Summary: Mrs D’s family complained that the care home where Mrs D was staying, refused to call an ambulance when Mrs D was unwell and that the care home stopped the family from visiting Mrs D in the days before her admission to hospital. They said that Mrs D had not eaten or drunk anything in the 4 days before her admission to the hospital. We have not found fault.

The complaint

1. Ms B and Mrs C are Mrs D’s daughter and granddaughter. The complaint relates to Oakleigh Residential Care Home in Swadlincote, Leicestershire.
2. Ms B and Mrs C complain that the Home would not call an ambulance for Mrs D on 27 February 2023 and the ambulance crew was not given Mrs D’s medication administration record (MAR) chart. They say that Mrs D was dehydrated when she attended hospital as she had not eaten or drunk for 4 days before her admission.

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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 how the organisation made its decision, 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 have discussed the complaint with Ms B and Mrs C. I have considered the evidence that they and the Council have sent, the relevant law, guidance and policies and the responses to the draft decision.

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What I found

Law, guidance and policies

6. The Care Quality Commission (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.
7. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The CQC has guidance on how to meet the fundamental standards which says:
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• The care and treatment must be provided in a safe way for service users. (regulation 12).
• The nutritional and hydration needs of the service user must be met. Where a person is assessed as needing a specific diet, this must be provided in line with that assessment (regulation 14).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17)

What happened.

8. Mrs D is an older woman who has dementia, a mental health condition and physical health conditions. She moved to the Home in November 2020. She was prescribed medication, including lithium, to manage her mental health condition.

Ms B and Mrs C’s complaint

9. I have summarised the complaint and the response provided by the Home.
10. Ms B and Mrs C said:
• They visited Mrs D on 27 February 2023. The Home had advised them not to visit Mrs D in the three days before the visit.
• When they visited Mrs D, she was slumped in her chair, with vomit on her front. She was unable to speak and confused. They said Mrs D was dehydrated and the manager told them that Mrs D had not been eating or drinking for 4 days.
• The Home had not sought medical advice for Mrs D in the previous days and did not agree that Mrs D needed medical attention urgently. The family called an ambulance and Mrs D was taken to hospital. The family said Mrs D was diagnosed with dehydration and lithium toxicity.
• The Home did not provide the ambulance crew with Mrs D’s MAR chart.
• In the past, the Home stopped them from visiting Mrs D in her bedroom and insisted that visits took place in the dining room.
• They gave £60 spending money to the Home every 5 weeks but were never given any records on how the money was spent.

The Home’s response

11. The Home’s manager said:
• She checked Mrs D’s paperwork. Mrs D had vomited over the weekend but her food and fluid intake was sufficient. Mrs D did not show signs of dehydration.
• On 27 February 2023, Mrs D had toast, marmalade and tea for breakfast. Mrs D was sick one time during the morning and staff changed her clothing. She ate her lunch which consisted of a baked potato, cheese and a banana. Ms B and Mrs C arrived at 13:45. Staff asked Mrs D what she wanted to drink and she said she wanted a banana milkshake. She drank a little of the shake. Staff said Mrs D was clean at this stage. She wore a black sweatshirt and was given a protective apron while she had her drink.
• The manager said she never told the family that Mrs D had not eaten or drunk for 4 days.
• The manager said that Ms B came to her office twice to say that Mrs C wanted to call an ambulance but Ms B disagreed that an ambulance should be called. The manager went to speak to Ms B and Mrs C. She said that, as there was no change in Mrs D’s behaviour, routine and no acute deterioration, she suggested ringing the Clinical Hub for advice and a visit. Both Ms B and Mrs C agreed to this proposal.
• The manager rang the Clinical Hub. (The Clinical Hub is an NHS department within the emergency operations centres. They assess patients over the phone and determine the best course of action.)
• The manager explained the situation to the Clinical Hub. The Clinical Hub’s call handler also spoke to Mrs D directly and asked questions to rule out the possibility of a stroke. The call handler ruled out a stroke and said a visit would be arranged later that day.
• The manager went home later in the afternoon but received a text from Mrs C in early evening saying that Mrs D had been sick a lot and wanted to know whether the staff could ring an ambulance. The manager responded and said the family could ring an ambulance but reminded them that a medic was coming.

The safeguarding enquiry

12. The Council carried out a safeguarding enquiry into the family’s complaint. The Council had also received a referral from the ambulance service. The enquiry related to concerns that Mrs D had not eaten or drunk for 4 days before she went to hospital and that the Home had not sought medical assistance.
13. The social worker noted the following in the enquiry report. The social worker spoke to the staff nurse at the hospital. The records showed the ambulance was called because Mrs D was in her chair, had slurred speech and left sided weakness. The hospital carried out a CT scan as there were concerns that Mrs D had suffered a stroke, but a stroke was ruled out. Mrs D was subsequently treated for ‘hypothyroidism, hypercalcaemia and high lithium’.
14. The social worker asked why Mrs D was given a drip in her arm at the hospital. The social worker said the family had told her that Mrs D was extremely dehydrated on admission to hospital and this had caused an acute kidney injury. The nurse reviewed the records and said there was no record of this.
15. The social worker said the Home did not keep a separate nutritional intake record for Mrs D. The Home’s manager said there had been no need as nutritional intake was not a problem for Mrs D. The social worker said nutritional intake records could be improved, including recording nutritional intake as a matter of course.
16. The social worker noted the involvement of medical services with Mrs D in the weeks before the hospital admission because of Mrs D’s vomiting.
17. The social worker noted that the Home had rung the Clinical Hub on 27 February 2023 and obtained medical advice and was acting on that advice. The Clinical Hub had said that a medic would visit Mrs D within 6 hours.
18. The social worker also addressed the referral from the ambulance service. She noted that most of the concerns the ambulance service raised were based on information provided by the family. This included information that Mrs D had not eaten or drunk for 4 days and that the Home had not involved medical services. The social worker noted that Mrs D had been eating and drinking in the days before and the day of admission to hospital and that the Home had involved medical services and was waiting for the medic to arrive.
19. The Council closed the safeguarding enquiry on 7 March 2023 and said the concerns had not been substantiated.

Further information

20. Mrs D’s care plan said that one of the side effects from the medication that Mrs D took to manage her mental health condition was vomiting. Mrs D also had a separate medical condition which caused vertigo (a sensation that the room is spinning causing problems with balance) and vomiting.
21. The care plan said Mrs D was independent in eating and drinking and had no specific dietary needs. The Home weighed Mrs D monthly and her BMI was in the overweight category.
22. The Home did not keep a separate food and liquid intake record but recorded this on the daily records. I have checked Mrs D’s intake in the 4 days before and on 27 February 2023:
• 23 February 2023 - Mrs D had her breakfast, a cup of tea and another hot drink in the morning. She ate her lunch, dinner and two bananas. She was sick once in the afternoon.
• 24 February 2023 - Mrs D ate her breakfast and lunch. She ate a small supper and was sick twice in the afternoon.
• 25 February 2023 - Mrs D had breakfast and lunch. She was sick a few times in the afternoon, but had sips of squash and some soup and later a hot drink.
• 26 February 2023 - Mrs D ate breakfast and a little lunch. She did not eat very much in the afternoon and was sick several times during the day.
• 27 February 2023 - Mrs D ate breakfast and a hot drink at 10:00 am. She ate a jacket potato with cheese and half a banana for lunch. She was sick in the morning and 4 times in the afternoon.
23. The Home obtained medical advice on the following days:
• 6 February 2023 – The Home contacted the Clinical Hub to inform them of Mrs D’s vomiting. A doctor visited and said all observations were normal and the vomiting may be linked to Mrs D’s vertigo.
• 8 February 2023 – A lithium blood test was carried out.
• 15 February 2023 – The Home contacted the advanced nurse practitioner (ANP) at the GP’s office and informed them that Mrs D’s vomiting had increased. The nurse said a visit by the doctor would be scheduled. The blood test showed that the lithium levels were normal.
• 22 February 2023 – The Home spoke to the ANP about Mrs D’s vomiting. The ANP and the doctor had a discussion and changed Mrs D’s medication to see if this would help. The Home asked whether the visit by the doctor could be rescheduled for earlier.
• 25 February 2023 – Mrs D started her new medication. The pharmacist said it may take some time for the new medication to take effect.
• 27 February 2023 – The Home called the Clinical Hub. They said a medic would visit and assess Mrs D.
24. Mrs D’s hospital discharge documents said that she had lithium toxicity and hypercalcaemia. The hospital liaised with the Mental Health Services regarding ‘the recommencement of lithium.’ (I therefore presume the lithium was stopped when Mrs D was admitted to hospital). The Mental Health Services advised the hospital not to restart lithium and to give Ms B a different medication instead. The discharge sheet also showed that some of the other medications that Ms B took were either reduced or stopped.
25. The Home responded to the complaint about the Home providing the MAR chart to the ambulance crew. The Home said staff tried to print a copy of Mrs D’s MAR chart on 27 February 2023 but its printer was not working. This caused a short delay and the ambulance crew was given the original MAR chart.
26. The Home responded to the complaint that the family had not been allowed to visit Mrs D in the days before the hospital admission. The Home said visiting restrictions had been in place during the COVID-19 pandemic but those restrictions had been removed. Families often still rang to find out what would be a good time to visit. For example, lunch times were busy so families were discouraged to visit during those times. Visits were never denied, but families were sometimes advised that a resident was not well so it may not be a good time to visit.
27. The Home said they did not receive any communications regarding a visit between 24 and 27 February except for the request for the visit on 27 February which took place.
28. The Home responded to the complaint that the Home said the family could not visit Mrs D in the bedroom. The Home said that there were restrictions on visits during the COVID-19 pandemic which said that contact should take place in designated areas but these had been lifted.
29. The Home responded to the complaint that the family gave Mrs D spending money and the Home had never told them what the money was spent on. The Home said the family had never asked for this information but it could have provided it. I asked the Home to send me evidence on how the money was spent for the months of January and February 2023. The Home sent me a spreadsheet and evidence relating to the expenditure (hairdresser and chiropodist).

Analysis

30. The records showed there were continuing issues with Mrs D’s vomiting in the days before 27 February. I note the Home had involved medical services in the days beforehand and was following medical advice. Mrs D’s medications were changed on 25 February 2023 in the hope that this would address the vomiting. Therefore I cannot say there was fault in the Home’s actions in the days before 27 February.
31. The Home contacted the Clinical Hub on 27 February 2023. The Clinical Hub was not of the view that Mrs D’s presentation was so severe that she needed an ambulance. The Clinical Hub said that a medic would visit Mrs D in 6 hours. Therefore, I note that the Home was acting on the medical advice it was given.
32. Then, later in the afternoon, Mrs D vomited again several times and the family wanted to call an ambulance rather than wait for the medic to arrive. The family rang the Home’s manager who was not at the Home at the time. The manager reminded Ms B and Mrs C that the medic would attend, but said they could ring an ambulance. I find no fault in that advice.
33. The family also complained that Mrs D had not eaten or drunk in 4 days. I have not found evidence to support that. There is evidence that Mrs D ate and drank in the 4 days before the ambulance arrived and on 27 February 2023.
34. In terms of the record keeping of intake of nutrition and liquids, I note that there was no requirement to keep a separate record of Mrs D’s intake as there was no concerns about Mrs D’s eating or drinking. I also note that a record of the intake was kept in the daily records. However, I agree it would have been good practice to keep a more detailed separate record in the days when Mrs D’s vomiting had increased.
35. There is no evidence, however, from the Council’s safeguarding enquiry that Mrs D was dehydrated on admission to hospital.
36. In terms of the visiting, I find no evidence that the family was not allowed to visit Mrs D in the days before 27 February 2023 or that restrictions were placed on visiting once the COVID-19 pandemic restrictions were lifted.
37. In terms of the complaint that the Home had not provided information on what Mrs D’s money was spent on, I note the family had not asked this before. I asked the Home to give information on what the money was spent on in January and February 2023 and find no concerns in that respect.

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Final decision

38. I have completed my investigation and have not found fault by the Council.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman