Summary: Ms X complained that a Council-commissioned residential Care Home failed to act when she told it her late mother, Mrs C, needed medical treatment. She also complained the Care Home did not keep proper records and had poor internal communication. She said Mrs C may not have died if the Care Home had acted on her concerns. We found the Care Home failed to seek appropriate medical advice and keep proper records. This fault caused Ms X uncertainty for which the Council has agreed to apologise and make a symbolic payment to her.

The complaint

1. Ms X complained about care commissioned by the Council which her late mother, Mrs C, received at Woodlea (the Care Home) owned by Trust Care Ltd (the Care Provider). Ms X said she told care staff Mrs C likely had an infection but the staff did not check her symptoms or seek advice from a medical professional. Mrs C was admitted to hospital the following day, where she died soon after. Ms X says if the Care Home staff had acted sooner, Mrs C may not have died.
2. Ms X also complains the Care Home failed to keep accurate records and did not share any concerns about Mrs C during a handover.
3. Ms X wants the Care Home to make changes to prevent this from happening to others in the future.

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The Ombudsman’s role and powers

4. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
5. We normally name care homes and other care 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)
6. 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 the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
7. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
8. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. 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)

9. 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(1), as amended)
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

11. I considered evidence provided by Ms X, her representative, the Care Provider and the Council. I also considered relevant law, policy and guidance.
12. Ms X, her representative, the Council and the Care Provider 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

Relevant law and guidance

Fundamental standards of care

13. 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 which care must never fall below. The following standards are relevant to this complaint:

• Regulation 12 requires care providers to provide care and treatment in a safe way, by assessing and mitigating risks to the health and safety of residents and working with health professionals to ensure the health and welfare of residents.
• Regulation 17 requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.

The Care Provider’s policies and procedures

14. The Care Provider has a policy for residents with catheters. It says:

• staff must monitor residents daily for signs of infection, such as a fever or pain in the lower abdomen or back;
• if staff identify any symptoms of an infection, they should immediately notify a nurse or GP; and,
• staff should record all observations, symptoms and actions taken in the resident’s care notes.

What happened

15. The following is a summary of the key background relevant to my decision. It does not include everything that happened during Mrs C’s stay in the Care Home.

The events leading up to Mrs C’s hospital admission

16. Mrs C was admitted to the Care Home in 2023. She had a catheter in place to manage her toileting needs.
17. In February 2025 Ms X visited Mrs C in the Care Home in the early afternoon. During the visit, Mrs C told Ms X she was in pain and suspected she had a urinary tract infection. Mrs C complained to Ms X that staff had not done anything about her concerns.
18. Ms X told care staff Mrs C suspected she had a urinary tract infection. Ms X says she reported it to three separate staff members in a half an hour period. Ms X then left the Care Home later in the afternoon.
19. Mrs C’s care notes did not have a record of any concerns about a possible infection being reported to staff.
20. In the evening care staff recorded on Mrs C’s care notes that she said she was in pain. The notes for the rest of the evening said Mrs C then ate some food, chatted with a staff member and went to sleep.
21. Mrs C’s care notes did not record any other concerns for the rest of that day. There were no records of Mrs C’s observations, such as temperature or blood pressure.
22. Ms X returned to the Care Home the next morning. She said she overheard staff at morning handover describing Mrs C as being ‘okay’. Ms X challenged this comment and said Mrs C could not be okay if she was in pain the day before.
23. Ms X checked on Mrs C. Mrs C was showing signs of being in pain, so Ms X went to tell care staff.
24. Mrs C’s care notes said:

• Mrs C was showing signs of pain and was not responding. Care staff took Mrs C’s observations such as temperature and blood pressure and then rang a medical professional for advice;
• the medical professional called an ambulance for Mrs C because they suspected she may be in sepsis due to her symptoms;
• the ambulance took Mrs C to hospital.

25. Mrs C died in hospital a month later.

Ms X’s complaint and the Care Provider’s response

26. Ms X’s representative, Miss G, complained to the Care Provider. Miss G was also a relative of Mrs C. She complained staff failed to act on Ms X’s concerns about Mrs C’s condition the night before she was admitted to hospital. She said Mrs C was fit and well before this incident and that she may not have died if the Care Home had rang a doctor for advice when Ms X first raised concerns.
27. The Care Provider replied to Miss G’s complaint. It said:

• staff did not check Mrs C’s temperature the same day Ms X reported her concerns as would be expected;
• although it accepted Ms X did tell staff members about her concerns, Mrs C’s care notes did not record her concerns about a potential infection,;
• although Mrs C’s signs of discomfort were not continuous, staff should have contacted a doctor or community nurse for advice once they were aware Mrs C was in pain; and
• the failure to record Ms X’s concerns on the care notes meant care staff were not aware of this information at the morning handover, which is why it was not raised.

