• The complaint
• The Ombudsman’s role and powers
• How I considered this complaint
• What I found
• Agreed action
• Final decision

The Ombudsman's final decision:

Summary: Mrs X complains the Council’s care provider, Cygnet Care Services Ltd, failed to care properly for her son, resulting in him suffering severe constipation and losing a lot of weight. There were failings to communicate properly with Mrs X and a GP about her son’s health, which prevented a holistic approach being taken. The Council needs to apologise and take action to prevent similar problems from happening again.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council’s care provider, Cygnet Care Services Ltd, failed to care properly for her son, resulting in him suffering severe constipation and losing a lot of weight.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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)
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)

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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. Mrs X’s son, Mr Y, has a learning disability and medical conditions, including swallowing problems for which a Speech and Language Therapist has made recommendations. He has a history of self-injurious behaviour. From 2009 he lived in a care home run by Cygnet Care Services Ltd (Cygnet). He regularly stays at his parents’ home.
7. The care home did an annual review for Mr Y in October 2016. The review does not mention his parents, but Cygnet’s records says Mrs X attended. The review says Mr Y weighed 46kg, as in the previous year. It says his self-injurious behaviour remained at a very low level both in intensity and in frequency. It includes these statements about his health:
   • “[Mr Y] hasn’t had any unscheduled doctor’s appointments but has had his routine health appointments and flu vaccinations. [He] has suffered with a few colds throughout the year but with paracetamol and good fluid and food intake he has recovered well. [His] weight has fluctuated throughout the year but in the last 4 months he has steadily gained weight and is no longer underweight in conjunction with his BMI. His food intake has greatly improved over the 12 months and is generally finishing most of his meals, if not, he is only leaving a few mouthfuls”.
   • “[Mr Y] hasn’t been suffering as badly as he is known to when it comes to constipation. If it has been a couple of days that he hasn’t gone then staff will mix in some prunes with his porridge or keep him hydrated with orange juice. This appears to be working for [him] as he is going more regularly”.
8. The Council also reviewed Mr Y’s needs in late 2016 but did involve his parents.
9. The care home reviewed Mr Y’s needs again in September 2017 with Mr & Mrs X and the Council. The review says he weighed 44.2kg. It says Mr Y “will occasionally suffer from loose bowels but this has not continued for a long enough period to be considered a health concern”. It says the Speech and Language Therapist “provides written guidelines on how to support [Mr Y] when eating and drinking” and recently provided training to the chef on Mr Y’s eating and drinking recommendations. The Speech and Language Therapist’s report says a target for the coming year was to identify the cause of occasional loose bowels. It had been suggested that Mr & Mrs X “keep extensive food charts when [Mr Y] is at home to record what he eats and in what quantities in order to identify a possible food source that [he] has an intolerance to”.
10. A GP visited Mr Y on 18 October 2017 for a health review. The care home’s record of the visit refers to flu and pneumonia vaccinations. The GP’s record of the visit says:
    • Mr Y weighed 41.8kg and had a body mass index (BMI) of 17.6;
    • Mr Y had diarrhoea, loose stools and incontinence when returning from visits to his parents;
    • the GP prescribed loperamide for loose stools to be taken when needed and advised the care home to “restart food fortification”.
11. On 2 November Mr Y weighed 42.8kg (BMI 18).
12. The care home gave Mr Y loperamide on 5 and 6 November.
13. On 4 December Mr Y weighed 42kg (BMI 17.7).
14. Cygnet says the care home gave Mr Y paracetamol on 19 December following self-injurious behaviour.
15. Mr Y was at his parents’ home 25 to 27 December. The care home did not include loperamide with his medication. Cygnet accepts this and apologises for the error.
16. Cygnet says the care home gave Mr Y loperamide on 27 December.
17. Mr Y was at his parents’ home on 1 and 2 January.
18. On 2 January Mr Y weighed 43.3kg (BMI 18.2).
19. Cygnet says the care home gave Mr Y paracetamol on 12 January following self-injurious behaviour.
20. According to Cygnet’s records, on 2 February 2018 Mr Y weighed 40kg (BMI 16.9). Mrs X says this is not accurate and that he weighed 36kg with a BMI of 16. She says she raised concerns about his weight when she picked him up.
21. Mr Y was at his parents’ home 3 to 5 February.
22. Cygnet says the care home gave Mr Y loperamide on 5 February.
23. On 12 February Mr Y weighed 38.2kg (BMI 16.1).
24. On 13 February the care home told Mrs X it had arranged a telephone appointment with her son’s GP to discuss his bowel movements.
25. Mr Y was at his parents’ home on 14 and 15 February.
26. On 14 February the care home contacted the GP about continuing issues with uncontrolled loose stools on returning from home visits. It said Mr Y’s parents described stools which suggest overflow from constipation and asked the GP to prescribe medication for constipation. The GP prescribed lactulose to be taken when needed.
27. On 15 February the care home told Mrs X the GP had prescribed loperamide in 2017. It apologised for not passing this information on at the time.
28. Mrs X spoke to the GP on 16 February. She said she was unhappy about the decision to prescribe loperamide in October, given her son’s history of faecal impaction. The GP said she had prescribed loperamide based on the information the care home had provided. Mrs X said she had concerns about her son’s significant weight loss. The GP proposed drawing up a plan with her son’s carers for managing his bowels and weight loss.
29. The GP spoke to the care home which said Mr Y was active and behaving normally. It said staff were filling in Bristol stool charts for Mr Y and weighing him weekly. The GP prescribed more high energy drinks. The GP visited Mr Y who appeared to be eating normally and showed no signs of faecal impaction.
30. On 19 February Mr Y weighed 39kg.
31. According to the GP’s records, on 22 February the care home said Mr Y was:
    • eating well;
    • taking extra supplements;
    • having food fortification;
    • opening his bowels regularly; and
    • passing normal stools.
32. The GP advised the care home to record Mr Y’s stools and weight, and to report any concerns.
33. On 22 February Mrs X thanked the care home saying it had attended to the situation “very quickly and professionally”.
34. On 26 February Mr Y weighed 41.2kg (BMI 17.4)
35. On 5 March Mr Y weighed 42.3kg.
36. On 3 April Mr Y weighed 44kg.
37. In July the care home produced a nutrition and mealtime support plan for Mr Y. This identifies the need to:
    • provide 1:1 support at mealtimes;
    • weigh him fortnightly, as he can lose weight rapidly;
    • tell Management and Clinical Nurse if his weight falls below 42kg and weigh him weekly.
38. Mrs X complained to Cygnet in January 2019.
39. When Cygnet replied in March it did not uphold the complaint. It said:
    • the GP prescribed Loperamide in November 2017;
    • it discussed the family’s concerns about chronic constipation with the GP;
    • it administered loperamide on four occasions after visits to his parents when he had extremely loose stools;
    • it had apologised for not telling Mr & Mrs X about the prescription for loperamide in November 2017;
    • the care home had consulted the GP and Cygnet’s nurse “throughout”;
    • it could not confirm or deny various claims based on who said what to whom as there were not records to show what had been said;
    • Mr Y’s weight loss could not have been foreseen;
    • the care home was monitoring this and taking action to prevent further weight loss (e.g. adding extra calories to his food)
40. Mr Y has since moved to another placement.

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

41. There is no dispute over the fact the care home did not tell Mr Y’s parents the GP prescribed loperamide. It has apologised for that fault. It also delayed in discussing the concerns that Mr Y was returning from his home visits with diarrhoea. That was fault, for which the Council is accountable (see paragraph 4 above).
42. There is no evidence to support the claim that the care home shared the parents’ concerns about constipation with the GP in October 2017, or that it consulted the GP “throughout”. That was also fault.
43. These failings prevented a more holistic approach being taken to the problems Mr Y experienced between October 2017 and February 2018. It is not possible to say what difference this made, given that the GP did not identify faecal impaction which was Mrs X’s principal concern. Nevertheless, the Council needs to apologise to Mrs X.
44. This complaint has revealed some poor working practices:
    • inadequate record keeping (care providers must keep records of the care they deliver but the Council has failed to provide all the records for the care provided for Mr Y between October 2017 and February 2018);
    • lack of communication with Mr Y’s parents about his needs.

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Agreed action

45. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the care home, I have made recommendations to the Council.
46. I recommended the Council:
    • within four weeks writes to Mrs X apologising for the failure to share information with her and the GP about her son’s health between October 2017 and February 2018:
    • within eight weeks draws up an action plan with Cygnet addressing the failure to:
      1. keep proper records; and
      2. the lack of communication with Mr Y’s parents.

The Council has agreed to do this.

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

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Final decision

48. I have completed my investigation as the Council has agreed to take action to remedy the injustice it has caused.

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Investigator's decision on behalf of the Ombudsman

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