Summary: Mr F complained on behalf of his late father about the care provided at Lyndhurst Rest Home on the day he died. We found no fault in the care provided but there was fault with complaint handling for which the Care Provider has now apologised.

The complaint

1. Mr F complained on behalf of his late father, Mr J, about the care provided at Lyndhurst Rest Home. In particular, he complained that the care provider failed to:
• Take preventative measures to reduce the possibility of his father developing deep vein thrombosis.
• Seek medical attention when his condition deteriorated on the night he died.
• Deal with his complaint properly.
2. This has caused the family significant distress, frustration and uncertainty that more could have been done for their father.

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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. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
6. We may investigate a complaint on behalf of someone who has died. 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)

7. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
8. 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

9. I spoke to Mr F about his complaint and considered the information he sent, including a video of Mr J and the care provider’s response to my enquiries.
10. Mr F 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

Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Person-centred care (Regulation 9): The service user must have care or treatment that is tailored and meets their needs and preferences. Providers must involve a person acting on the service user’s behalf in the planning of their care and treatment.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety. The provider must have arrangements to take appropriate action if there is a clinical or medical emergency.
• Complaints (Regulation 16): The provider must have a system in place to handle and respond to complaints.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

What happened

12. Mr J was in his 80s, had dementia and used a wheelchair. He had been assessed as not having capacity to make decisions about his care. He moved into Lyndhurst Rest Home (“the Home”) in July 2023. His son, Mr F, had lasting power of attorney for health and welfare. He placed a CCTV camera in Mr J’s room.
13. Mr J’s care plan says a GP or 999 should be called if he stopped breathing. There is reference to high blood pressure, for which Mr J was on medication, but no reference to a risk of developing a blood clot or deep vein thrombosis.
14. In September 2023, Mr J saw a district nurse due to a wound on his arm. The daily records from 6 to 11 October show that Mr J received personal care, medication and was eating and drinking. He spent some time in the Home’s lounge and also went out with Mr F. The records do not show any concerns about his health. He was checked hourly during the night of 10 October.
15. On 10 October Mr J saw a mental health consultant. There was a discussion about his being sleepy and whether this was caused by the medication he was on. The doctor said she would request a blood test. Mr F asked for Mr J’s medication to be reviewed by the GP.
16. At around midnight on the night of 11 October, a carer checked on Mr J and found he was not breathing. An ambulance was called and the paramedics found that Mr J had sadly passed away.
17. The Home called Mr F four times in the early hours of 12 October but he did not pick up so messages were left. The police contacted Mr F that morning. Mr J’s cause of death was later determined to be a pulmonary embolus due to a deep vein thrombosis.

Mr F’s complaint

18. Mr F reviewed the CCTV footage from the night his father died. He considered it showed that, when carers were getting Mr J ready for bed, he was breathing in an irregular manner as if suffering shortness of breath. In addition he had made a noise which suggested he may have been in pain or discomfort.
19. On 5 December, Mr F asked the Home for its policy on prevention of DVTs, the daily records for the week before Mr J died and the records of phone calls made to the family on 12 October.
20. In January, the Home asked Mr F for a copy of Mr J’s will to determine who his legal representative was and asked why he required the records. Mr F replied on 9 January that he had concerns that indications of a DVT were missed and that staff had made unnecessary phone calls and left inappropriate voicemails.
21. The Home said Mr F would need to speak to the doctor about Mr J’s health. It had provided training to the member of staff who had made the phone calls. Mr F came to the Ombudsman.

My findings

22. Mr J’s care plan does not state that he was at risk of developing a blood clot, nor have I seen medical records indicating this. I would therefore not expect the Home to have had specific actions in place for Mr J. The Home does not have a specific policy on blood clots but this is not fault as I would expect the Home to follow guidance from health professionals.
23. The Home’s pressure sore prevention policy says people, especially those using wheelchairs, should be monitored for skin lesions and any concerns reported to a nurse. A district nurse was caring for a wound Mr J had on his arm during September but I have seen no evidence that he had any pressure sores which required re-positioning.
24. The Home’s policy on what to do if a person’s condition deteriorates says that shortness of breath could be a reason to raise concerns with a manager or a GP.
25. I have reviewed the video of the night of 11 October. Whilst it does show Mr J’s breathing to be heavy, in response to my enquiries the carers gave statements saying they had had no concerns about Mr J’s health when he went to bed. In addition, the daily records in the days prior to Mr J’s death do not show any concerns about his condition. Mr F queried why the carers checked on Mr J at midnight and felt this may indicate they were more concerned than usual. However, the records show he had been checked throughout the night the night before, so I do not find it was unusual.
26. My view is that there was insufficient indication that Mr J’s health was deteriorating to require the Home to seek medical advice or to escalate any concerns on 11 October.
27. I find the Home’s response to Mr F’s concerns of 9 January 2024 to be insufficient as a complaint response. It should have followed its complaint policy to investigate and provide a full response within 28 days. Instead it advised Mr F to contact the doctor. This was fault which caused Mr F the time and trouble of having to come to the Ombudsman to have his complaint investigated.

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Agreed action

28. Within a month of my final decision, the Care Provider should apologise to Mr F for not dealing with his complaint properly.
29. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

30. There was fault by the Care Provider. The actions the Care Provider has agreed to take remedy the injustice caused. I have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman