Summary: Mrs Y complains about the failures of Lyndhurst Nursing Home during the time it cared for her elderly aunt, Ms T. We find the care provider acted with fault when Ms T suffered a stroke. This caused avoidable distress which the care provider should apologise for and make a symbolic payment of £500 to Mrs Y.

The complaint

1. Mrs Y complains about the standard of care provided to her Aunt, Ms T, before she died. Mrs Y says that carers failed to identify that her Aunt was having a stroke and failed to provide relevant information to the ambulance service meaning they did not attend as quickly as they should have.
2. Mrs Y says the failure of the care provider caused significant distress and uncertainty.

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The Ombudsman’s role and powers

3. 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)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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)
6. If we are satisfied with an organisation’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

7. During my investigation I discussed the complaint with Mrs Y by email and considered any information she provided. I also made enquiries of the care provider and considered its response.
8. I consulted any relevant law, guidance and policies and these are referenced where necessary within this statement.
9. Mrs Y and the care provider had an opportunity to comment on my draft decision. Mrs Y provided comments however the care provider did not respond to confirm that it agreed with our findings and recommended actions.
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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What I found

What should happen

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
12. Regulation 12 of the Health and Social Care Act 2008 sets out the requirement for care and treatment to be provided in a safe way for service users. This says a registered person must, amongst other requirements, do the following:
• assess the risks to the health and safety of service users of receiving the care or treatment;
• do all that is reasonably practicable to mitigate any such risks;
• ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
13. Regulation 17 says providers must, “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided”

What happened

14. At the time of the matters complained about, Ms T lived in a residential nursing home which throughout this statement I will refer to as ‘the home’ or ‘the care provider’. In response to our enquiries the home said that Ms T had a history of dementia and cognitive impairment and was at a high risk of falls. Initially Ms T went into the home in January 2020 for a three-month period of respite, but her stay was extended with the agreement of her relatives. This was due to the onset of the COVID-19 pandemic and associated travel restrictions which prevented her relatives, who live overseas, from travelling to the UK to help Ms T relocate home.
15. In December 2020 Ms T suffered a fall and became unwell. The day after the fall the home called the GP and then 999 for an ambulance. After the paramedics’ intervention, the local safeguarding authority, which I will refer to as ‘the Council’, received a referral from the ambulance service. The referral outlined the service’s concerns about a failure of care staff to seek timely medical attention for Ms T after suffering a stroke.
16. Ms T sadly died as a result of the stroke in January 2021. After Ms T’s death the Council undertook a safeguarding investigation and concluded:

“Based on the information gathered it appears the care staff were not familiar with clients’ needs as well as awareness signs of stroke therefore unable to relay the urgency to [ambulance service] the urgency of the case. However the late delay in the [ambulance service] response to the client’s health needs only added to the client’s further deterioration in her health”.

“Therefore, based on the information on balance of probabilities the allegation of neglect has been substantiated. This is based on the fact the home failed to seek medical attention when it was first noticed that [Ms T] had a ‘facial droop, non-verbal and her right sided weakness’ which are signs of a stroke”

