Summary: The Ombudsmen found fault by the Council in relation to the care provided to a woman when she was resident in a nursing home. The Council agreed to apologise to the complainant and pay him a financial sum in recognition of the distress and uncertainty this caused. The Ombudsmen found no fault with the care provided by the Practice or Trust during the woman’s time in the nursing home and her subsequent hospital admission.

The complaint

1. The complainant, who I will call Mr B, is complaining about the care and treatment provided to his wife, Mrs B, by Brighton and Hove City Council (the Council), Brighton and Sussex University Hospitals NHS Trust (the Trust) and Charter Medical Centre (the Practice). Specifically, Mr B complains that:

• Staff at a nursing home placement allowed Mrs B to become severely dehydrated and did not support her to take on regular fluids.
• Staff at the nursing home failed to ensure Mrs B took her prescribed medication.
• The Practice failed to arrange hospital admission for Mrs B when she became dehydrated and her condition deteriorated.
• The Trust threatened to withdraw Mrs B’s food and fluids during her hospital admission.
• The Trust gave Mrs B morphine. Mr B feels this contributed to her death.

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The Ombudsmen’s role and powers

2. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
3. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.

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How I considered this complaint

4. In making this decision, I considered information provided by Mr B and discussed the complaint with him. I considered documentation provided by the Council, Trust and Practice, including the clinical records. In addition, I obtained independent clinical advice from a nurse and a GP. I also took account of relevant legislation and guidance.
5. In addition, I considered comments on my draft decision statement from Mr B and the organisations he is complaining about.

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What I found

Relevant legislation and guidance

Nutrition

6. The National Institute for Health and Care Excellence (NICE) publishes guidance for professionals caring for adults who are considered to be at risk of malnutrition. This is entitled Nutrition support for adults: oral nutrition support, enteral tube feeding and parental nutrition [CG32].
7. This guidance emphasises the importance of assessing and reviewing an adult’s nutritional needs on an ongoing basis and planning nutritional and fluid care accordingly. This can include the introduction of daily fluid balance charts as a tool for measuring an adult’s fluid intake and urinary output. This is to prevent unnecessary dehydration or weight loss.

Dementia

8. The Social Care Institute for Excellence (SCIE) publishes guidance entitled Eating and drinking at the end of life that provides information about the impact of advanced dementia on an adult’s nutritional care.
9. The guidance explains that food and fluid intake of adults with advanced dementia tends to decrease slowly over time, along with the level of nutrition they require to sustain energy levels.
10. The guidance explains that having reduced food and fluid intake, as well as decreased interest in eating and drinking, can be thought of as a natural part of the end of life and dying.

Medication

11. The Nursing and Midwifery Council’s (NMC) Standards for medicines management guidance sets out that nurses must make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient, ensuring the signature is clear and legible.

Treatment of infections

12. NICE also publishes guidance entitled Respiratory tract infections (self-limiting); prescribing antibiotics [CG69]. This guidance sets out strategies for the prescribing of antibiotics for patients with respiratory tract infections.
13. The guidance notes that antibiotics can be of limited effectiveness in the treatment of many respiratory tract infections. The guidance says it can be appropriate to delay in prescribing antibiotic medication for some patients for this reason, and due to the side effects associated with this medication.
14. The guidance emphasises the importance of a clinical review if the patient’s condition worsens or becomes prolonged.

Key facts

15. Mrs B had dementia with limited mobility and required assistance to manage her personal care needs. She also needed help to eat and drink. By 2017, Mrs B was resident in the nursing home. This placement was funded by the Council.
16. On 22 December 2017, nursing home staff noted Mrs B was a little chesty and was coughing intermittently.
17. A GP from the Practice reviewed Mrs B on 24 December as part of a routine ward round and noted she no longer appeared to be coughing or wheezing.
18. On 7 January 2018, an advanced nurse practitioner from the Practice reviewed Mrs B again as staff reported she remained chesty. The nurse took observations but these revealed no abnormalities.
19. The following day, the nursing home contacted the Practice as Mrs B was still unwell and coughing a lot. A GP felt Mrs B was likely suffering from a viral infection and advised the nursing home staff to continue giving her fluids.
20. On 9 January, nursing home staff contacted the GP again and requested a telephone consultation with a GP. However, this did not take place.
21. In the following week, Mrs B remained unwell and staff noted she was not eating or drinking well.
22. The nursing home contacted the Practice again on 15 January following discussions with Mrs B’s family. A GP visited Mrs B later that day and prescribed antibiotics for a suspected infection.
23. Mrs B’s condition deteriorated and she was admitted to hospital on 16 January.
24. Clinicians treated Mrs B with intravenous fluids and antibiotics. However, her condition continued to deteriorate and she died on 4 February.

Analysis

Dehydration

25. Mr B complained that the nursing home allowed Mrs B to become severely dehydrated and that she consequently required admission to hospital. Mr B said he often visited Mrs B at the nursing home and found cups of drink that had been left untouched near her bed. He said the nursing home did not support Mrs B to take on fluids.
26. I have reviewed the nursing home’s care records for Mrs B for December 2017 and January 2018. The nursing notes show that Mrs B was initially eating and drinking relatively well during this period, although she occasionally refused meals.
27. By 9 January, nursing home staff were concerned that Mrs B appeared unwell and had little appetite. The nursing home decided to commence food and fluid balance charts to monitor her nutritional and fluid intake.
28. However, the charts contain no record of Mrs B’s urinary output or how often her incontinence pads were changed. Similarly, there is little information in the nursing notes to indicate whether Mrs B drank the fluids she was offered during this period.
29. The information that is recorded in the charts and nursing notes indicates Mrs B was eating only small amounts of the food that was offered to her during this period and was generally drinking only sips of fluid.
30. As the SCIE guidance explains, it is not unusual for an adult with advanced dementia to experience reduced appetite and correspondingly reduced food and fluid intake.
31. Nevertheless, the NICE guidelines emphasise the importance of accurately monitoring the nutritional and fluid intake and output of an adult considered to be at risk of malnutrition or dehydration as a preventative measure. The nursing home’s nutritional records are inadequate and do not allow for an accurate picture to be established of Mrs B’s fluid intake. This is fault.
32. The Trust’s records show Mrs B was severely dehydrated on admission to hospital. In my view, the evidence suggests the nursing home’s failure to properly monitor Mrs B’s fluid intake is likely to have contributed to her becoming dehydrated.
33. I should clarify that Mrs B’s hospital admission was not a result of her dehydration. Rather, the clinical records of the Trust and Practice make clear Mrs B was admitted as the GP believed she may she may have suffered a stroke. However, I accept the nursing home’s failure to provide appropriate nutritional care contributed to Mrs B’s deterioration. This in turn caused Mr B and his family unnecessary distress.

Medication (nursing home)

34. Mr B complained that the nursing home failed to give Mrs B her medication as prescribed. He said Mrs B required her thyroid medication in soluble form due to her swallowing difficulties. Despite this, Mr B said nursing home staff continued to give the medication to Mrs B in tablet form. Mr B said he often visited Mrs B to find discarded tablets on Mrs B’s clothing or on the floor.
35. The nursing home’s medication administration charts clearly record the need for Mrs B’s thyroid medication to be administered in soluble form. The charts were completed accurately and indicate Mrs B’s medication was administered as prescribed. This was in keeping with the NMC’s standards for medicines management guidance.
36. I have no reason to disbelieve Mr B’s account. However, the clinical records do not support his recollections. I find no fault with the management of Mrs B’s medication, therefore.

Deterioration and admission

37. Mr B complained that the Practice failed to have Mrs B admitted to hospital in a timely manner when she became unwell in January 2018.
38. The nursing home’s records show Mrs B first became unwell in late December 2017. Staff noted she was wheezing and coughing. A GP from the Practice reviewed Mrs B during a ward round on 24 December 2017, but noted she was not coughing or wheezing at that time.
39. An advanced nurse practitioner from the Practice reviewed Mrs B again on 7 January 2018 as nursing home staff reported she was still wheezing. The nurse took observations, including temperature and respiratory rate. These revealed no abnormalities. The nurse advised staff to monitor Mrs B and call the Practice if they remain concerned.
40. The nursing home contacted the Practice the following day as Mrs B was still coughing. The GP who took the call noted “still coughing/flushed after lunch today. no new [Lower Respiratory Tract Infection] symptoms. encouraged staff to treat symptomatically.” The GP decided not to visit Mrs B at that stage.
41. The nursing home’s records also refer to this consultation. These record “[s]poken to [GP] about high temperature, coughing – GP said it is viral infection.”
42. There is a discrepancy between these two accounts. The GP’s note suggests Mrs B had no new symptoms at that time. By contrast, the nursing home’s notes suggest Mrs B had a raised temperature. This is an important distinction as a raised temperature would have been a new symptom that indicated Mrs B’s condition had changed. This in turn should have prompted the GP to visit Mrs B to carry out a clinical review in line with NICE guidelines.
43. Unfortunately, no recording of this telephone consultation now exists. In the absence of any further evidence, I am unable to reach a robust view on what information the nursing home shared with the Practice.
44. However, the GP’s clinical notes contain no record of any advice being given to nursing home staff on what action to take if Mrs B’s condition deteriorated. This should have been clearly recorded. This is fault by the Practice.
45. The following day, when Mrs B remained unwell, the nursing home contacted the Practice again. The nursing home notes record “[s]poken to Surgery Receptionist to request telephone referral. GP…will be notified by the receptionist. [Mrs B] still unwell.” The nursing home made a further call to the practice later that day.
46. Again, there is a discrepancy between the records of the nursing home and those of the Practice in relation to these calls. The Practice confirmed that it received two calls from the nursing home that day. However, the Practice’s records suggest the nursing home requested only paracetamol medication to treat Mrs B’s raised temperature. It arranged this prescription through its pharmacy team that day.
47. There is no further evidence available that would allow me to determine whether the nursing home requested a GP visit, or simply a medication prescription. The records suggest there was some confusion, but it is unclear how this developed and I am unable to attribute it to fault by the Practice or nursing home.
48. I have reviewed the nursing home’s records for the period between 9 January and 14 January. These suggest Mrs B’s condition was relatively stable, albeit with a raised temperature at times.
49. However, one entry in the records from 11 January notes that Mrs B “had a shower and hair wash, as she was being assisted to get dressed she became unresponsive and floppy, we assisted her straight into bed where she came back.” This should have prompted the nursing home to contact the Practice as it represented an obvious change in Mrs B’s presentation. Furthermore, the nursing home’s records suggest Mrs B’s food and fluid intake decreased further over this period. Again, this should have led the nursing home to contact the Practice for advice. There is no evidence that it did so. This is fault.
50. The nursing home eventually contacted the Practice on 15 January and a GP visited Mrs B later that day. Mr B was also present at this consultation. The GP noted “rapid deterioration”. He also noted “increased tone on the right side in terms of her arm”. This is a stiffening or contracting of the muscles that can be symptomatic of a stroke.
51. The GP’s note of this consultation is as not as detailed as I would have expected. For example, he made no record of Mrs B’s observations or vital signs and it is unclear whether he carried out a respiratory examination. It is similarly unclear whether the GP advised nursing home staff what to do if Mrs B’s condition deteriorated further.
52. This did not result in any significant injustice to Mrs B, however, as she was seen again by a GP the following day as nursing home staff reported she could no longer take on fluids. This GP’s note of the initial telephone conversation with the care home records that “acc to [the previous GP] may have had a [stroke] resulting in deterioration.”
53. The GP visited Mrs B later that day. Following an examination, he concluded Mrs B had suffered a stroke. He noted that he had discussed options for Mrs B’s care with Mr B and their daughter. These included continuing to treat Mrs B in the nursing home. However, Mrs B’s family were keen for her to be admitted to hospital and this was arranged.
54. For the reasons I have explained above, there was fault by the nursing home in the care it provided to Mrs B when her condition appeared to deteriorate on 11 January.
55. However, it is important to consider these events in the context of Mrs B’s general frailty. The clinical records show Mrs B was very unwell and that her condition was deteriorating. Hospital admission is not always appropriate for very frail patients who are potentially approaching the end of life as it carries additional risks (such as increased risk of infection). It was appropriate, and in line with good clinical practice, for the GP to discuss with Mr B the possibility of continuing treatment in the nursing home in the first instance.
56. In my view, it is not possible to say whether Mrs B would have been admitted to hospital sooner, even if the nursing home had acted without fault. Similarly, I cannot say whether earlier admission would have affected the ultimate outcome of Mrs B’s care given her general frailty. Nevertheless, this situation caused unnecessary uncertainty for Mr B and his family.

Nutritional care

57. Mr B complained that clinicians threatened to withdraw Mrs B’s food and fluids during her hospital admission.
58. The Trust said Mrs B had been assessed by a Speech and Language Therapist (SALT) on 17 January 2018, shortly after her admission. The SALT noted Mrs B’s swallowing had deteriorated and that she was at risk of aspiration (inhaling particles of food or fluid into the airway). The SALT made recommendations for thickened fluids and a mashed diet. At the same time, the Trust treated Mrs B with intravenous fluids and antibiotics.
59. A doctor spoke to Mr B on 23 January to explain that, once Mrs B had been rehydrated, the plan would be to stop the intravenous fluids to see if she was able to drink. The doctor also explained that reduced eating and drinking can be part of end stage dementia and is a natural part of dying. The doctor suggested that, if Mrs B, did not start eating and drinking, consideration should be given to keeping her comfortable. The doctor recorded that Mr B and his daughter agreed with this approach.
60. The clinical records for the following days suggest Mrs B was a little brighter and was taking some oral food and fluids.
61. However, by 29 January, it was noted Mrs B’s condition had deteriorated and that she had developed pneumonia. The doctor recorded that he discussed Mrs B’s “guarded prognosis” with Mr B over the phone and that he was keen for the pneumonia to be treated with antibiotics. Another doctor had a similar discussion with the family later that day, recording that she had explained Mrs B may not recover.
62. Mrs B’s condition continued to deteriorate. She was drowsy and would not eat or drink. This led a doctor to speak to the family again on 31 January. The doctor recorded that the family were keen for feeding to continue. The doctor also explained that Mrs B had been treated with antibiotics since her admission but that her condition had not improved. As a result, the treating clinicians decided to stop the antibiotics.
63. Another doctor spoke to Mr B on 1 February. By this point, Mrs B’s condition had deteriorated further and she was eating and drinking only very small amounts and sometimes declined meals altogether.
64. This was an understandably difficult time for Mr B and his family. However, the evidence shows doctors discussed Mrs B’s condition with him regularly and took his views into account when planning her care. The clinical records show the Trust continued to offer Mrs B food and fluids up to her death on 4 February. I found no fault by the Trust in this regard.

Medication (hospital)

65. Mr B complained that the Trust gave his wife morphine and feels strongly that this contributed to her death.
66. The British National Formulary (BNF) provides guidance for the use of Diamorphine Hydrochloride for adults experiencing chronic pain and who are not already being treated with strong opioid pain medication. In this situation, the BNF recommends a dose of 2.5 to 5mg every four hours, to be given subcutaneously (injected into the tissue under the skin).
67. The records show a doctor prescribed Diamorphine Hydrochloride to be administered in the event of Mrs B experiencing discomfort. On 4 February 2018, nurses administered one 2.5mg dose of this medication at 13:25. This dosage was within the recommended guidelines set out by the BNF. I found no fault by the Trust in this matter.

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Agreed actions

68. Within one month of this final decision statement, the Council will write to Mr B to:

• Apologise for the failure of the nursing home to provide Mrs B with appropriate nutritional and fluid care and the impact this had in terms of Mrs B’s hydration levels and the distress this caused to Mr B and his family.
• Apologise for the failure of the nursing home to seek advice from the Practice between 11 and 14 January 2018 when Mrs B’s presentation changed and the uncertainty this caused for Mr B and his family.
• The Council will also pay Mr B £200 in recognition of this distress caused to him by the fault I have identified above.

69. Within one month of this final decision statement, the Council should also discuss Miss B’s case at one of its monthly Service Improvement Panel meetings. This will allow the Council’s Quality Monitoring Team to determine whether the nursing home needs additional support or training to provide nutritional and fluid care that is in keeping with NICE guidelines. The Council should write to the Ombudsmen to explain the outcome of this discussion.

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Final decision

70. I found fault by the Council in relation to the care provided to Mrs B during her time in the nursing home. However, I found no fault with the care provided by the Practice or Trust during Mrs B’s time in the nursing home and her subsequent hospital admission.
71. In my view, the actions I have recommended represent a reasonable and proportionate remedy to the injustice suffered by Mr B as a result of this fault.
72. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman