Summary: Miss B complained that a Council-funded care home failed to provide appropriate or timely care to her father, Mr C in the last few weeks of his life. She also complained that it failed to communicate properly with the family during this period. We found the Council-funded care home at fault. The Council has agreed to apologise to Miss B and make a symbolic payment to her.

The complaint

1. Miss B complained that the Suffolk County Council-funded care home run by Athena Care Homes UK Limited, failed to provide appropriate or timely end-of-life care to her father, Mr C, in the last weeks of his life. It also failed to communicate properly with the family during this period. This has caused the family considerable distress.

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The Ombudsman’s role and powers

2. 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 recommend a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
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(1), as amended)

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How I considered this complaint

4. I considered evidence provided by Miss B and the Council as well as relevant law, policy and guidance.
5. Miss B and the Council 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

The Home’s End of Life care Planning Policy and Procedure

6. This document says under the heading ‘Assessment’:

“If it is thought that a Resident is approaching the end of their life, nurses and Care Workers should carry out an initial holistic needs assessment with the Resident and document this. This will enable the right support to be provided when it is needed. These discussions should be between the Resident nearing the end of life, and those important to them…The Registered Manager should ensure that nurses and Care Workers caring for Residents approaching the end of their life have the training and skills to sensitively carry out holistic needs assessments.”

What happened

7. Mr C was discharged to Avocet Care Home (the Home) following a stay in hospital. He had dementia and lacked capacity to make decisions about his care. The placement was funded by the Council.
8. Miss B visited Mr C the day after he arrived at the Home and observed he seemed fine. A week later she visited and was very concerned about his condition. He did not recognise her, his feet and legs were purple, he was slumped in a chair and could not speak. She raised her concerns with care staff. A nurse visited to check his leg ulcers. She gave advice and said she would return in four weeks. The GP also visited as the Home was concerned about his poor food and fluid intake. The GP made no changes to his medication and advised that staff should continue to push food and fluids. The GP planned to return the following week to review his condition, including his ‘Do Not Resuscitate’ and RESPECT form.
9. The following day another family member visited and raised similar concerns about Mr C’s condition. The Home was also concerned about his condition and considered he may need end-of-life care. A senior member of staff discussed his condition with Miss B by telephone, who suggested he may be ready for palliative care. The Home then called an ambulance and the paramedics visited.
10. The Home gave an account of their concerns about Mr C and the paramedics assessed him. They said Mr C appeared alert and was not expressing that he was in pain. The only abnormal reading was his heart, but this was due to an existing condition. They did not consider he needed hospital treatment and recommended a GP visit.
11. The GP visited later that evening and also concluded Mr C was not experiencing any acute condition and his observations were normal. The discolouration in his legs and feet was due to poor circulation, and they advised staff to continue encouraging fluids, along with management of his leg ulcers. They noted Mr C was not expressing any experience of pain. After this visit the Home notified Miss B that Mr C was staying at the Home and did not need hospital care.
12. Miss B visited Mr C the following day and was very concerned about his condition. She said she raised her concerns with every member of staff who she saw. The Home had held a meeting about Mr C and relayed the medical advice to monitor his condition and follow the advice regarding management of the leg ulcers.
13. Miss B visited the following day and noted Mr C was in the same poorly condition. She spoke to an occupational therapist who she said agreed Mr C should be in bed. She also said a member of staff advised her that they were not treating Mr C palliatively because of the advice of the paramedics and the GP.
14. Another family member visited the next day and was shocked to find Mr C in a chair in the communal lounge rather than in bed They said staff reported this was due to an electrical issue which had affected his inflatable mattress. Once this was resolved he would go back to bed.
15. The following day was a Sunday and Miss B called the Home nine times over four hours to find out how her father was and decided whether to visit as she was concerned he might be dying. No-one replied until early afternoon. The staff member she spoke to said Mr C was back in the communal lounge, as he had been given a bath and something to eat. Miss B was shocked by this as Mr C was not supposed to have baths due to his leg ulcers and felt he should be in bed.
16. A member of staff tried to offer Mr C tea in the lounge about an hour and a half after his lunch but discovered he was unresponsive. He had died. The Home called Miss B and the GP, who confirmed the death.
17. A few days later Miss B returned to the Home to collect Mr C’s things. She said no-one offered their condolences, his things had not been packed and used sheets were still on the bed with the remains of food and drink from his last days.
18. Miss B complained to the Home about the failure to listen to her regarding Mr C’s condition and her view he needed palliative care. She also complained about the poor communication on the day Mr C died and the visit after he had died.
19. The Home responded saying it had sought advice from the GP and paramedics when Mr C’s condition deteriorated and he was not eating or drinking much. Staff had shared their concerns and those of Mr C’s relatives, but none of the medical professionals felt he needed palliative care or hospital admission. It said that palliative care was generally guided by medical professionals and the Home was required to follow their recommendations.
20. The Home said it had spoken to all care staff to remind them about the importance of clear, compassionate and open communication with families about medical decisions and appointment outcomes. It also explained that Mr C had been given a gentle bed bath and not an actual bath as this was not appropriate for him. It apologised for any miscommunication regarding this and said it had spoken to the staff member concerned about the importance of clear and precise language around the care given to a resident.
21. The Home said on the morning of his death staff reported that Mr C was alert and bright and he wanted to join the other residents. He sat with other residents and was assisted with a meal. He did not show signs of discomfort nor expressed feeling unwell. A senior member of staff spent time with him around lunchtime and said he appeared brighter. Unfortunately, a little later staff offered Mr C a drink they discovered he had died. The Home said he was moved to a more private location and a screen placed around him until he could be moved, once death had been medically certified.
22. The Home also sincerely apologised for the treatment Miss B received when she came to collect Mr C’s belongings. It said the state of the room and the lack of condolence were unacceptable and staff would be spoken to so these mistakes were not repeated.
23. In response to my enquiries the Council said it had not been involved in the discharge arrangements and that Mr C died before the Council was able to carry out a care needs assessment.

Findings

24. I understand this must have been a very distressing time for Miss B finding her father in a deteriorating condition and concerned he was in pain and discomfort.
25. However, I have not found fault with the actions the Home initially took once Mr C’s condition declined: The GP had visited the day Miss B visited and did not note anything exceptional, advising the staff to continue encouraging food and fluids. The GP intended to review the case in a week indicating they did not consider he was in need of end-of-life care at that point.
26. The following day the Home spoke to Miss B and shared the same concerns about Mr C’s deteriorating condition, feeling that end-of-life care may be appropriate. It then took medical advice again via the paramedic service. They did not consider Mr C needed hospital treatment nor was he experiencing pain. This was confirmed later the same evening by an out-of-hours GP. With these views expressed by three different medical professionals I do not consider it was reasonable for the Home to have taken different action at this point.
27. However, given that Mr C’s condition was variable, that he was eating and drinking very little by this point and Miss B and another family member continued to express concern with various staff members over the next three days, I consider the Home should have reassessed Mr C’s overall condition, discussed it with the family and sought medical advice again rather than simply waiting for the next scheduled appointment. This would have been in line with its policy which suggests a holistic assessment may be appropriate when a resident is nearing the end of their life.
28. It would have avoided some of the uncertainty Miss B has experienced since Mr C’s death as to whether anything could have been done differently to avoid distress and discomfort.
29. However, I do not consider the Home acted inappropriately in the last few days in the specific care it gave to Mr C. Staff said he had seemed brighter, wanted to go to the communal lounge and ate a small amount of lunch just before he died. There was no indication that his condition or behaviour had deteriorated markedly to warrant a different approach or total bedrest.
30. In terms of communication, it was fault for the Home not to answer Miss B’s numerous calls on the morning of the day Mr C died. If it had done so Miss B may have had the chance to visit Mr C before he died. This missed opportunity must have caused significant distress.
31. It was also fault for the staff member to have given unclear information about the type of bath Mr C had received that morning and not to have reassured Miss B that he seemed brighter.
32. I also consider the manner in which Miss B was treated when she came to collect his belongings was insensitive and inadequate. The room should have been cleared and cleaned, his belongings packed up and a member of staff should have expressed their condolences to her. The failure to do so was fault.

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Action

33. I note the Home has recognised most of these faults and apologised but I consider a symbolic payment is appropriate. In recognition of the distress caused to Miss B I recommend the Council within one month of the date of my final decision:
• apologises to Miss B and makes a symbolic payment of £300.
34. The Home has spoken to care staff in respect of the specific faults to ensure the errors are not repeated. So, I have not made any recommendations for service improvements.
35. The Council should provide us with evidence it has complied with the above actions.

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Decision

36. 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