Summary: We have found fault in the care home’s record keeping and communications during the end-of-life care for Mrs E. This meant that there was uncertainty on how the decisions were made in the end-of-life care and this caused distress and uncertainty to Mrs E’s family. The care home has agreed to apologise and to carry out a service improvement.

The complaint

1. Mrs B complains on behalf of her grandmother, Mrs E, who has died. Mrs B complains about the care, and particularly the end-of-life care that the Old Vicarage and the Willows care home (the Home) in Warrington provided to Mrs E.

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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 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)
3. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
4. 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) and 34C(2), as amended)

5. 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)

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How I considered this complaint

6. I considered evidence provided by Mrs B and the Home as well as relevant law, policy and guidance.
7. Mrs B and the 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

Law, guidance and policies

8. 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.
9. 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 following.
• The care and treatment of service users must be appropriate, meet their needs and reflect their preferences (regulation 9).
• Service users must be treated with dignity and respect (regulation 10).
• The care and treatment must be provided in a safe way for service users. This includes the proper and safe management of medicines (regulation 12).
• Any complaint must be investigated and necessary and appropriate action must be taken in response to any failure identified (regulation 16).
• The Home must, as far as is reasonably practicable, ensure that service users are able to make decisions about their care or treatment (regulation 11).
• The Home must securely maintain accurate, complete and detailed records in respect of each person using the service. (regulation 17). This should include an accurate record of all decisions taken in relation to care and treatment and make reference to discussions with people who use the service, their carers and those lawfully acting on their behalf.

End-of-life care

10. The Local Government and Social Care Ombudsman has written a report ‘No second chance: what complaint teach us about end of life care.’ This report highlights common failings identified in complaints about end of life care. These are:
• Basic care needs including medication not being met.
• Poor record keeping.
• Poor communication with families and loved ones. Not keeping them informed or communicating without warmth and empathy.
11. The Parliamentary and Health Services Ombudsman has also written a report ‘Dying without dignity’ which illustrates the issues they regularly see in casework on end of life care. This notes the key themes which include:
• Not recognising that people are dying and not responding to their needs.
• Poor symptom control. People have watched their loved ones dying in pain or in an agitated stated because their symptoms have been ineffectively or poorly managed.
• Poor communication.

What happened

12. Mrs E was an older woman who needed care and support . She moved into the Home in March 2023 and died on 28 February 2025.
13. Mrs B’s main complaint relates to the end-of-life care that the Home’s staff provided to Mrs E. I will first set out the information on the Home’s records for the last days of Mrs E’s life.

The Home’s records

14. 24 February 2025
15. Mrs E was settled and had a good appetite for food and drink. No concerns were noted.
16. 25 February 2025.
17. The nurse called 111 at 04:58 as Mrs E’s oxygen saturation level and respiratory rate were declining. While the nurse waited for the call back, Mrs E recovered. The 111 service advised the nurse to call Mrs E’s GP in the morning.
18. The out of hours GP visited Mrs E at 06:11. The GP said all of Mrs E’s observations were fine except for her breathing so the GP prescribed antibiotics for a chest infection. The GP spoke to Mrs E’s daughter, Mrs D, and asked if she agreed that Mrs E should be treated at the Home for the chest infection and Mrs D agreed. The GP said that, if Mrs E deteriorated, then staff needed to keep Mrs E comfortable and get the end-of-life process ready.
19. At 16:07 Mrs E was seen by Enhanced Care Home Support Service (ECHSS). They advised staff to continue with antibiotics. Note: ECHSS is an NHS service which provides support to care homes and triages the call to a member of the team or the GP. ECHSS carries out comprehensive health needs assessments using a mix of nurses, and works closely with GPs and staff within the Primary Care Networks.
20. 26 February 2026
21. Mrs E was checked 10 times during the night and assisted with personal care and repositioning during some of those checks. Mrs E had breakfast and was washed in the morning. She was reported to be content.
22. At 12:22, Mrs E’s clothes were changed.
23. At 13:42 Mrs E had lunch in her bedroom and ate most of her meal and all of her desert. No concerns were raised.
24. The next note states that the nurse carried out observations of Mrs E at 15:23. The nurse contacted the ECHSS and was waiting for a call back.
25. A note timed at 19:41 by the nurse said: ‘This afternoon staff came to me to say she was struggling to breathe. [Mrs E] appeared very distressed and sounded very chesty, very drowsy. Observations taken, all out of range. The GP was contacted and did a video call and prescribed end-of-life medication. The note said: ‘He has explained to the family that she may not be here in the morning.’
26. The GP filled in a drug administration form on 26 February 2026. This said that Mrs E could be given drugs on a PRN basis which meant they were administered ‘as and when required.’
27. The drugs were:
• Drug 1 for pain
• Drug 2 for agitation, restlessness and breathlessness
• Drug 3 for respiratory secretions
28. The drugs could be administered subcutaneously and the form said what the minimum interval between administering the drug was. The drug could also be administered via a syringe driver which released the drug over 24 hours. The form set out the maximum amount that could be administered over 24 hours.
29. The note timed at 19:41 said drug 2 and drug 3 had been administered, subcutaneously as prescribed.
30. The MAR chart recorded the times when the drugs were administered.
• Drug 1. 01:24, 09:30 and 14:25 on 27 February.
• Drug 2. 19:02 on 26 February, 00:51, 05:04, 09:11 and 16:23 on 27 February.
• Drug 3. 19:03 on 26 February, 00:43, 04:51, 11:40. 16:37 on 27 February.
31. 27 February
32. The notes said the syringe driver was started on 27 February.
33. The nurse noted at 05:14 that Mrs E was asleep in her bedroom at the start of their shift (no time specified – presumably sometime in the evening). Drug 2 and 3 were administered. Later drug 1 was administered when Mrs E was restless. Mrs E was restless at 5:00 so drug 2 and 3 were administered.
34. 27 to 28 February
35. The notes for the night of 27 to 28 February say that Mrs E was restless during the early part of the nightshift and was given drug 2 and then later at 23:45 she was given drug 3. At 00:50 Mrs E’s pulse was very faint and her respiratory rate was very slow. Mrs E died at 01:02 and family members were present.
36. Safeguarding enquiry
37. The GP raised a safeguarding referral after Mrs E’s death. This was started after a comment Mrs D made to the GP that Mrs E died 5 minutes after receiving an injection.
38. This led to a safeguarding enquiry by the Council and a police and Coroner’s investigation. The Home denied that Mrs E was injected with medication 5 minutes before she died. The Council and the police checked the records and carried out their investigations. The matter was closed and no concerns were found.

Complaint – June 2025

39. Mrs B complained to the Home in June 2025 and the Home responded in July 2025. I have grouped the complaints chronologically.
40. 26 February 2025
41. Mrs B said:
• The family visited Mrs E at 15:30 on 26 February and found Mrs E ‘alone, extremely distressed, gasping and struggling to breathe, dressed only in a t-shirt and an adult nappy.’ Mrs D went to get help and when the nurse arrived, the nurse explained that Mrs E had already been prescribed antibiotics for a chest infection. The family insisted that the nurse call a GP. The nurse called the GP who informed the family that Mrs E was unlikely to recover.
• Throughout Mrs E’s end of life care, communication from the nursing staff was poor and inconsistent. There was no formal handover to the family when nursing staff changed shifts.
• On the first night, a man entered Mrs E’s room wearing an outdoor coat and did not introduce himself. The family had no idea who he was until they asked if he was the night nurse, which he confirmed.
• During the night, various care staff entered the room, scanned a barcode on the wardrobe, and left without explanation.
42. The Home responded and said:
• When the family visited, the staff had already alerted the nurse to Mrs B’s distress and the nurse was calling the GP when the family arrived.
• The family’s issues about the end-of-life care were referred to the police and the Council’s safeguarding team who carried out in-depth investigation and closed the case with no risk identified
• The staff did not handover to family or visitors. When a family is visiting, staff would keep interruptions at a minimum out of respect. Staff carried out regular checks on Mrs E and scanned a barcode in the room to show that this was done. This was recorded electronically on the system.
43. Mrs B said:
• On the night of 26 to 27 February, the nurse delayed administering medication to Mrs E and the family had to go and locate the nurse on several occasions asking for the medication as Mrs E was ‘becoming extremely distressed, gasping for air and visibly suffering’. The nurse delayed the medication and also at one point refused to administer medication as the nurse said Mrs E had already received the maximum dose, but a later nurse said that was not true.
• During shift changes, loud laughter and joking were heard outside the corridor which was inappropriate given the circumstances.
• Mrs D asked management what the timescale was for Mrs E’s end of life. Management said they had seen patients live for 19 days to 10 years. The family then decided, as it did not seem that Mrs E’s death was near, that the family would stay with Mrs E in shifts.
44. The Home said:
• The nurse followed the drug administration form from the GP. The nurse administered the medication later ‘as it was able to be administered at that time due to the stipulating time frame between doses.’
• The Home acknowledged the family may have heard laughter as Mrs E’s room was near the main entrance and reception where staff and visitors entered and left the building. The Home said that no disrespect was intended.
• End-of-life timelines varied significantly between individuals and were not always possible to predict. The managers tried to explain this to the family.
45. 27 February 2026
46. Mrs B said:
• On 27 February 2026 (during the daytime) the nurse fitted a syringe driver and said that they would administer 75% of the prescribed dose and keep 25% in reserve as a top up, for when Mrs E needed it.
• During the night of 27 to 28 February, Mrs D asked the nurse to administer medication to Mrs E as she was ‘visibly restless’. Mrs D said the nurse initially refused without checking on Mrs E, but then agreed after Mrs D became upset.
• Mrs D asked the nurse to let her know when Mrs E was nearing the end so she could ring the other family members to be present. The nurse said there was no real change and no need to make calls. Mrs D returned to her chair but ‘five minutes after the medication had been administered’ she noticed that Mrs E had died.
47. The Home responded and said:
• The nurse provided incorrect advice about the syringe driver dosing. The drug authorisation form did not allow for the drug to be administered in percentages. End-of-life drugs should be given subcutaneously a maximum of three times and only then was a syringe driver to be used.
• In terms of delaying the medication administration, the Home said the nurse was following the drug authorisation form.
• The nurse administered the last medication at 23:45 to assist Mrs E’s breathing. At 00:50 Mrs E’s vital signs deteriorated and she died at 01:02 while the family was present.
48. Mrs B said:
• The following day one of the Home’s staff told the family after Mrs E’s death that ‘suffering is necessary to pass to the next life.’ This was entirely inappropriate and insensitive and left the family questioning whether religious beliefs had influenced the end-of-life decision making.
49. The Home said:
• ‘The above concern formed part of the safeguarding enquiry of which we were answerable as above.’

Other complaints

50. I have summarised Mrs B’s other complaints. Mrs B said:
• When Mrs D visited Mrs E on 26 February, she found the door of the bedside drawer was broken and sitting by the side and £30 was missing from Mrs E’s purse in her handbag which was kept in the drawer.
• Mrs E often had dirt beneath her fingernails and the nails were broken and uncomfortable. Mrs B attached a photo as evidence.
• The Home used Mrs E’s bedroom as a storage room for spare continence pads and she attached photos.
• The Home also sometimes lost or mislaid Mrs E’s clothing and other belongings, in particular multiple pairs of glasses. The family raised the issue of Mrs E’s impaired vision and was assured that the Home would arrange new glasses. The Home never did so and in the end Mrs D arranged an eye test and ordered the new glasses herself.
51. The Home responded as follows.
• If there was an issue which needed maintenance attention, it would be logged in the maintenance book for actioning, and once it had been completed the maintenance operative would confirm this. The missing door had not been reported to staff or management and they only became aware when the family emailed them.
• Staff were questioned about the missing money but denied being aware of the purse in the handbag or stealing the money.
• Mrs E ate with her hands so there may have been times when her fingernails were dirty. Mrs E’s nails were checked and cleaned regularly and she received a manicure every Thursday.
• In terms of Mrs E’s belonging, the Home said it was not aware of dirty items being returned to residents. The Home said labels may have come off clothing so it would refund any items that had been lost if the family provided receipts.
• The Home’s optician visited Mrs E on 23 May 2023 and prescribed glasses. Mrs E’s glasses were lost on 14 November 2023. The Home contacted the optician to inform them. The Home’s optician visited every 6 weeks. Mrs D contacted a different optician and obtained new glasses before the Home’s optician could complete the task.

Further information

52. Mrs B sent a letter in August 2026 to the Home with further comments on the Home’s complaint response. The Home did not respond to the letter but I will note some of the comments which are relevant to the decision. Mrs B said:
• Mrs D clarified that she had noticed the door missing from the bedroom cabinet a week before Mrs E’s death, but noticed the missing money on 26 February.
• In terms of the glasses, Mrs B said the Home never obtained glasses for Mrs E. Mrs E used glasses she had obtained from her own optician and she then lost her glasses in November 2023. The Home assured her it would obtain new glasses from its optician. Mrs D rang the Home’s optician and the optician told Mrs D that the glasses had been ready for 5 months, but nobody from the Home had picked them up and Mrs E would now need a new prescription. In the end Mrs D obtained new glasses for Mrs E from another optician, but Mrs E was without glasses for 6 months.
• Mrs B said the Home also stored other residents’ continence pads in Mrs E’s room and attached a photo of Mrs E’s bedroom which contained a lot of continence pads.
53. I asked the Home what action it took following the inappropriate comment the staff member made about suffering and the after-life, to ensure a similar incident did not happen again. The Home said it had been unable to ascertain who made the comment despite asking the staff.
54. The Home said continence pads were delivered every three months so this is why there were a lot of continence pads in Mrs E’s room.
55. I checked the records for two weeks in February and Mrs E’s nails were checked most days (12 times in total).
56. The Home also sent me the records which showed how often staff checked whether Mrs E’s glasses were available to her. These showed Mrs E’s glasses were available on 14 November 2023 but also on the following days.

Analysis

57. I have focussed my investigation on the end-of-life care.
58. The Home says Mrs B’s complaints about the end-of-life care were already addressed by the Council’s safeguarding enquiry and the police/Coroner’s office’s investigation. These agencies had carried out thorough investigations into the allegations and had found no concerns.
59. I am of the view that this is a misrepresentation of Mrs B’s complaint. The Council and the police/Coroner’s office investigated an allegation that Mrs E died a few minutes after receiving an injection. That was an entirely different allegation from the complaints made by Mrs B about the end-of-life care.
60. The family says that, when they visited Mrs E at 15:30 on 26 February, she was extremely distressed, gasping and struggling to breathe and the family had to convince the nurse to call the GP. The Home says the staff alerted the nurse to Mrs E’s distress and nurse was already calling the GP when the family arrived.
61. There is a note from the nurse at 15:26 that Mrs E’s condition had deteriorated and she had contacted ECHSS and was waiting for a call back. So it does appear that the staff had alerted the nurse to Mrs E’s distress and the nurse was taking action a few minutes before the family arrived.

Administration of medications

62. I have investigated the incidents between 26 and 28 February where the family felt that Mrs E was in distress and suffering and needed urgent medication and the nurse refused to administer the medication.
63. Record keeping is always important in the administration of medication but even more so with PRN medication as there is no set time when the medication is to be administered and it depends on the nurse’s clinical judgment. All the guidance on end-of-life care also stresses the importance of good communication with the person and their family in end-of-life care.
64. When a situation arises where the family says that their relative is suffering and requires medication and the nurse refuses to administer the medication, I would have expected the nurse to keep a record of the reason why they refused to administer medication (for example because the maximum dose would be exceeded or the nurse’s clinical observation of the relative was different from the family’s) and say how this had been explained to the family.
65. I found no records at all in this respect in Mrs E’s records and that is fault. Therefore, it is impossible to say how the decisions were made about the refusal of the PRN medication and whether the communication with the family was appropriate. There was fault in this failure to keep an adequate record.
66. I note, for example that the Home said in its complaint response that the nurse administered the medication later (after refusing it earlier) ‘as it was able to be administered at that time due to the stipulating time frame between doses’ but I cannot say what evidence the Home relied upon to make that statement. The Home does not say at what time the family requested the medication, which medication was refused, and at what time the medication was administered later. So I am not sure what the Home based its response on although it may be on the verbal evidence of the nurse. But this should have been properly recorded.
67. The Home has already upheld the complaint that the nurse should not have advised the family, when the driver was installed, that the medication would be administered in a % dose of the prescribed amount as that was not the way the medication was to be administered. So I agree there was fault in that respect and this poor communication added to the family’s confusion regarding the medication.

Communication

68. I have also considered the complaints about the poor end-of-life communication. I appreciate that it is difficult to predict exactly when a person will die, but staff should always at least attempt to provide an estimate based on the person’s presentation, rather than give general statistics, as it is important for the family to be able to plan accordingly.
69. I note that the nurse observed (28 February) at 00:50 that Mrs E’s ‘pulse was very faint, respiratory rate was very slow and blood pressure.’ Mrs E died at 01:02. Mrs D says that she asked the nurse for an update at 00:50 and the nurse said there was no change. There are no records regarding this communication but I do not understand why the nurse told Mrs D there was no change when Mrs E’s vital signs were deteriorating so that was poor communication.
70. In terms of staff entering the room for the hourly checks and a member of staff not introducing themselves, I cannot say this was fault. I appreciate that the family wanted introductions and explanations from the staff, but I accept that the staff may have thought it better to be as quick as possible and not to disturb the family at such a stressful time.
71. Similarly, I fully understand that it would have been difficult for the family to hear laughter and chatting while sitting with a relative who is at the end of their life, but I cannot say there was fault here as care homes are the home of many residents and the workplace of a lot of staff. I agree it would have preferable for people near Mrs E’s room to be quiet but I accept there may always be some background noise.
72. A staff member then made a comment on the following day that suffering was needed for entry to the afterlife. Clearly, this comment was entirely inappropriate and I fully understand why it upset the family so much and made them question the Home’s end of life care. Also, the Home’s initial complaint response was that this was addressed in the Council’s and the police’s enquiry when this was not the case at all so that lack of an appropriate response made the situation worse. I would have expected the Home to properly respond to the complaint and the failure to do so was fault.

Other complaints

73. In terms of the broken cabinet, the Home says broken cabinets are entered in the maintenance book so they can be repaired and it notes that Mrs E’s cabinet was not entered in the maintenance book. It is not in dispute that the cabinet was broken as Mrs B has sent a photo as evidence. So I do not know why the Home’s staff did not report this and enter it into the maintenance book but that should have happened so I uphold the complaint that the Home did not properly address the broken cabinet.
74. In terms of the missing money, the Home says the staff denied stealing any money from Mrs E and, in the absence of any other evidence, I cannot say, unfortunately, what happened regarding the money.
75. Unfortunately, I cannot add much further to the investigation into the other complaints Mrs B made. In terms of the fingernails, the photo showed that Mrs E’s nails were dirty on that occasion, but I cannot say whether this happened frequently. The records showed that Mrs E’s nails were checked most days.
76. Also, in relation to the glasses, it appears to me that the evidence of the Home and Mrs B are compatible. Mrs E moved in with her own glasses. She was seen by the Home’s optician in May 2023 but the Home failed to pick up the glasses. So there was some fault in that respect. Mrs E then lost her glasses in November 2023 and the family arranged their own optician visit and glasses as they did not trust the Home to do this quickly. I also note that the Home’s care records say that Mrs E had glasses throughout November 2023 but I accept this may be because she was given temporary glasses which may not have been suitable.

Injustice and remedy

77. Mrs B said that her main aim of coming to the Ombudsman was for some accountability from the Home and to ensure that no other resident experienced what Mrs E experienced. She also felt that compensation should be provided.
78. I explained to Mrs B that the Ombudsman is not a court and does not provide compensation. Also, when the complaint is made on behalf of a person who has died, we cannot, unfortunately, remedy the distress that they have suffered.
79. I appreciate that Mrs B and Mrs D have also suffered an injustice as they suffered distress by the poor communication and the uncertainty caused by the poor record keeping.
80. I therefore recommend the Home apologises in writing to Mrs B and Mrs D for the fault I have identified which should provide them with the accountability they are seeking. I also recommend the Home reminds relevant staff of the importance of good communication and record keeping.
81. The CQC is best placed to address any outstanding issues in terms of the Home’s performance so, under our information sharing agreement, we will share this decision with the CQC. 

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Action

82. I recommend the Home takes the following actions within one month of the final decision. The Home should:
• Apologise to Mrs B and Mrs D in writing for the fault I have identified
• Ensure all relevant staff understand the Home’s policies on record keeping and communication. It will provide training or guidance as needed.
83. The Home should provide us with evidence it has complied with the above actions.

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Decision

84. I have completed my investigation and have found that the Home’s actions have caused an injustice.

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Investigator's decision on behalf of the Ombudsman