17. The Council further explained its view of the ‘seriousness of the risk’ because, “risk of developing aspiration pneumonia due to being prompted with food/drink/medication after experiencing signs of stroke” and “[Ms T] resided in a home with other residents who are vulnerable and if staff members are not aware of stroke signs and support needs of their residents there is potential health risks to those clients”
18. The Council made the following recommendations of the home:
• staff at the home to be trained about stroke/symptoms. 
• staff to have a better understanding of client care and support needs. 
• the Council to continue monitoring staff training within the home.
19. In addition to reviewing the safeguarding papers, we also made enquiries of the care provider to gather more information about the events leading up to Ms T’s admission to hospital. In summary, the care provider said:
• Ms T received all the care she needed during her stay at the home. She did not experience any falls and her skin integrity remained good.
• Ms T was sometimes tearful and asked to go home.
• During her stay, Ms T’s relatives did not raise any concerns. They were given updates of her health and condition.
• The Nurse in charge on the day of Ms T’s admission to hospital acted professionally and called the ambulance. She sought appropriate advice from the manager of the home when the ambulance was delayed.
• The home considers the timeliness of the ambulance caused Ms T’s condition to worsen.
20. Mrs Y has provided an alternative account of events with supporting evidence. These documents show that:
• Ms T suffered an unwitnessed fall in April 2020 and sustained an injury to the back of her head which required stitching. This is documented in medical records obtained by Mrs Y. Ms T fell again on the day before her admission to hospital in December 2020.
• Ms T sometimes had poor skin integrity. In September 2020 Ms T had a bed sore managed by care staff. The medical records show Ms T’s GP made a referral to the Tissue Viability Nurse.
• Ms T’s insulin was not always under control. Medical records from August and September 2020 show concerns about Ms T’s blood sugars possibly caused by her recent weight loss. The records show that Ms T’s medication was then adjusted accordingly.
21. Mrs Y says that family members were not informed by the home about any of the above incidents.
22. We asked the care provider to send us copies of Ms T’s contemporaneous care records, including her care plan, daily care records and details of any contact with Ms T’s GP. We also asked the care provider to comment on the assertion that staff members continued to offer food and fluids to Ms T despite there being signs of stroke.
23. In addition, we also asked the care provider to share any policies or guidance which staff refer to when managing and responding to service users who display signs of a stroke.
24. The care provider did not share this information with the LGSCO.

Was there fault by the care provider causing injustice to Mrs Y and Ms T?

25. The care provider did not engage with the LGSCO’s investigation and has given only a short summary of events in response to our enquiries. This summary was not supported by any evidence. The absence of accurate and contemporaneous records in respect of Ms T is fault.
26. However, we do have the benefit of the Council’s safeguarding papers which provide an overview of events following a thorough safeguarding investigation. During the investigation the Council reviewed records from the home, gathered information from the GP, ambulance service and a medical professional who gave their view about Ms T’s prognosis. We have also reviewed the medical records provided by Mrs Y.
27. The safeguarding investigation substantiated the allegation of neglect and reached the conclusion quoted in paragraph 16 of this statement.
28. In my view, and based on the information available to us, I uphold Mrs Y’s complaint. Although the LGSCO has not had sight of the care records, I am satisfied the Council has reviewed the relevant files and I am confident the finding of substantiated is evidence-based and one which the LGSCO can rely upon.
29. We find staff at the home failed to identify the signs of stroke and did not relay that Ms T had possibly suffered a stroke when they called 999. This was despite Ms T presenting as sleepy and having one-sided weakness after having fallen over the day before and hitting her head.
30. Furthermore, the safeguarding investigation found that staff members gave 400ml of fluid to Ms T whilst waiting for the ambulance, which placed her at significant risk of Aspiration Pneumonia. This demonstrated that some staff did not have adequate knowledge around managing the signs and symptoms of stroke.
31. Although the care provider is critical of the ambulance service, we are not investigating their actions. I am only considering the actions of the care provider because Mrs Y has chosen not to make a complaint about the ambulance service. The actions I have recommended are to remedy the effects of the care provider’s role in the events complained about.
32. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment.
33. However, if we consider the person who has complained to us has been adversely affected by the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress. When deciding upon an appropriate remedy, I took into consideration the actions which the Council completed as listed in paragraph 17 of this statement. With this in mind, I decided it was not necessary to recommend any service improvements.

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Recommended action

34. Within four weeks of my final decision, we said the care provider should apologise in writing to Mrs Y. However, Mrs Y has since confirmed that she does not wish to receive an apology from the care provider and so the LGSCO will not seek compliance with this part of the remedy.
35. The care provider should make a symbolic payment of £500 to Mrs Y for the distress and uncertainty caused by the failures identified in this statement. We will seek compliance with this part of the remedy within four weeks of the final decision.
36. At the time of writing this final decision, the care provider has not confirmed its agreement to carry out the actions we have recommended.

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Final decision

37. We have completed our investigation with a finding of fault causing injustice for the reasons explained in this statement. The actions we have recommended are an appropriate remedy for the injustice caused.

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Investigator's decision on behalf of the Ombudsman