Summary: We uphold Mrs A’s complaint about poor wound care for her late father Mr B. The Council will apologise and pay Mrs A £1000 to recognise her avoidable distress.

The complaint

1. Mrs A complains about her late father’s (Mr B’s) care in Pat Shaw House (the Care Home), owned and managed by Gateway Housing Association (the Care Provider). London Borough of Tower Hamlets (the Council) arranged and funded Mr B’s care.
2. Mrs A says care for Mr B’s pressure sores was inadequate. She complains there was failure by care staff to arrange an x-ray. Transport arrangements and the handover of care were inadequate for Mr B when he moved from Pat Shaw House and this caused a delay in the new care home arranging appropriate equipment.
3. Mrs A wants the Council to waive some or all of the fees.

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The Ombudsman’s role and powers

4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
5. 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)
6. 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, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. I considered Mrs A’s complaint to us, the Council’s response to her complaint and documents described later in this statement. The parties received a draft of this statement and I took comments into account.

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What I found

What should have happened

8. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (Care Act 2014, section 42)
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision. When investigating complaints about council-funded care placements, the Ombudsman considers the 2014 Regulations when determining complaints about poor standards of care.
10. Regulation 13 of the 2014 Regulations requires people receiving care to be safeguarded from abuse and improper treatment.
11. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
12. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete and contemporaneous records of care and treatment.
13. Regulation 12(i) of the 2014 Regulations says a care provider must provide care and treatment in a safe way including by working with health professionals to ensure the health and welfare of residents.

What happened

14. Mr B had Parkinson’s disease and lived in the Care Home until the beginning of March 2018 when he moved to a nursing home. The Council arranged and funded the placement. Mr B did not bear his own weight and required care for all activities of daily living including personal care, continence and eating and drinking. He had a speech impediment and could sometimes be difficult to understand. Mr B’s health continued to decline after he left the Care Home and he died at the end of March.
15. The day after Mr B moved to the nursing home, Mrs A made a safeguarding alert about Mr B having pressures sores and about a poor handover of care by the Care Home. Mrs A said the Care Home had not told the nursing home about the pressure sores. She also said she had been shown photos of her father’s pressure sores on admission to the nursing home; she found this distressing and she had not been aware of them before.
16. The Council started a safeguarding enquiry shortly after receiving the alert. The Council’s own record of that enquiry states the facts established were:
• Mr A was admitted to the nursing home on 9 March with multiple wounds and pressure sores
• A nurse practitioner from the GP surgery attended to the pressure sore on Mr B’s lower back on 7 March. She failed to make a referral to the district nursing service to follow Mr B up. The sore was a Grade 2 when the nurse practitioner assessed it
• On discovery that the lump on Mr B’s lower back had broken down on 7 March, the nurse practitioner failed to grade the pressure sore and did not provide a care plan to the Care Home. The nurse practitioner told the Care Home to report it to the district nurses, but did not make a referral herself. The district nurses saw the fresh dressing later that day when they tended to Mr B, but decided not to tamper with it
• The sore had deteriorated from Grade 2 on 7 March to Grade 4 on 9 March. This was likely due to a long period of sitting in the wheelchair on the day Mr B moved which could also have caused deterioration
• The district nurse also did not attend to the pressure sores in between Mr B’s toes
• The Care Home failed to arrange an x-ray of a lump on Mr B’s lower back over a period of three months despite Mr A receiving one to one care since January 2018
• The GP failed to raise a safeguarding alert when the x-ray was not carried out
• Both the GP and the Care Home failed to communicate with Mr B’s daughter about medical appointments and the decline in Mr B’s health, despite family asking to be made aware of health issues. As a result, Mr B’s daughter did not possess full facts when she decided not to pursue the x-ray appointment on the day of Mr B’s move
• Communication between all the professionals involved with Mr B’s care was poor
• The lack of a proper handover by the Care Home meant the nursing home did not have the right equipment in place to care for Mr B
• There was poor case recording by staff at the Care Home, by the nurse practitioner and by the district nurse which did not provide an accurate record of Mr B’s change in health.
17. The outcome of the safeguarding enquiry was that there was evidence abuse (neglect) took place and there was

‘a systemic failure that proved the allegations of neglect and acts of omission as conclusive. Poor medical intervention/communication were the key contributing factor as a result of the Care Home, GP and nurse practitioner not sharing [information] or ensuring appropriate medical interventions were carried out in a timely manner….there was no adequate protocol or mechanism in place to ensure the x-ray was followed up….it has been recognised that the Grade 4 pressure sore and discomfort could have been avoided if the x-ray/diagnosis was achieved in a timely manner. As a result there was a missed opportunity to put potential preventative medical intervention in place….

The nurse practitioner failed to tell staff at the Care Home as to the grading of the pressure sore and did not refer him to community nursing. There was also a missed opportunity for the district nurse to review Mr B’s pressure area on the day he was being discharged to the nursing home….

