Summary: Mrs Y complains the Care Provider did not put proper safeguarding measures in place to protect Mrs X. Mrs Y says this caused her Mrs X physical harm, and meant she died sooner than expected. The Ombudsman finds the Care Provider at fault, which caused Mrs X and Mrs Y injustice. The Care Provider has agreed to apologise to Mrs Y and make a service improvement.

The complaint

1. Mrs Y complains the Care Provider did not put proper safeguarding measures in place to protect Mrs X.
2. Mrs Y says this caused her Mrs X physical harm, and meant she died sooner than expected. Mrs Y says this caused avoidable and unnecessary distress and uncertainty to her and her wider family.

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The Ombudsman’s role and powers

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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How I considered this complaint

4. I considered the information and documents provided by Ms X and the Care Provider. Ms X and the Care Provider had an opportunity to comment on my draft decision. I considered all comments received before making this final decision.
5. I also considered the relevant statutory guidance, and Care Provider’s policy, as set out below.
6. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

What should have happened

7. 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.
8. 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 must be provided in a safe way for service users (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
9. The Care Provider’s bed rails policy states risk assessments should be:
• Reviewed and documented after any significant change in the Resident's condition or needs which include a reduction or improvement in weight, and/or a reduction or improvement in mobility
• Reviewed and documented after any change of equipment for the Resident
• Reviewed as a minimum, monthly. Frequency will vary depending on the Resident and their circumstances.
10. The Care Provider’s bed rails policy states risk assessments should consider:
• How likely is it that the Resident would fall from their bed
• If likely, are bed rails an appropriate solution or could the risk of falling from the bed be reduced by means other than bed rails
• Could the use of a bed rail increase risks to the Resident's physical or clinical condition
• How likely is it that the Resident may attempt to climb over the bed rails
• Has the Resident used bed rails before? Do they have a history of falling from bed, or conversely of climbing over bed rails
• What are the Resident’s views on using bed rails
• What configuration of bed, mattress and rail system is being used
• Are other devices being used, which could increase risk, such as lateral turning devices

What happened

11. Mrs X lived in a care home. Her bed did not have rails.
12. In late 2023, Mrs X had several falls. The Care Provider completed a falls risk assessment which scored Mrs X as a very high risk of falls. It documented Mrs X had an alert mat by the side of her bed to alert staff if she got out of bed. It recorded Mrs X now needed staff to help her move around the care home.
13. In early 2024, medical staff put Mrs X on end-of-life care. She remained in the care home. That day Mrs Y visited Mrs X and told staff Mrs X was rolling onto her right side, close to the edge of the bed. The Care Provider records show staff moved her to her left side. It recorded Mrs X’s behaviour as erratic. She was given strong pain relief medication and a medication to ease anxiety. The possible side effects of the medication included restlessness and disorientation.
14. That night, Mrs X fell out of bed. She was taken to hospital to treat her injuries. The paramedics completed a safeguarding referral because she did not have safety rails on her bed. The Care Provider recorded an accident log.
15. The day after her fall, Mrs X returned to the care home. That morning the Care Provider completed a bed rails risk assessment and a falls risk assessment. It scored her as a very high risk of falls. It decided she required rails to be added to her bed. It recorded she was now bedbound. Mrs X died later the same day.

Analysis

16. Mrs X had several falls and reduced mobility in the months before she died. The Care Provider’s bed rail policy says it should complete a new bed rail risk assessment when there is a significant change to a residents’ mobility. The Care Provider did not complete a bed rail risk assessment following Mrs X’s reduction in mobility. This is fault.
17. Three days before she died, Mrs X began receiving end of life care. This was a significant change in Mrs X’s condition. The Care Provider’s bed rail policy says it should complete a new bed rail risk assessment when there is a significant change to a residents’ condition. The Care Provider should have completed another bed rails assessment at this point. This is fault.
18. The evening before her fall, the Care Provider recorded that Mrs X presented as agitated. This is a significant change in Mrs X’s condition. It also recorded she had been provided with medication she had not taken before. The possible side effects of this medication include restlessness and disorientation.
19. The Care Provider completed a bed rails assessment when Mrs X was discharged from hospital following her final fall. The assessment details Mrs X’s history of falls and falls out of bed. The assessment concluded she required bed rails. I am satisfied if the Care Provider completed the assessment at an earlier opportunity, it is likely the assessor would have reached the same conclusion.
20. I am satisfied that, on balance, if Mrs X had bed rails fitted it is less likely she would have fallen out of bed. The fall caused Mrs X physical harm and significant distress. Her injury needed hospital treatment, and so her last days were spent visiting hospital, rather than remaining in the familiar care home setting. It is not possible to know whether Mrs X’s final fall caused her to die sooner than she would have if the fall had not occurred. In any case, this has caused Mrs Y and Mrs X’s family avoidable and unnecessary uncertainty and significant distress.

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Action

21. Within four weeks of my final decision, the Care Provider has agreed to:
1. provide a written apology to Mrs Y and her wider family for unnecessary and avoidable uncertainty and distress caused by not following its bed rail policy, which meant it did not complete a bed rails assessment when it should have.
2. tell us what steps it will take to ensure its staff are properly trained in its bed rail policy. It will also provide this information to Mrs Y as part of its apology letter, so she can see how things have improved as a result of her complaint.
22. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
23. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

24. I find fault causing injustice. The Care Provider will apologise and make a service improvement.

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Investigator's decision on behalf of the Ombudsman