Summary: Mrs X complained there were failings in the way staff at the care home dealt with her mother-in-law, Mrs Y, on the day of her death causing uncertainty about the care Mrs Y received and they were unable to be with Mrs Y when she passed away. We found no evidence of fault in the actions of the care home and have completed our investigation.

The complaint

1. Mrs X complains for her mother-in-law Mrs Y there were failings in the way staff at the care home dealt with Mrs Y and her family on the day of her death. Mrs X says this caused the family uncertainty about the Mrs Y received that day and a lost opportunity for them to be with her when she passed away.

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The Ombudsman’s role and powers

2. 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)
3. 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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What I have and have not investigated

4. I have investigated Mrs X’s complaints about the actions of the care home. I have not investigated any concerns Mrs X may have about the action and information provided by a Health Care Organisation (HCO). The HCO provides services to the NHS frontline in the area. This includes urgent and emergency care, primary care, clinical specialist services, out of hours services and NHS 111. As such the Parliamentary Health and Service Ombudsman is responsible for considering any complaints about the HCO.
5. I have included the responses and information from the HCO in this statement to provide background to Mrs X’s complaints.

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How I considered this complaint

6. I considered evidence provided by Mrs X and care home as well as relevant law, policy and guidance.
7. Mrs X and the care home had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What happened in this case

8. What follows is a brief chronology of key events. It does not include all the information I have reviewed during my investigation.
9. Mrs Y was on a pureed diet while at the care home due to medical conditions. Her care plan included being monitored/repositioned by staff every two hours. On the day of Mrs Y’s death, the care home says it provided support in the morning with breakfast and care interventions. There were no concerns reported about Mrs Y. Mr X visited Mrs Y during the morning and again no concerns raised about her presentation.
10. At 12.15 staff went to reposition Mrs Y before lunch but found she had been sick. Staff checked Mrs Y, noted clear airways, and she was alert and responsive. A senior staff member said not to give Mrs Y lunch but fluids and to monitor her during the afternoon. The care home reports Mrs Y was sick again at 17.00 while staff were attending to her. Mrs X remained alert and responsive although seemed chesty and ‘gargly’ at this point. A senior staff member contacted the HCO at 17.16 because of Mrs Y’s presentation and being sick again.
11. The HCO advised a doctor would attend to Mrs Y to provide medical help within two hours and gave staff advice about Mrs Y. Shortly after the call Mrs Y deteriorated so a senior staff member called for an ambulance. The staff member called Mrs X at 17.56 to explain the situation, Mrs Y’s deterioration and if they could attend the care home.
12. Sadly, Mrs Y passed away shortly after the call to Mrs X. The senior staff member called Mrs X to explain about Mrs Y, and Mr and Mrs X arrived at the care home a few minutes later. Staff cancelled the ambulance and were advised to wait for an HCO doctor to attend to certify Mrs Y’s death.
13. The care home says staff spoke to Mr and Mrs X, explained what had happened and offered condolences for Mrs Y’s passing. Staff attended to Mrs Y before Mr and Mrs X saw her. Mr X mentioned he had given Mrs Y a chocolate treat that morning. Staff reported the treat to the doctor when they arrived because Mrs Y was on a pureed diet only. The doctor advised staff to raise a safeguarding concern. Mr and Mrs X were able to spend time with Mrs Y after the HCO doctor completed observations and paperwork.

Mrs X’s complaints to the care home and care provider

14. Mrs X complained to the care home she had not been contacted by them following Mrs Y’s death. Mrs X explained information from staff about calling for a doctor, ambulance and Mrs Y’s sudden deterioration. Mrs X complained staff did not offer condolences about Mrs Y’s passing, she and Mr X were left to feel irrelevant, and did not know what to do. Mrs X asked what personal care Mrs Y received between 13.00 and 17.00 and why they were not called at 17.00.
15. The care home responded and extended condolences again to the family. It explained what had happened that afternoon with Mrs Y placed on 15-minute monitoring after lunch. It explained Mrs Y’s rapid decline after 17.00 and senior staff called for an emergency ambulance.
16. Mrs X complained to the head office of the care home as she remained unhappy with the care home’s response. Mrs X said:
• The care home had not explained why they had not been called at 17.00 so they could be with Mrs Y when she passed away.
• Why staff did not realise how poorly Mrs Y was until checked before 17.00 and call an ambulance then if she was under 15-minute observations.
• Staff inferred family giving her a chocolate treat endangered Mrs Y due to her diet when she had routinely been given such treats. This caused upset to the family.
17. The head office wrote to Mrs X. It agreed with information already sent to them from the care home about events on the day. It apologised for the presentation of response. And said it could understand how queries from staff and doctor would have made them feel about the chocolate treat. But it was something the care staff had to consider. The head office said there was no intention to make them feel uncomfortable and apologised if this was how they felt.
18. Mrs X also complained to the HCO. The HCO said the care home called at 17.00 for end-of-life medication and a call out for Mrs Y. Mrs X said reports from the care home and HCO did not match. Mrs X suggested the care home staff knew Mrs Y was unwell if they were asking for such medication and failed to contact her family until nearly 18.00.
19. The HCO provided a further response and explained two calls made on the day. In the first call at 17.16 care home staff reported Mrs Y had vomited three times and her chest making a wet gargling sound. The doctor at HCO could hear Mrs Y in the background and was concerned. They requested staff checked Mrs Y’s pulse and oxygen levels. And asked about Mrs Y’s RESPECT form (for end of life) which said she did not wish for CPR or hospital admission. The doctor asked if Mrs Y had family and were told of Mr and Mrs X. The doctor advised staff to keep Mrs Y upright. The doctor asked about Mrs Y’s presentation and when informed said Mrs Y was probably dying and they would get the HCO out to the care home as soon as possible.
20. The doctor rang the care home at 17.23 to speak to staff. The doctor advised the care home to ring Mrs Y’s GP surgery to obtain end of life medication so this could be put in place. The doctor advised the staff to say Mrs Y was really poorly and dying, the HCO were attending but the surgery needed to put the medication in place.
21. Mrs X reported Mrs Y’s cause of death was confirmed as heart disease. So considered it unnecessary for the care home to make allegations about the chocolate treat causing the family hurt and distress. Mrs X obtained recordings from HCO of the calls between the care home and HCO on the day Mrs Y died. The recordings confirmed the two calls noted by HCO in its second response to Mrs X.
22. Mrs X’s continuing concerns are:
• They were told care home staff were making 15-minute checks on Mrs Y that afternoon. This suggested staff were aware of the seriousness of Mrs Y’s condition, but still did not contact them until it was too late.
• Care home staff did not contact the family straight away after the HCO doctor said Mrs Y was dying. Mrs X says if so, they could have been at the home before Mrs Y passed away as they lived 10 minutes away.
• The way she and Mr X were made to feel by care home staff after Mrs Y passed away. This was due to a lack of compassion and a safeguarding concern raised about them giving Mrs Y a chocolate treat.

Care Home comments on the complaint

23. The care home says staff were advised to increase monitoring Mrs Y to ‘regularly at a minimum by sight’ after she was sick at lunch time. Mrs Y did not vomit again after lunch and was presenting well. So, staff continued to observe her hourly and provide support with repositioning and any care interventions as needed.
24. The care home confirms it did not put 15-minute observations in place between 13.00 and 17.00. The 15-minute checks were put in place after Mrs Y was sick the second time at 17.00. But due to the input she required there were not 15 minutes between the onset of this and staff calling 999. It says a member of staff stayed with Mrs Y following escalation for an emergency call.
25. The care home says there is therefore no formal record of 15-minute observations from 17.00 as staff recorded all information and timeline in the incident report. If there had not been such a rapid escalation of the situation then staff would have completed 15-minute observation sheets.
26. The care home says it did not fail to mention to Mrs X the telephone call made to the HCO. It confirms the incident form shows the time the contact was made, and the rapid onset of Mrs Y’s deterioration was discussed. At the time the staff could not predict if Mrs Y was at the end of her life. The staff would have had to wait for medical opinions on attending to Mrs Y to deliver this news. And Mrs Y’s condition deteriorated too rapidly to enable this to be the case. The care home says senior staff are not trained clinically and cannot identify Mrs Y’s condition as such.
27. The care home does not consider there were delays in contacting Mrs Y’s family when she began vomiting again and the HCO contacted. Or again when Mrs Y ‘s condition deteriorated, to call 999. It says unfortunately Mrs Y’s deterioration was very rapid in its onset. Staff had to prioritised calling the medical professionals and for medical help before then calling the family. This was how the care home expected staff to prioritise. However, staff did contact the family immediately after each medical call once the senior staff had been given advice and information. Staff called the family again when they felt Mrs Y had passed away.
28. The care home reports multiple staff expressed condolences to the family while they were at the home and extended further condolences in complaint responses. Unfortunately, due to Mr X’s disclosure about giving Mrs Y a chocolate treat staff had to tell the HCO doctor as it could have been key information. Staff also had a duty to disclose it, and the doctor advised to make a safeguarding referral. The referral was later closed without any action. The care home says it responded to Mrs X with an understanding how this may have made them feel and this was regrettable, but it needed to be disclosed. It was not intended to make them feel intentionally uncomfortable. The care home confirmed staff remain supportive to Mr and Mrs X, offered refreshments and to contact funeral directors. However, staff could not remain directly with the family the whole time they were there as they needed to respond to care needs of other residents. And to complete documentation which was time critical.

My assessment

29. The care home has provided records of its monitoring of Mrs Y from the day before and the day Mrs Y passed away. The records of the day and night before show Mrs Y was repositioned and checked about every two hours as required. The records of the day of Mrs Y’s death show again she was monitored about every two hours. The care home says in response to my enquiries Mrs Y was monitored ‘regularly on sight’ in the incident report with no more vomiting episodes until 17.00. Mrs Y was not placed on 15 min observations until after 17.00. However, staff could not do observations due to her presentation and rapidly deteriorating condition. It is clear from the care home’s records there was some monitoring of Mrs Y during the afternoon. But it is unclear when the ‘regularly by sight’ monitoring took place as staff did not record the timing of those observations.
30. It is unfortunate the care home’s response to Mrs X’s complaint was unclear by referring to 15- minute observations between 13.00-17.00 when these were not put in place until after 17.00. However, I am satisfied the care home records show Mrs Y was monitored during the afternoon and no concerns raised about her presentation until after 17.00.
31. It is also unfortunate the HCO’s first response to Mrs X’s complaints referred to the care home seeking end of life medication in the first call. This misled Mrs X into considering the care home was aware how poorly Mrs Y was at 17.00. The evidence shows was not the case. The care home rang at 17.00 to seek advice and help about Mrs Y’s presentation not for end-of-life medication. This was made clear in the HCO’s second response to Mrs X.
32. Mrs X considers the care home failed to call the family, once the HCO doctor said Mrs Y was dying, and left it until nearly 18.00. The care home says it needed the HCO doctor to visit to see Mrs Y to be able to confirm her medical condition as staff not medically trained to do so. I am aware Mrs X considers Mrs Y’s family should have been called at around 17.00. But the care home had to prioritise its care to Mrs Y and seek medical support first as advised by the HCO doctor. This is action which would be expected, and it was also a requirement of the care home for its staff to prioritise the care of a resident. I acknowledge the distress caused to Mr and Mrs X that they were not with Mrs Y when she passed away. But I do not consider there was any undue delay in contacting them and records show care home staff called Mr and Mrs X as soon as they could.
33. The care home’s response shows staff expressed their condolences to Mr and Mrs X on the passing of Mrs Y when they arrived at the care home. And offered support to them however staff were unable to remain with them while they were there due to other commitments. Care home staff were also required to report any safeguarding concerns to the HCO doctor. I am aware this has caused distress to Mr and Mrs X, but I am satisfied from the evidence I have seen there is no evidence of fault in the actions of staff at the care home. This is because the care home staff were required to make such reports.

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Decision

34. I find no fault in the actions of the care home.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman