Summary: Mrs X complained on behalf of her late father, Mr Y about the care he received whilst at Beckenham Park Care Home. Mrs X said the care home failed to call a doctor despite requests to do so and allowed Mr Y’s physical condition to deteriorate significantly. We find the care home at fault, causing significant upset and distress. The care provider has agreed to apologise and make a symbolic payment in recognition of the injustice.

The complaint

1. Mrs X complains about the care her late father, Mr Y received from Beckenham Park Care Home. Mrs X says the care provider failed to call out a doctor to assess Mr Y despite several requests to do so and allowed his physical condition to deteriorate significantly. Mrs X also says the care provider failed to properly answer all her complaint points.

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The Ombudsman’s role and powers

2. 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)
3. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C) If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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)
5. 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

6. I considered evidence provided by Mrs X and the care provider as well as relevant law, policy and guidance.
7. Mrs X 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 policy

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. 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.
9. Regulation 12 sets out the requirement for care providers to deliver safe care and treatment. It says that medicines must be supplied in sufficient quantities, managed safely and administered appropriately to make sure people are safe. Those administering medication must be suitably trained and competent and kept subject to review.
10. Regulation 16 sets out how care providers should deal with complaints about their service. It says providers must have effective systems to make sure that all complaints are investigated without delay. This includes:
• Undertaking a review to establish the level of investigation and immediate action required, including referral to appropriate authorities for investigation. This may include professional regulators or local authority safeguarding teams.
• Making sure appropriate investigations are carried out to identify what might have caused the complaint and the actions required to prevent similar complaints.
• When the complainant has identified themselves, investigating and responding to them and where relevant their family and carers without delay.

What happened

11. I have summarised below some key events leading to Mrs X’s complaint. While I have considered everything submitted, this is not intended to be a detailed account of what took place.
12. Mr Y had been resident at the care home since March 2024.
13. Mr Y had also been receiving care from a hospice but was discharged from their care in December 2024.
14. In January 2025, Mr Y was briefly admitted to hospital before returning to the care home.
15. On 15 March 2025, Mr Y complained about pain in his back and leg, and pain medication was administered.
16. On 16 March 2025, nurses at the care home observed swelling to Mr Y’s legs but he expressed he did not want to be transferred to hospital that morning. Later in the afternoon the care home called an ambulance after Mr Y reported further pain in his legs and blood in his urine.
17. On 17 March 2025, Mrs X complained to the care home. Mrs X said:
• Mr Y had been taken to hospital by ambulance the previous day as he was in pain but the care home could not advise ambulance staff what pain relief Mr Y had been given.
• She had asked several times in the past few months for Mr Y to be seen by a doctor, but this had not happened.
• Mr Y’s health had deteriorated quickly but the care home was slow to act on this.
18. On 17 March 2025, the Council started a safeguarding enquiry. This concluded that Mr Y’s health conditions meant his pain was not responding to the prescribed medication and stronger pain relief should have been prescribed. It also concluded staff should have contacted NHS 111 and Mr Y was not receiving regular visits from the hospice. The enquiry report made recommendations for the care provider:
• Nurses to immediately contact NHS 111 when pain was not responding to available medication.
• Chasing up visits from the hospice.
• Duty manager to be contacted when there is a query about new medications and a concern regarding a resident.
19. The care provider issued a written response to Mrs X’s complaint on 15 May 2025. The care provider said:
• Mr Y had been administered with prescribed pain relief as required. The care home had sent a copy of Mr Y’s medication chart to the hospital with him but agreed there was a communication failure at the point of transfer. The care provider said it had now implemented a formal protocol to verbally brief ambulance teams and had retrained its nurses on ensuring clarity at handovers.
• Mr Y was reviewed or discussed with the GP team on at least eight occasions since returning from the hospital in January 2025. However, not all of Mrs X’s requests were followed up. The care home also did not then proactively act to re-engage the hospice despite Mr Y’s increasing frailty. The care provider explained it had put a new system in place to log and track family GP requests and had introduced a hospice contact protocol requiring review of all palliative care residents monthly.
• Mr Y had been administered pain relief throughout his final days in the home, but his health conditions continued to advance which meant this became increasingly ineffective. Mr Y had declined hospital transfer twice on 16 March 2025 before an ambulance was called. The care provider agreed it ought to have escalated to NHS 111 or contacted the hospice for specialist advice sooner than it did. The care provider confirmed it had put a new pain management flowchart in place with an escalation decision check list for when a resident refused hospital transfer during health deterioration.
20. Mrs X said she was unhappy with the care provider’s response to her complaint. Mrs X said she remained concerned about the level of communication from staff at the care home and the way her complaint had been handled. Mrs X also said the care provider had failed to properly answer her questions.
21. The care provider responded further to Mrs X’s complaint on 2 July 2025. The care provider said:
• Nurses at the care home maintain a follow-up list to identify residents requiring medical review which is reviewed by the senior clinical team prior to submission to the GP. It explained it understands the process may not have been clearly communicated to Mrs X and said it would take steps to improve transparency.
• A review of internal audits, staff records, and care documentation found general compliance with regulatory standards. However, inconsistencies in communication and documentation was identified, particularly during December 2024 and January 2025. The care provider explained it was addressing this through a quality improvement plan.
• It was evident communication with Mrs X did not consistently meet expected standards and it had reminded the care home’s management team of the importance of proactive, transparent and timely communicat6ion.
• Mr Y was discharged from the hospice on 18 December 2024. After hospital admission, he returned to the care home in January 2025 but was not re-referred to the hospice which represented a significant lapse in continuity of care.

Analysis

22. 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. 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.
23. 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.
24. Based on the information available to me, I find fault with the care provider. As there has been a thorough safeguarding investigation, it is not necessary for me to review the contemporaneous records because Mrs X’s concerns have already been validated. It follows, I find the care provider at fault for:
• Failing to properly communicate with ambulance staff about what pain medication had been administered.
• Failing to ensure a continuity of hospice care.
• Failing to properly review pain medication when pain was no longer responding to it.
• Failing to follow up on Mrs X’s requests for a doctor to visit Mr Y and for failing to effectively communicate with her.
25. The faults identified caused significant injustice for Mr Y. Although we cannot make casual links about the effects of any delays in seeking medical advice, the safeguarding enquiry notes there may have been a worsening of Mr Y’s symptoms that could have been treated sooner.
26. 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. I cannot say, even on the balance of probabilities, that Mr Y’s declining health was directly caused by the identified faults. However, the uncertainty from this has been a significant cause of avoidable distress for Mrs X which the care provider should acknowledge with an apology and a symbolic payment.
27. I am aware Mrs X wants answers to specific questions, for example around the reasons why her requests for a doctor referral were not properly acted on. I understand this is a real cause of frustration for Mrs X but it is not always possible to provide an answer beyond that a service failure has occurred.
28. I have also considered whether to recommend any service improvements for this case. However, the care provider has already made wide-ranging recommendations to ensure the improvement of care delivery. These recommendations are thorough and proportionate to the fault and so it would not be appropriate for the Ombudsman to recommend any further improvements.

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Action

29. To remedy the injustice identified above, the care provider should complete the following actions within one month of the date of this decision:
• Provide Mrs X with a written apology for the injustice caused by the failure to effectively communicate with ambulance staff, to ensure continuity of hospice care, to effectively manage Mr Y’s pain relief and for delay in seeking further medical treatment advice. 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.
• Make a symbolic payment of £500 to Mrs X in recognition of the avoidable distress and uncertainty caused by the care provider’s actions.
30. The Care Provider should provide us with evidence it has complied with the above actions.

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Decision

31. I find fault causing injustice. The Care Provider has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman