Summary: Mr X complained about the care Barchester Healthcare Homes Limited (the Care Provider) provided to Mr Y at the end of his life. He says this caused them both significant distress. We find the Care Provider was not at fault in most of the issues he complained about, but it did cause significant distress when Mr Y’s bed crashed down unintentionally. We recommended the Care Provider apologise, check all beds for similar risks, and put in place a strategy to avoid similar incidents in future. It agreed to do this.

The complaint

1. Mr X complained on behalf of his father Mr Y. He said that Barchester Healthcare Homes Limited (the Care Provider) failed to ensure Mr Y was comfortable while during end of life care. Mr X says this caused significant distress to both Mr X and Mr Y.
2. Mr X says the Care Provider did not have enough staff when Mr Y was at the end of life. He also complained that Mr Y had been cold because the heating had broken down over the last few months, and that a member of staff caused Mr Y’s bed to crash down.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
4. 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

5. I considered information from both Mr X and the Care Provider.
6. Mr X and the Care Provider had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

7. Mr Y had life limiting health conditions which affected his mobility. He was frail.
8. One evening, in mid March 2022, a few months after Mr Y moved to Harper Fields, he fell in his room. He had fallen several times over the previous two weeks. The Care Provider telephoned for an ambulance and let Mr X know. The ambulance service advised there would be a four to six hour wait for a paramedic to arrive. The Care Provider’s response to the situation was appropriate, and it had no control over the delay. Eventually, a paramedic arrived and discussed, with Mr X, whether it would be best for Mr Y to stay at Harper Fields or go to the hospital. They agreed the best option would be for him to stay at the home as he would be more comfortable there. The paramedic advised Mr X that Mr Y had developed a problem with his speech; he could only speak a few words repeatedly.
9. Mr Y’s condition worsened throughout the day. He became restless and Mr X says he was “clearly in pain”. The Care Provider telephoned Mr X to advise him to visit as it believed Mr Y to be at the end of life. It also called a doctor, who did not arrive for some hours. Again, the Care Provider’s actions were appropriate, and the delay was something over which it had no control. The doctor gave Mr Y morphine and advised that he would settle in around 20 minutes. Mr X says this was not the case and he became more restless and uncomfortable, crying out in pain. The doctor handed Mr Y a prescription for more morphine before she left which he then took to the pharmacy. Mr X says he felt he was expected to collect the prescription, though the Care Provider says Mr X offered to do this and it would have done so if he had not.
10. The Care Provider tried to contact the doctor again due to concern that Mr Y had not settled as expected but was told the case was closed and to call NHS 111. There was a one hour wait to get through; the Care Provider’s actions here were also appropriate and it had no control over the delay. A member of staff tried to lower Mr Y’s bed but it became stuck on a wall socket although this was not apparent at the time. When she tried to pull the bed away from the wall, it crashed down and Mr Y cried out. Mr X recognises this was an accident but it was distressing for them both and should not have happened. The Care Provider initially did not comment on this in its response to his complaint but apologised in a later response.
11. Mr X says for the last two hours of Mr Y’s life, he watched him struggle and cry out in pain knowing there was no more help. He says this was “truly horrific”. Mr X called for help when he realised Mr Y was passing away and a nurse came and confirmed this. The nurse called a colleague and she also confirmed this. Mr Y sadly died around 24 hours after the fall.
12. Mr X complained that Mr Y did not receive the correct medication. Records show that the GP prescribed morphine sulphate which could be given four hourly if needed. Mr Y received one dose in the GP’s presence and sadly died around three hours after this. The Care Provider was not responsible for the medication or dosage. I found no fault in this.
13. In his letter of complaint to the Care Provider, Mr X said while he was “very pleased with the majority of [Mr Y’s] care throughout his time at Harper Fields, the manner of his death is extremely concerning and raises a number of serious issues.”. Mr X was also concerned that the Care Provider had not prevented Mr Y’s falls. However, Mr X recognised that Mr Y was frail, unwell and stubborn. He would not use the call bell to call for support when he wanted to get up. I found the Care Provider had taken appropriate actions to reduce the risk of falls as far as possible. It was also not responsible for the delays around attendance of a paramedic and a GP. I found no indication that there were insufficient staff. When Mr X called for help, a staff member arrived and then called another who also arrived promptly. I found no fault here.
14. Mr Y complained about the temperature in Mr Y’s room, he says a staff member told him the heating had broken down. The Care Provider said there had been no breakdown and advised that Mr Y felt very cold because of his poor health. It says it provided blankets and increased the heating in his room. In response to my enquiries, the Care Provider supplied details of room temperature monitoring while Mr Y was resident. The recorded temperatures did not indicate any problem with the heating. Bedroom temperatures for older people should be 18 degrees minimum and all temperatures were above that. I found no evidence of injustice here.
15. The Care Provider did cause injustice to Mr Y and Mr X when the bed crashed to the floor. This should not have happened, although I accept this was an accident. This caused Mr Y and Mr X significant undue distress and an increased risk of harm to Mr Y. However, unfortunately, we cannot now remedy this injustice to Mr Y. The Care Provider has since completed a full bed assessment in the home.

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Agreed action

16. To remedy the injustice identified above, the Care Provider agreed to, within one month of my final decision:
• Provide Mr Y with a further written apology for the incident with the bed, setting out the actions it has taken, or will take, to avoid similar incidents in future.
• Check all beds for similar risks and put in place a strategy to avoid similar incidents business wide, in future.
17. The Care Provider has agreed to these actions and should provide us with evidence it has complied with the above actions.

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Final decision

18. I have completed my investigation. The agreed actions will remedy the injustice caused as far as possible.

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Investigator's decision on behalf of the Ombudsman