The nursing home should have recognised …he would require an air mattress on admission, in view of him having longstanding pressure areas….this preparation would have ensured there was not a three day delay in putting pressure relieving equipment in place’

18. The safeguarding enquiry recognised the Care Home (which has since closed) later put in appropriate transfer summaries for residents and the NHS services introduced new procedures including:
• a tool to monitor medical action plans.
• the nursing practitioner would make referrals to the district nurse directly and would document this in the client’s care plan at the care home.
• the GP would raise safeguarding alerts after two weeks if a care home had not actioned their recommendations.
• the district nursing team would complete a transfer summary and body map for anyone moving between care homes.
19. After the safeguarding enquiry concluded, Mrs A complained to the Council about Mr B’s care. The Council responded saying the waiver panel had considered her request for the fees to be waived but declined to do so because ‘the safeguarding enquiry concluded the deficits in care were mainly attributable to the care provider and the health professionals’. The Council advised Mrs A to complain to Gateway Housing, the Care Provider. She did. Gateway Housing’s response was that the Council was wrong to direct her complain to it and the Council had already paid its invoice and so it was not owed any money.
20. The Council told us the outcome of the safeguarding enquiry was there was a systemic failure across relevant services that may have compromised Mr B’s skin integrity and caused the lump on his back to burst, resulting in a Grade 4 pressure sore.

Was there fault?

21. The Council commissioned the Care Provider to deliver services to Mr B on its behalf in order to discharge its duty to meet Mr B’s eligible social care needs. The Council remains responsible for those services and for the actions of the Care Provider.
22. The Council is not responsible for NHS services. The Council’s safeguarding enquiry found NHS agencies to be at fault. But we have no power to investigate complaints about NHS services and so my investigation concerns actions of the Council and the Care Home acting on its behalf.
23. The Council’s own safeguarding investigation found serious systemic faults in Mr B’s care. These faults included faults by the NHS for which the Council is not responsible. There were also faults by the Care Provider, for which the Council is responsible.
24. There was fault by the Care Provider, acting for the Council. This included:
• A failure by the Care Home to work with health professionals to ensure safe treatment for Mr B. (a failure to ensure he had an x-ray, a failure to provide a handover of care to the nursing home). This meant Mr B’s care was not in line with Regulations 12,13 and 17 of the 2014 Regulations
• A failure by the Care Home to ensure transport arrangements on the day of the move were appropriate for Mr B’s needs. This means Mr B did not receive safe, personalised care in line with Regulations 9 and 13 of the 2014 Regulations
• A failure by the Care Home to keep Mr B’s family properly informed about changes to Mr B’s condition, in line with what had previously been agreed. This was also a failure to deliver personalised care in line with Regulation 9.
25. The Council was wrong to refer Mrs A to Gateway Housing for a complaint response after the Council had already responded to her complaint. The Council remained responsible for Mr B’s care provision as outlined in this statement.

Did the fault cause injustice?

26. Mr B suffered avoidable distress as a result of the fault in his care described in the previous two paragraphs. The Council accepts the failures in care compromised Mr B’s skin integrity.
27. Mrs A also suffered avoidable distress. She saw photos of the wounds and was upset at the Care Home’s failure to tell her about changes in her father’s health. She may have made a different decision about the x-ray on the day of the move had she been properly brief. This distress was avoidable had the Care Home done what it should have done.

Agreed action

28. We recognise Mr B suffered avoidable distress. He died shortly after the incidents that are the subject of this investigation. Our approach to remedies where fault caused injustice to someone who has died depends on the injustice. We do not normally seek a substantive remedy in the same way as we might for someone who is still living. We would not expect a public body to make a payment that would enrich a person’s estate. So, we do not recommend a refund or waiver of the care fees that are outstanding and owed by Mr B’s estate.
29. Mrs A also suffered avoidable distress. We have taken into account that she had to make the safeguarding alert and that she saw photos of her father’s wounds which were upsetting. The Council also inappropriately referred Mrs A to the Care Provider about the fees, when it held responsibility as the body which commissioned Mr B’s care. This caused further confusion and distress.
30. We consider Mrs A’s distress was severe and so a payment of £1000 by the Council to reflect this as well as an apology, is justified. This payment and the apology should be made to Mrs A directly within one month of our final decision.
31. We are satisfied the Council put in place measures to reduce the chance of recurrence and so we need not make any recommendations for changes to procedure. It is important though, that the Council recognises it retains responsibility for contracted services and so in future, it should not refer people back to contractors for a complaint response if the Council has already provided a response.

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Final decision

32. We uphold Mrs A’s complaint about poor wound care for her late father Mr B. The Council will apologise and pay Mrs A £1000 to recognise her avoidable distress.
33. We have completed the investigation.

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Investigator's decision on behalf of the Ombudsman