Summary: Mrs X complained her mother, Mrs T, did not receive proper care at a care home run by The Orders of St John Care Trust which was arranged and paid for by the Council. Mrs X said the care provider did not properly respond to her complaint about the matter and gave confusing accounts. We found the care provider gave conflicting information which caused Mrs X distress. It has already provided an appropriate remedy.

The complaint

1. Mrs X complained her mother, Mrs T, did not receive proper care at the care home run by The Orders of St John Care Trust (the care provider) which was arranged and paid for by the Council. Mrs X said the care provider did not properly respond to her complaint about the matter and gave confusing accounts. Mrs X said the poor care caused her mother to have bed sores, be dehydrated and to die without her family present, which also caused her family distress. Mrs X wants the care provider’s mistakes to be acknowledged and compensation for the distress her mother was caused.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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)
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 read the information Mrs X provided.
6. I considered the information the Council and Care Provider sent in response to my enquiries.
7. Mrs X, the Council and the care provider 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

8. Mrs T had previously lived at home with her husband. Mrs T had two daughters, Mrs X and Ms L.
9. Mrs T had been in hospital after an incident at home. In May 2022 Mrs T was ready to be discharged but needed an assessment of her needs to understand how best to meet them. The Council arranged for Mrs T to be discharged from the hospital to the care provider for an assessment of her needs.
10. The discharge paperwork from the hospital told the care provider Mrs T needed support in all areas of her life and appeared to be confused. It said she could move around using a frame with support of one staff member but was at risk of falls. The form said Mrs T had a history of Alzheimer’s disease and other medical issues. It listed Mrs T’s daughter Ms L as her next of kin.
11. The care provider completed an assessment of Mrs T’s needs. It assessed her as being at low risk from pressure sores. It said she needed assistance from one person to move around, and two people and equipment to reposition her in bed. It provided an airbed mattress for Mrs T to relieve pressure on her skin.
12. The care records show that within a few days of arriving with the care provider Mrs T began spending more time in bed. The care provider ensured that Mrs T was repositioned every four hours to avoid pressure sores.
13. The care provider identified a pressure sore on Mrs T’s sacrum on day 12 of her stay, and on her heel on day 17. It reviewed the risk assessment and assessed Mrs T was at high risk of pressure sores. The care provider arranged for the doctor to visit Mrs T as it appeared her health had deteriorated. The records show the care provider gave Mrs T a heel mat to relieve the pressure, it repositioned Mrs T at a minimum of every four hours. The care provider applied cream and dressings to the pressure sores and they were regularly monitored by the care staff and the nurse was updated.
14. The doctor recommended Mrs T fluid intake was monitored to ensure she was sufficiently hydrated. The records show the care provider was encouraging Mrs T to drink fluids regularly, and was monitoring her intake of liquids in line with the doctor’s advice.
15. The care provider states it asked the doctor to visit Mrs T again on day 24 as she appeared unwell. The doctor prescribed antibiotics for Mrs T and the care provider administered them in line with the prescription. The doctor visited Mrs T again on day 29 but did not suggest any further action was needed.
16. Mrs T died the following morning. The care provider contacted Mrs T’s next of kin, Ms L.
17. Mrs X wrote to the care provider and asked some question about her mother’s care. She asked:
• Why, when she had visited Mrs T the care provider told her to use a toothbrush to wet Mrs T’s mouth when she asked for a sponge?
• Why there was a note on Mrs T’s door specifying how much water she should drink per hour?
• What food and medication Mrs T had been given on the day she died?
18. The care provider responded to Mrs X’s questions and said:
• For patients on end-of-life care a sponge caused an increased risk of choking, so it used a toothbrush instead.
• The notice on the door was because it was monitoring Mrs T’s fluid intake on the doctor’s advice.
• It provided information on the food and medicine Mrs T had on the day she died.
19. Mrs X complained to the care provider. She said no-one informed her Mrs T was on end-of-life care and if she had known she would have stayed with Mrs T so she did not die alone.
20. The care provider responded and said the cause of death recorded on the death certificate was old age, frailty and infection. It said Mrs T was not on end-of-life care and it did not uphold Mrs X’s complaint.
21. Mrs X was dissatisfied with the care provider’s response and asked it to progress her complaint to stage two of its complaint process. Mrs X complained the cause of death provided by the care provider was different to that on the death certificate and the care provider had sent conflicting responses about what had happened. Mrs X wanted to know when Mrs T started to receive end of life care and why she was not notified.
22. The care provider responded and:
• confirmed that it had stopped using sponges for people on end-of-life care as it was a safety risk;
• apologised for the error in its initial response about Mrs T’s cause of death and apologise for upset that may have caused;
• apologised for conflicting information provided in its complaint responses about the use of sponges for end-of-life care; and
• offered a symbolic payment of £150 for the upset and confusion caused to Mrs X
23. Dissatisfied with the care provider’s response Mrs X complained to us.

My findings

Care

24. The care provider assessed Mrs T’s needs based on the information it had available at the time of her arrival from hospital. It completed appropriate risk assessments and the records show the care provided met Mrs T’s needs.
25. When the care provider identified Mrs X had pressure sores because of her decreasing mobility, and was becoming unwell, it took appropriate action to seek medical advice. It then put in place the identified actions and care. It encouraged Mrs T to drink and monitored her intake. I have seen no evidence Mrs T was dehydrated.
26. The care provider could not have known when Mrs T would die and Mrs T was not on an end-of-life care plan. It was therefore not in a position to suggest family stay with Mrs T.
27. There is no evidence of fault in the care provider’s actions.

Complaint response

28. The care provider responded to Mrs X’s questions and subsequent complaints appropriately.
29. The care provider’s response to Mrs X’s question about the use of a sponge referred to people on end-of-life care being at risk of choking as an explanation of why it could not provide Mrs X with a sponge. This led Mrs X to believe her mother was on end-of-life care. The care provider confirmed in its complaint response that was not the case. There is no evidence of fault in the care provider’s actions.
30. In its stage two response, the care provider apologised for the error in its stage one complaint response regarding Mrs T’s cause of death and offered Mrs X £150 to recognise the distress that may have caused her. That was an appropriate remedy for the distress caused to Mrs X and so I have not made any further recommendations.

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Final decision

31. I have completed my investigation. I found fault causing injustice and the Council commissioned care provider has already provided an appropriate remedy for the injustice this caused.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman