Summary: Mrs X complained about how a Care Provider acting on the Council's behalf cared for her late father, Mr Y. The Care Provider has accepted its laundry service was not adequate. This caused Mrs X distress. It has apologised to Mrs X and put suitable improvements in place to prevent the fault occurring again. The Council was not at fault in the other matters Mrs X complained about.

The complaint

1. Mrs X complained about how a Care Provider acting on behalf of the Council cared for her late father, Mr Y. She said it was neglectful and led to Mr Y’s death. She said the failings caused her stress, upset and frustration. Specifically, Mrs X complained:
1. the Care Provider did not take the need to monitor Mr Y’s calcium levels seriously or ensure he receive the full dose of his calcium tablets;
2. the Care Provider did not take a stool sample requested by Mr Y’s GP;
3. the Care Provider did not take the swelling in Mr Y’s hands, face and legs seriously or act on it promptly despite her raising concerns;
4. she found Mr Y on several occasions in bed with his windows closed and his room smelling of urine;
5. Mr Y’s clothes kept going missing and some of his clothes were stained;
6. Mr Y’s room was too small;
7. Mr Y was given soup to eat every day even though he refused to eat it;
8. Mr Y was dehydrated and the Care Provider failed to monitor his fluid intake;
9. she had to chase the Care Provider to arrange Mr Y’s COVID-19 booster vaccine and it failed to tell her Mr Y had become ill after receiving it;
10. Mr Y was distressed and unwell during one of her visits. He was wearing thick socks on a hot day, wearing a lunch bib well after lunch and there was no clean laundry in his room;
11. the Care Provider did not help Mr Y with his discomfort with his catheter or check for a urinary tract infection (UTI);
12. Mr Y was later admitted to hospital after removing his catheter on his own. On admission he was found to have low calcium and potassium levels, low blood pressure and a UTI which led to sepsis and his death;
13. she saw a resident sitting outside in the sun without suncream or hat on;
14. the Care Provider did not try to improve residents’ quality of life;
15. the staff to resident ratio was too low;
16. there was never a pen to sign in and out of the Care Provider, which she felt was unsafe; and
17. the staff were disinterested; she saw them on mobile phones in the corridor.

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What I have and have not investigated

2. I have investigated points (a) to (l). I have not investigated points (m) to (q) because the Ombudsman considers complaints where there is an allegation of personal injustice. We are not a regulatory body and do not carry out overall reviews of services; that is for the Care Quality Commission. In addition, the Care Provider responded to points (m) to (q) as follows:
1. Staff offered residents sunscreen and advice on wearing hats but could not force them to use either.
2. The Care Provider offered a range of activities and staff took care to engage residents in conversation or hobbies. It could not force residents to take part if they did not want to.
3. The staff to resident ratio was at the level required to meet the relevant regulation and residents’ needs.
4. Government guidance recommended care homes remove communal use pens to prevent the spread of COVID-19. In addition, a sign in book does not comply with GDPR regulations. Staff keep a separate record of visitors for safety reasons.
5. Staff use handheld devices to make care records; they appear similar to mobile phones so is likely what Mrs X saw. Staff are not allowed to make personal calls while on duty. It had reminded staff of this in case any had been using their phones.
3. Further consideration of these issues would not result in a different outcome.

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The Ombudsman’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. 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)
5. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide there is not enough evidence of fault to justify investigating. (Local Government Act 1974, section 24A(6))
6. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

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How I considered this complaint

7. I have considered:
1. all the information Mrs X provided and discussed the complaint with her; and
2. the Care Provider’s complaint response and the supporting documents the Council provided.
8. Mrs X and the organisation 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

What happened

9. Mr Y moved into the Care Home in late March 2022 following a period in hospital. The stay was intended to be short term until Mr Y was well enough to return home with a package of care. Mr Y had capacity to make decisions about his own care and wellbeing.
10. In late June, Mr Y was admitted to hospital where he died shortly after. Mrs X said Mr Y died of sepsis resulting from a UTI.

Complaint to the Care Provider

11. Mrs X complained to the Care Provider in July. Her complaint and the Care Provider’s response are set out below:
1. The Care Provider did not take the need to monitor Mr Y’s calcium levels seriously or properly administer his calcium tablets. She said the tablet sunk to the bottom of the cup of water they were meant to be dissolved in.

The Care Provider said the Care Home was not a nursing home so did not have staff on site to take blood tests to check Mr Y’s calcium level. It was only able to act on the instructions of Mr Y’s GP and the district nurse. It passed her concerns about Mr Y’s calcium levels to medical professionals.

2. The Care Provider did not take a stool sample requested by Mr Y’s GP after Mr Y’s stools were seen to contain blood while he was in hospital.

The Care Provider said after his discharge from hospital, Mr Y moved to a new GP. That GP did not request a stool sample and instead wanted to monitor Mr Y’s condition with blood tests.

3. The Care Provider did not take the swelling in Mr Y’s hands, face and legs seriously or act on it promptly despite her repeatedly raising concerns.

The Care Provider said staff made referrals to medical professionals for advice on Mr Y’s swelling. Mr Y was seen by a GP on ten occasions during his stay.

4. She found Mr Y on several occasions in bed with his windows closed and his room smelling of urine.

The Care Provider said Mr Y’s bedroom windows should have been open if Mr Y wanted them to be; staff said that they were open most of the time. Mr Y tended to empty his catheter bag onto the floor and staff were not always able to stop him in time. It said it had cleaned the floor, but it was hard to eliminate the urine smell. It said it was nonetheless sorry Mr Y lived in those conditions.

5. Mr Y’s clothes kept going missing and some of his clothes were dirty and stained. She also said she found him with his clothes only part way put on his body.

The Care Provider accepted its laundry system had not worked properly. Mr Y’s clothes should not have gone missing, for which it was sorry. It said it had identified it needed to have clearer labelling of residents’ clothing and that staff needed to take more care to ensure residents’ clothes were properly sorted so they were not mixed up. It also reminded staff that clothes needed to be properly cleaned, stains removed as much as possible and that clothes needed to be properly fitted to the person. The Care Provider said it would monitor this during checks on the Home.

6. Mr Y’s room was too small.

The Care Provider said Mr Y had the smallest room by coincidence. The Home was full so it was not possible to move him but had he remained at the home longer it would have tried to move him when a room became available.

7. Mr Y was given soup to eat every day even though he refused to eat it.

The Care Provider said staff gave residents a choice of options of what to eat each day. It said it had no record that Mr Y complained about what he was eating and that he ate reasonably well.

8. Mr Y was dehydrated and the Care Provider failed to monitor his fluid intake.

Mr Y was at low risk for dehydration so it did not closely monitor his fluid intake. Nonetheless staff would have encouraged Mr Y to drink and he would have always had access to water.

9. She had to chase the Care Provider to arrange Mr Y’s COVID-19 booster vaccine and it failed to tell her Mr Y had become ill after receiving it.

The Care Provider said it had no influence over when Mr Y received his COVID-19 booster vaccine; this was administered by the NHS. Mr Y’s condition after the vaccine was not serious so it did not think it was necessary to contact Mr Y’s next of kin; Mrs X’s sister.

10. Mr Y was distressed and unwell during one of her visits. He was wearing thick socks on a hot day, wearing a lunch bib well after lunch and there was no clean laundry in his room.

The Care Provider said Mr Y may have chosen to wear thick socks. He was likely wearing the lunch bib in preparation for afternoon tea and biscuits because he could sometimes spill his food and drink. The Care Provider said it assumed there were no clean clothes because staff were doing Mr Y’s laundry.

11. The Care Provider did not help Mr Y with his discomfort with his catheter or check for a urinary tract infection (UTI). Mr Y was later admitted to hospital after removing his catheter on his own. On admission he was found to have low calcium and potassium levels, low blood pressure and a UTI which led to sepsis and his death.

The Care Provider said staff would have monitored Mr Y’s catheter every day. The District Nurse also visited him four times to check it and clean it if needed. Mr Y removed his catheter towards the end of his stay in the Care Home (late May 2022). The same day staff called the district nurse, who told staff to monitor Mr Y and she visited the following day to try and reinsert the catheter. The Nurse was unable to do so and advised staff to call for an ambulance to take Mr Y to hospital. It said catheters increased the risk of infection but there was no evidence of one before Mr Y removed his catheter.

Response to the Ombudsman

12. I have reviewed records of Mr Y’s care. They were detailed and support the Care Provider’s response to Mrs X’s complaint.
13. In terms of Mr Y’s catheter care, records confirm staff helped Mr Y every day. They also show that in late March, staff had concerns Mr Y developed a UTI because he had started to pass little urine. They called the district nurse, who visited the same day and confirmed Mr Y was passing urine well and not in pain.
14. When Mr Y removed his catheter in late May, staff promptly asked the district nurse to visit. She was not able to attend until the following day but in the meantime, staff continued to monitor Mr Y’s urine output. He was initially able to pass urine but the amount he was passing reduced overnight. As a result, staff chased up the appointment. The records confirm that once the district nurse visited and failed to reinsert the catheter, staff requested an ambulance on her advice. There are no records to confirm Mr Y was experiencing a UTI at that time.
15. Mr Y reported one of his hands was swollen and felt heavy in early April. In response to a previous draft decision, the Care Provider said staff did not observe any swelling on Mr Y’s hand at the time or subsequently. It also said Mr Y did not report discomfort in his hand after raising it in April.
16. Nonetheless, a care worker took a photograph of the hand and told a senior member of staff. A record from a few days later asked staff to observe Mr Y’s hands and if they were swollen, call the GP. Mr Y was later seen by a GP in late April and early May. The Care Provider told me a senior member of staff was in the room when the doctor visited in late April and confirmed Mr Y spoke about his hand. The early May visit related to nose bleeds Mr Y had been experiencing due to an infection.
17. In late May Mrs X asked the Care Provider to call Mr Y’s GP about the swelling. The records note that by that time, Mr Y’s “face and hands appears puffy”. Mrs X says swelling was also visible on his legs and fluid was leaking from his skin. The GP requested blood tests and later prescribed Mr Y medication to manage fluid retention. The GP continued to visit Mr Y regularly to monitor his condition.

Findings

Calcium levels and tablets

1. Mrs X said the Care Provider failed to properly monitor Mr Y’s calcium levels through blood tests. The staff at the Care Home are not medically trained; it is not for them to carry out blood tests or decide when such tests are necessary. It can only act on the advice of medical professionals and it says it passed Mrs X’s concerns on to them. The Care Provider was not at fault.
2. Mrs X also complained Mr Y’s calcium tablets were left at the bottom of his cup of water which meant he did not get the full dose. I will not be able to reliably confirm if this was the case, or how frequently it happened so I will not investigate this matter further.

b) Stool sample

20. The Care Provider has explained Mr Y’s new GP decided to monitor the blood in his stool through blood tests. It was appropriate for the Care Provider to act on that advice, so it was not at fault.

c) Swelling

21. Mr Y first reported a feeling of heaviness and swelling in his hand in early April. The Care Provider acted appropriately at that time, by taking a photo of the hand, alerting a senior member of staff and telling other staff to monitor Mr X’s hand for any signs of swelling. Staff did not notice any. The Care Provider has explained that during one GP’s visit Mr Y raised his concerns about his hand. During the other visit in early May, the GP looked at Mr Y’s nose and so presumably would have identified any swelling in his face if it had developed by then.
22. When, in late May, Mrs X visited and noticed the swelling in Mr Y’s face, hands and legs, she asked the Care Provider to contact Mr Y’s GP. It did so without delay. The GP then started to treat Mr Y’s condition and continued to check on it. On balance, I am satisfied the Care Provider acted without fault to monitor Mr Y’s condition and to seek prompt medical advice when the swelling justified it. It was not at fault.

d) Windows closed and room smelling of urine

23. Based on the information available to me, I will not be able to say if Mr Y asked for his windows to be closed regularly. However, I note Mr Y had capacity to make decisions about his day to day life. He was able to decide if he wanted his windows opened or closed.
24. The Care Provider has explained it tried to remove the smell of urine in the room, caused by Mr Y emptying his catheter bag onto the floor. It said it had been hard to eliminate the smell entirely and apologised. The Care Provider took the action we would expect so it was not at fault.

e) Missing and stained clothes and improperly dressed

25. The Care Provider has accepted it was at fault in how it managed its laundry system and that this meant Mr Y’s clothes sometimes went missing and some had stains on them. This caused Mrs X distress. The Care Provider apologised, which suitably remedies the injustice Mrs X experienced. It also identified steps to take to prevent the fault occurring again, including reminding staff to take more care sorting residents’ clothing and carrying out monitoring. I am satisfied the action the Care Provider has identified is appropriate to prevent the fault occurring again.

f) Size of Mr Y’s bedroom

26. Mrs X feels Mr Y’s bedroom was too small. The Care Provider explained it did not have any other available rooms for Mr Y when he moved into the Care Home or during his stay. The Care Provider was not at fault.

g) Choice of food

27. The Care Provider’s complaint response said Mr Y had a choice of foods each day and it had no record he complained about the food. This is supported by the care records, which show he had a variety of meals throughout his stay. The Care Provider was not at fault.

h) Fluid intake

28. Mrs X complained the Care Provider did not properly monitor Mr Y’s fluid intake. Care Providers typically only closely monitor fluid intake for residents who are at risk of dehydration. That was not the case for Mr Y. In any event, records show Mr Y had access to, and consumed, drinks throughout the day during his stay in the Care Home. The Care Provider was not at fault.

i) COVID-19 booster vaccine

29. The NHS is responsible for deciding when people receive the COVID-19 booster vaccine. Mrs X was keen Mr Y could receive the vaccine promptly, but this was not within the Care Provider’s powers.
30. Many people experienced a short period of discomfort after the COVID-19 vaccines and this was often stronger in older people. Mr Y became briefly unwell after his vaccine and the Care Provider explained his symptoms were not significant enough to justify contacting his family. The care records do not note any concerns about Mr Y’s wellbeing in the days after the vaccine so I am satisfied the Care Provider was not at fault for not contacting Mrs X or other members of Mr Y’s family.

j) Visit where Mrs X says Mr Y was distressed

31. Mrs X said that on one visit Mr Y was distressed, wearing a food bib late in the day, wearing thick socks unsuitable for the weather and had no clean clothes in his bedroom. The Care Provider has explained Mr Y was likely wearing a bib in preparation for afternoon tea and had capacity to decide to wear thick socks so may have asked to do so. It also said Mr Y’s clothes were likely being washed. The Care Provider’s explanation was feasible and, on the evidence available to me, I will not be able to say exactly what happened on the day of the visit. I therefore will not investigate this issue further.

k) Catheter care and UTI

32. Mrs X says the Care Provider did not provide Mr Y with adequate catheter care or check for UTI’s. She feels this was neglectful and led to Mr Y’s death from sepsis resulting from a UTI.
33. The Ombudsman is not able to make judgements on whether care providers have been neglectful. In addition, UTI’s can develop very quickly and older people are at increased risk of them, particularly if they have a catheter inserted. We expect care providers to provide appropriate catheter care day to day and to act promptly to seek medical advice when they identify symptoms that indicate a UTI. We then expect them to act on that advice without delay.
34. Records show staff supported Mr Y with his catheter every day and arranged for the district nurse to visit him when they had concerns or if it needed cleaning. After Mr Y removed his catheter towards the end of his stay in the home, staff quickly contacted the local district nurse to request an appointment; this was appropriate action. When Mr Y’s urine output dropped, staff chased up the visit from the district nurse and when she arrived, promptly acted on her advice to call an ambulance. The Care Provider acted as we would expect so it was not at fault.

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Final decision

35. I have completed my investigation. I have found evidence of fault, which the Care Provider acting on behalf of the Council has already remedied appropriately.

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Investigator's decision on behalf of the Ombudsman