in any care facility, and a full assessment must be undertaken before they are used. Fall history and general fall risk should always be taken into consideration before advocating their use, because bedrails themselves always pose the risk of causing injury and entrapment and can also be deemed to be a form of restraint. The use of bedrails should only be considered if fall risk is high and other methods to prevent falls from bed cannot be put into operation.”
53. The home could have taken other measures as explained by the Certified Healthcare Security Supervisor Practitioner in the Social Services investigation, such as lowering the bed to its lowest level and having crash mats available.
54. The bed was positioned in the middle of the room rather than next to a wall.
55. There is no evidence to show the home should have put bed guards up before Ms X fell out of bed, but other safety measures should have been implemented after the Falls Risk Assessment on 10 June 2021, if not before.
56. The investigation by the Council and Social Services both show this to be fault and as a result, learning has been taken by the home around appropriate recording of risk assessments, care plans and communication with families.
57. The home did not have any suitable safety measures in place for Ms X when she was moved to bed care. This lack of effective risk assessment left Ms X at an increased risk of harm and so I find fault with the home. As a result Mrs Y suffered distress.
58. I cannot find fault with the way the home dealt with Ms X after she fell out of bed. Records show she was not left unattended, and the delay was due to the ambulance.

Ring

59. When Ms X moved into the home, the nurse in charge took a property list and photographs of all the jewellery.
60. She asked Ms X’s daughter over the phone to take any expensive jewellery away and was told the only expensive jewellery she had was on her finger and could not be removed.
61. A property disclaimer was signed on admission and a clause included in the signed contract states “The Client should make such arrangements for insurance for belongings brought into the home as she/he considers fit.”
62. The contract also states:

• “Clause 1.5(b) Unless caused by negligence or breach of this Contract, they cannot accept any liability for any property of any nature belonging to the client being lost, mislaid it otherwise damaged.
• Clause 3.7 The Client should make any arrangements for insurance for belongings brought into the Home as they see fit.”

63. At the time the ring was noticed to have gone missing, the Care Plan said Ms X was able to make decisions about her care, put on make up and choose what jewellery she wanted to wear.
64. The home provides a lockable bedside cabinet in every room for the residents to use.
65. The home was Ms X’s home so of course she should be able to have her precious items with her. However the risk of valuables is likely higher than in your own home, so the home advise against keeping it there, or to take out insurance.
66. I therefore cannot find fault with the home for the missing ring.

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Agreed action

67. Within one month of the final decision the home should:
• pay Mrs Y £500 for the distress caused by the identified faults;
• write-off 50% of the outstanding balance of fees for Ms X.

The home should provide us with evidence it has done so.

68. Within six weeks of the final decision, the home should forward details of any service improvements that will be or have been implemented to ensure this does not happen again.

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Final decision

69. I find fault with the home for not having suitable safety measures in place. The fault has caused Mrs Y injustice and I have made recommendations to remedy that injustice.

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Investigator's decision on behalf of the Ombudsman