Summary: Mrs X complains about the care her father-in-law received at a Care Home run by the Council. He did not receive all the pain relief he was entitled to. The Council needs to apologise, pay financial redress and consider what action the Care Home needs to take to improve its management of medication.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains Meadowfield House Home for Older People (the Care Home):
• failed to look after her father-in-law, Mr Y, properly when his condition declined;
• refused to call an ambulance when asked to do so; and
• suggested Mrs X take him to hospital in a wheelchair.

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What I have investigated

2. I have investigated the actions of the Council and its Care Home.

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The Ombudsman’s role and powers

3. 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, sections 30(1B) and 34H(i), as amended)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Mrs X and the Council, and invited comments for me to consider before making my final decision.

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What I found

What happened

6. Mr Y went into hospital on 17 April 2018, having had a fall. The discharge records say he had right hip pain and chest sepsis. The hospital treated the sepsis and provided him with mobility aids and pain relief (paracetamol and 30mg dihydrocodeine tablets). When he left hospital on 5 May 2018, he went to stay at the Care Home for respite care.
7. On 8 May the Care Home Effective Support Service (CHESS Team) discussed Mr Y with the GP. The record of the discussion says dihydrocodeine was increased to 60mg when needed. The record says to “monitor pain relief on increased dose”.
8. On 9 May the Care Home noted the need to encourage mobility (Mr Y was reluctant due to pain) and “to have pain relief before mobilizing”. Mr Y was upset at having to wait for his pain relief, as there had been a 12-hour gap.
9. On 14 May the Care Home called the GP as the box of dihydrocodeine ordered from 111 services at the weekend said he could only have one tablet four times a day. But the Advanced Nurse Practitioner had changed the dose on 8 May. Mr Y had already had two tablets twice that day. The GP said to follow the discharge prescription until a GP visited the next day. The Care Home noted Mr Y should receive no more dihydrocodeine that day. It also noted the need to alternate paracetamol and dihydrocodeine.
10. On 15 May the CHESS Team reviewed Mr Y’s pain and medication. It noted he had not been receiving 60mg of dihydrocodeine, as agreed by the GP on 8 May, as the medication box still said 30mg. The CHESS Team ordered more tablets as Mr Y only had four tablets left.
11. When the CHESS Team spoke to Mrs X over the telephone on 16 May, it told her Mr Y was now taking iron tablets daily and the GP had increased the prescription for dihydrocodeine on 15 May to 1-2 tablets as needed. When Mrs X raised concerns about Mr Y being in pain, the CHESS Team told her the GP had reviewed him the previous day.
12. On 17 May Mrs X told the Care Home she wanted a GP to see Mr Y that night over the pain he was experiencing and to call her, no matter what time the GP arrived. A GP reviewed Mr Y in the early hours of the morning. Mr Y complained about pain in his right hip, which he said had been worse the night before. The GP prescribed ibuprofen gel for Mr Y’s hip, in addition to his other pain relief.
13. Mrs X says the Care Home called her at 04.43 on 18 May, telling her a GP had visited between 03.30 and 04.00 and prescribed exercises (leg raises and extensions) and ibuprofen gel.
14. Mr Y stayed in bed on 18 May, saying he was “sore”. A Doctor visited because of his hip pain and according to the Care Home’s record said it was “soft tissue”. Mrs X had concerns about him being in constant pain and believed he needed to have a scan. She called his Surgery and spoke to one of the GPs who said Mr Y was now out of their catchment area. Mrs X says the GP said she should ask the Care Home to call an ambulance. Mrs X called the Care Home at 11.18 and asked the Assistant Care Manager to call an ambulance, but she refused. The Assistant Care Manager told her Mr Y was not that bad when she was not around. The Assistant Care Manager offered to lend her a wheelchair to take Mr Y to hospital. Mrs X called an ambulance herself.
15. The CHESS Team assessed Mr Y. It took his vital signs and noted continued pain in his hip/buttock. It noted he had had two x-rays in April, but an Orthopedic Consultant had identified no fracture. According to the notes, the Orthopedic Consultant’s secretary advised Mr Y would be put in the urgent queue for “repeating” a pelvic scan that day. However, other NHS records say a GP arranged for a repeat x-ray for 23 May.
16. The CHESS Team had a telephone call with the Ambulance Service which advised speaking to Mr Y. The CHESS Team record says Mr Y did not want to go to hospital. The CHESS Team contacted the GP to review Mr Y’s pain relief medication. The Care Home says the CHESS Team cancelled the ambulance. However, other NHS records show the Ambulance Service cancelled it after speaking to Mr Y on his mobile phone. They say he did not want to go to hospital and did not think there was anything it could do for him. Mrs X says Mr Y told her someone at the Care Home discouraged him from going to hospital as he would not perform a scan at the weekend so he would be waiting around until Monday.
17. Mrs X arrived at the Care Home at 12.15, after the ambulance had been cancelled. Her husband called for another ambulance which arrived at 15.15 and took Mr Y to hospital. The Paramedics told Mr Y he had a scan booked for 23 May. The Paramedics told Mrs X this information came from the Care Home. NHS records say a GP arranged the scan. Mrs X says a Doctor at the hospital told her no scan had been booked. When Mr Y had a scan, it showed he had a broken back.
18. The Assistant Care Manager says:
• she told Mrs X she could not call an ambulance just because she asked her to;
• Mr Y had said he did not need an ambulance and did not want to go to hospital;
• when Mrs X asked how she could get Mr Y to hospital, she said they could provide a wheelchair, but Mr Y would have to consent to this.
19. The medication administration records for dihydrocodeine show:

20. The records say dihydrocodeine was:
• withheld at 15.00 on 7 May as Mr Y said he had taken it at 12.00. The earlier record initially said he took it at 09.00 but was later amended to 11.00;
• withheld in the evenings of 9, 10 and 11 May, as it was not due (i.e. less than four hours after previously taking it);
• not given at 12.40 on 12 May as there was no stock, resulting in a gap of 15 hours;
• withheld on 13 and 14 May as Mr Y had already had the maximum dose.
21. The Council made enquiries into safeguarding concerns. It found:
• best practice around medication management was not robustly followed;
• there was no clear record to explain why Mr Y did not self-administer medication;
• although Mr Y had a lockable cabinet the keys were not available;
• there was no evidence to show Mr Y did not receive medication one day due to lack of stock;
• Mr Y’s pain relief was reviewed;
• Mr Y expressed his views about access to medical professionals;
• the Care Home spoke to Mr Y about contact with the ambulance service;
• a member of staff denied advising Mrs X to take Mr Y to hospital in a wheelchair;
• there was no evidence to show a scan had been booked for Mr Y;
• food choices had been discussed with the Care Home
22. The Council “partially substantiated” the safeguarding allegations. It made these recommendations:
• everyone to have the opportunity to self-medicate if that is their choice;
• where agreed, everyone to have access to a locked cabinet;
• bedroom keys to be organised so staff can identify the relevant key for each room;
• ensure the label on medication corresponds with any changes to medication administration records.
23. When the Council replied to Mrs X’s complaint it:
• said it would address the issue of no bedroom door key or lockable cabinet, to prevent this from happening again, and apologised;
• did not accept Mr Y’s pain relief was not appropriate, pointing out it had been reviewed six times while he was at the Care Home;
• apologised this information was not shared with his family and said it would remind managers they need to inform families of all reviews;
• apologised for advising Mrs X to take Mr Y to hospital in a wheelchair and said it had taken action to address this;
• said an x-ray had been booked for 23 May as an urgent appointment and apologised this information was not shared with her.

Is there evidence of fault by the Council which caused injustice?

24. There is no dispute over the fact the Care Home did not mange Mr Y’s medication properly. There is nothing to explain why he could not self-medicate. There was conflicting information about dihydrocodeine which meant he did not always receive 60mg, although that had been agreed on 8 May. Twice Mr Y was left for long periods without pain relief, once because of a lack of stock. It also appears Mr Y did not always receive dihydrocodeine because the evening medication round was too soon after he had received it at tea-time. But that should not have prevented Mr Y from receiving the maximum dose in 24 hours, if he wanted it, as it should have been offered to him again (i.e. four hours after he had previously taken it). These are faults by the Council’s Care Home which caused injustice to Mr Y, as they prevented him from receiving all the pain relief he was entitled to.
25. The Care Home did not check with Mr Y before telling Mrs X it would not call an ambulance on 18 May. While that was fault, I cannot say this caused significant injustice, as the records show Mr Y told the Ambulance Service he did not want to go to hospital.
26. The Council accepts it was wrong to tell Mrs X she could take Mr Y to hospital in a wheelchair. It has apologised for the distress this caused.

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Agreed action

27. I recommended the Council:
• within four weeks writes to Mr Y apologising for the failure to meet all his needs for pain relief and pays him £250:
• within eight weeks considers what action the Care Home needs to take to improve its management of medication.

The Council has agreed to do this.

28. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of my final decision statement.

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Final decision

29. I have completed my investigation as the Council has agreed to take the action I recommended.

Parts of the complaint I did not investigate

30. I have not investigated Mrs X’s concerns about the actions of medical professionals, and we have referred them to the Parliamentary & Health Service Ombudsman who has the jurisdiction to do so.

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Investigator's decision on behalf of the Ombudsman