Summary: Mr X complained about end-of-life care for his mother, Mrs Y, from Jewish Care, Gants Hill Medical Practice, Partnership Of East London Co-Operative, NHS North East London Integrated Care Board and London Ambulance Service NHS Trust. We would likely find fault with the Practice, PELC and ICB if we investigated the complaint. Those organisations have agreed to resolve the complaint by providing a proportionate remedy for the injustice Mr X suffered.

The complaint

1. Mr X complains about the care and support provided to his mother, Mrs Y (deceased) toward the end of her life. Specifically, he complains that:
• Vi & John Rubens House (the Care Home - owned by Jewish Care) and Gants Hill Medical Centre (the Practice) missed symptoms that Mrs Y was nearing the end of her life from September 2022.
• The Practice missed an opportunity to refer Mrs Y for a fast-track continuing healthcare assessment and issue anticipatory end of life medication on 28 December 2022.
• Partnership of East London Co-Operatives (PELC) did not attend Mrs Y for 18 hours between 1 and 2 January 2023.
• NHS North East London Integrated Care Board (the ICB) and London Ambulance Service NHS Trust’s (the Trust) local pathway to obtain end of life medication was not fit for purpose.
• The ICB significantly delayed handling his complaint.
2. Mr X says he suffered distress at witnessing Mrs Y in pain toward the end of this life. He also missed the opportunity to spend more time with his mother because he was trying to find medication. Also, he says the ICB’s complaint handling compounded the distress and anxiety he suffered.
3. Mr X would like the organisations to apologise, change their procedures, and make a financial remedy to reflect the injustice he has suffered.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe it is unlikely we would find fault. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
6. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. I considered evidence provided by Mr X and the organisations as well as relevant law, policy and guidance.
8. Mr X and the organisations 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

Background

9. Mrs Y lived at the Care Home and received Funded Nursing Care (FNC) from the ICB. This is funding provided by the NHS to residential nursing homes that also provide care by registered nurses.
10. On 28 December 2022, the Practice reviewed Mrs Y. The GP noted she looked unwell, and was not eating or drinking, so prescribed liquated antibiotics. The same day, a Nurse Assessor for the ICB reviewed Mrs Y’s FNC package.
11. In the early hours of 1 January 2023, the Care Home considered Mrs Y was nearing the end of her life, so called 111 to request end of life medications. 111 could not find any locally, so asked PELC to visit Mrs Y and prescribe some. By 4.30pm, PELC prescribed the medications.
12. The Care Home tried to obtain the end-of-life medication locally from pharmacies but was not successful due to it being a Bank Holiday.
13. On 2 January, Mr X and a carer drove around trying to obtain the end-of-life medication but again were not successful. In the afternoon, Mr X’s daughter called 999 who sent an ambulance which administered the end-of life medications. By early evening, Mr X had also obtained the medications from a friend who owned a pharmacy. His friend opened the pharmacy specially to dispense them.
14. In the early hours of 4 January, Mrs Y died.

My view

The lack of support for Mrs Y’s health from September 2022

15. In response, the Care Home said it consistently referred Mrs Y to the Practice when necessary. Mrs Y also had weekly GP reviews. The Practice also said it should have provided better support in December 2022, not earlier.
16. I consider I am unlikely to find fault with their actions. The Care Home and Practice have provided robust explanations why it did not consider Mrs Y was at the end of her life earlier than December 2022. Before then, Mrs Y would engage well, and her symptoms could be explained by other causes. Based on this, I do not consider we should investigate this part of Mr X’s complaint further.

The missed opportunity to make a fast-track Continuing Healthcare (CHC) referral in December 2022

17. CHC is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’.
18. The Department of Health and Social Care’s National Framework for NHS Continuing Healthcare and NHS funded Nursing Care (July 2022 (Revised)) (the National Framework) is the key guidance about Continuing Healthcare. It states that where an individual is eligible for Continuing Healthcare funding, the ICB is responsible for care planning, commissioning services and case management.
19. For most people who may be eligible for CHC, the first step in assessment is for a health or social care professional to complete a CHC Checklist, potentially followed by a full multidisciplinary assessment.
20. However, the National Framework allows for an alternative process to be used for a person who has a rapidly deteriorating condition and is considered to be near the end of their life. This is known as the Fast Track Pathway Tool.
21. The Fast Track Pathway replaces the need for a Checklist and full assessment. This is intended to ensure the person receives the care and equipment they need without delay. The National Framework says ICBs should take urgent action to agree and commission a care package and that this should usually be done within 48 Hours of the Fast Track Pathway Tool being completed.
22. I am unlikely to find fault with the Practice. I will explain why.
23. The same day the Practice reviewed Mrs Y (28 December 2022), an ICB Nurse Assessor carried out a review of her FNC package. The nurse could have also made the fast-track CHC referral following that review. So, I do not consider the Practice acted with fault by leaving that decision to the ICB Nurse Assessor. In any event, even if the Practice had made a fast-track CHC referral on 28 December, we likely could not say if Mrs Y would have received the end-of-life medications sooner than she did.

Mrs Y’s end of life care

24. Mr X complains:
• The Practice missed an opportunity to issue anticipatory medication on 28 December
• PELC significantly delayed attending Mrs Y in January 2023; and
• The ICB’s end-of-life medication pathway was not fit for purpose.
25. If we investigated these complaints, it is likely we would find each organisation at fault. Each organisation has accepted their respective faults, which caused Mr X significant distress at the end of his mother’s life. He clearly should not have been trying to obtain the end-of-life medication himself. Mr X should have spent that time with her instead.
26. Mr X told me the organisations had each apologised, but they had not shown learning from their fault. He also felt they should make a symbolic payment to recognise the distress he suffered.
27. I asked the Practice, PELC and ICB how they had improved their services following Mr X’s complaint. They each provided good evidence of learning. I then asked each organisation to consider remedying Mr X’s distress by sharing that learning and making a payment to him to resolve the complaint early. They each agreed to do this.
28. Mr X also complained about the way the Ambulance Trust handled his call on 1 January 2023.
29. I am unlikely to find fault with the Ambulance Trust. I will explain why.
30. The Ambulance Trust said it appropriately acted in line with the local end of life medication pathway. It contacted local palliative care teams to check for stocks of medications, and arrnaged for someone to attend Mrs Y. I agree that was in line with the local policy. However, the ICB was ultimately responsible for ensuring the availability of end-of-life medications locally. So, I would likely find the ICB at fault, as I have said above. Based on this, I do not consider we should investigate the Ambulance Trust further.

The ICB’s complaint handling

31. As I will not be investigating the substance of Mr X’s complaint, I do not consider it would be proportionate to investigate a complaint about how the ICB handled his complaint. Therefore, I will not consider this part of his complaint further.

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Action

32. To their credit the Practice, PELC and ICB have agreed to resolve the complaint. Within four weeks, they should each pay Mr X £200 to recognise the distress he suffered from their respective faults. They should also share evidence with him that they have learnt from this complaint and improved their services.
33. The organisations should provide us with evidence they have complied with the above actions.

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Decision

34. We have upheld Mr X’s complaint about Mrs Y’s end of life care. The Practice, PELC and ICB have agreed to resolve the complaint by providing a proportionate remedy for the injustice caused to Mr X.

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Investigator's decision on behalf of the Ombudsman