28. The Care Provider said it would reflect on the lessons learnt from this incident and would make changes to improve its service and prevent similar incidents in the future. It created an action plan which included the following actions:

• provide relevant training for staff;
• remind staff of procedures to follow when an infection is suspected;
• remind staff of the importance of accurate record-keeping; and
• complete reflections with senior staff to discuss what actions to take to prevent similar incidents in the future.

Analysis

Observations

29. The Care Home staff did not take Mrs C’s temperature or check any other observations when Ms X first reported concerns that she may have an infection.
30. The Care Home’s policy says staff should monitor residents with a catheter daily for signs of infection and record all observations. Therefore, not checking Mrs C’s observations, when told about a possible infection was fault.
31. This failure to take Mrs C’s observations in response to Ms X’s concerns possibly put her at risk of harm which could have been avoided, which was an injustice to Mrs C.
32. The lack of observations also caused Ms X uncertainty. She was left wondering if Mrs C’s infection may have been identified and treated earlier if staff had taken her temperature sooner.
33. The Care Provider told us that, in response to this failing, it has provided training for senior staff on catheter management and reminded staff of the importance of following up on concerns about possible infections.

Record-keeping

34. Mrs C’s care notes did not record Ms X’s concerns about a possible infection. Failure to keep accurate records was fault by the Care Home. The notes potentially breached Regulation 17 of the fundamental standards of care which says that care providers should ensure internal records are correct and accessible to staff to allow them to deliver people’s care in a way that keeps them safe.
35. This fault resulted in concerns not being communicated by staff at the morning handover, because they were not aware of them. This, again, possibly put Mrs C at risk of avoidable harm and prolonged distress.
36. This fault further increased Ms X’s distress. She overheard staff describing Mrs C as being ‘okay’ which upset her because she felt care staff were not acting on her concerns or providing Mrs C with the treatment she needed.
37. In its complaint response, the Care Provider explained to Ms X the reason staff did not take Mrs C’s observations or record Ms X’s concerns was because they had assumed Mrs C’s pain was caused by a different medical issue. It told her it accepted that staff should have recorded the concern about a possible urinary tract infection and they should have taken Mrs C’s observations.
38. In response to our enquiries, the Care Provider told us it has since reminded staff of the importance of accurate record keeping. It said it has changed its handover process so that it is more structured and includes staff confirming information on a patient’s care record.

Medical advice

39. The Care Provider’s policy says staff should contact a doctor or community nurse if they suspect a resident may have an infection. When Ms X first reported that Mrs C may have an infection, the Care Home staff did not seek any further medical advice. This was fault.
40. The failure to seek medical advice also contributed to Mrs C being put at risk of avoidable harm and possibly delayed medical treatment.
41. Ms X was concerned that if the Care Home contacted a doctor or community nurse earlier, Mrs C could have received treatment sooner and may have not died. The Care Home’s failure to seek medical advice sooner than it did means Ms X has been left with uncertainty about whether Mrs C’s death was preventable. This uncertainty is a significant injustice.
42. The Care Provider told us senior staff have now had training on the correct process to follow when seeking advice from a medical professional on a health or catheter issue.

Remedy

43. As explained in paragraph four, where a council arranges or commissions care services from a provider, we would treat the care provider’s actions as if they were the council’s. If we find any fault with the care provider’s actions, we can make recommendations for the council to remedy any injustice.
44. Where we find fault by an organisation, we can recommend changes to improve how the organisation delivers its services to prevent the same issue happening to others.
45. As identified above, the Care Provider has sent us evidence that it has reflected on this complaint and made changes to improve its service and prevent similar issues from happening again in future. The actions the Care Provider has taken are proportionate and relevant to remedy the issues in this complaint. Because of this, we will not recommend any service improvements.
46. If we find there has been fault by an organisation which has caused significant injustice, we can also suggest personal remedy.
47. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.
48. In this case, Ms X experienced her own injustice caused by the Care Home’s failings. She was upset that care staff appeared to not know about Mrs C’s health concerns, and she was left with the uncertainty about whether Mrs C’s death was preventable.
49. We cannot say, even on the balance of probabilities, if the Care Home’s actions likely caused or contributed to Mrs C’s death because we do not have any clinical evidence to enable us to make this decision. However, our guidance on remedies states that a symbolic payment can acknowledge the distress caused to Ms X by uncertainty of not knowing if the death of Mrs C was preventable. When arriving at a figure for a symbolic financial remedy, I have taken into consideration that Ms X’s distress was particularly severe because her uncertainty relates to the death of a relative.

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Action

50. Within one month of our final decision, the Council will:
1. consult and work with the Care Home to write an apology to Ms X for the injustice caused to her by the failings identified during this investigation. This apology should be in accordance with our guidance for making an effective apology.
2. pay Ms X £500 to acknowledge the avoidable uncertainty and distress caused to her by the Care Home’s failings in relation to this complaint.
51. The Council should provide us with evidence it has complied with the above actions.

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Decision

52. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman