Summary: Mr X complained on behalf of his father, Mr Y, about a safeguarding enquiry carried out by the Council. The Ombudsman found there was some fault in the Council’s initial safeguarding enquiry and record keeping. There was no fault in the outcome of the enquiry.

The complaint

1. Mr X complained on behalf of his father, Mr Y, about the Council’s safeguarding enquiry into the care Mr Y received at Hazelwood nursing home prior to his hospitalisation and death. Mr X said the Council’s report was inadequate, lacked accuracy, trivialised events, and did not address his main concerns about neglect.
2. Mr Y was caused distress in his final hours, which Mr X believes contributed to his death. Mr X has been affected deeply by this.

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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. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

5. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), 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)
7. Under our information sharing agreement, we will share this decision with the CQC.

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How I considered this complaint

8. As part of the investigation I have considered the following:
• The complaint and the documents provided by the complainant.
• Documents provided by the Council, including its safeguarding enquiry records.
• The Care Act 2014.
• The Care and Support Statutory Guidance.
• The Council’s safeguarding procedure.
9. Mr X and the Council had an opportunity to comment on a draft of this decision. I considered their comments before making a final decision.

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What I found

10. Councils have a duty to make safeguarding enquiries if they reasonably suspect an adult who has care or support needs is at risk of being abused or neglected and cannot protect themselves (section 42 Care Act 2014).
11. The aims of a safeguarding enquiry are to establish facts, assess the adult’s need for protection, support, and redress, and to make a decision about what follow-up action should be taken regarding the person or organisation responsible for the abuse. The main purpose of a safeguarding enquiry is to decide whether or not the council, or another organisation, or person, should do something to help protect the adult.
12. As part of a safeguarding enquiry, councils must gather relevant information from the person who raised the safeguarding alert, the vulnerable person in question (if appropriate), professionals involved in their care, and family members. Councils should share information and liaise with those involved when making decisions and manage any potential risk. Councils must also keep accurate records of safeguarding enquiries and outcomes.
13. The Care and Support Statutory Guidance (the guidance) sets out what a safeguarding enquiry should look like. This could range from a conversation with the adult or their representative, through to a formal multi-agency plan or course of action. The guidance says it is for the council to determine the appropriateness of the outcome of the enquiry.
14. The guidance says action taken as a result of a safeguarding enquiry can include disciplinary action, complaints or criminal investigations, or work by contracts managers and the Care Quality Commission to improve care standards.
15. Councils are responsible for keeping the person who raised the safeguarding alert updated about any investigation and proposed actions. This can be orally or in writing.
16. A council can stop a safeguarding enquiry if it is satisfied there are no safeguarding issues, or the risk has been managed effectively.
17. It is not for the Ombudsman to reinvestigate the safeguarding referral but to consider whether the council conducted a suitable investigation in line with its safeguarding procedures.

What happened

18. Mr Y was a resident of Hazelwood nursing home (the nursing home). Mr X told me Mr Y had previously suffered a heart attack and a stroke. He had an attack of sepsis in the nursing home a few months before the events Mr X complained about.
19. At 5:36am on 24 February 2019 the nurse in charge (NIC) on shift at the nursing home telephoned 999. The NIC told the operator they had tried to telephone 111 but could not get through. They explained Mr Y had a chest infection, high temperature, looked pale, and was shaking. The operator asked if this posed an immediate threat to Mr Y’s life, but the NIC said they did not know. The NIC asked for advice about giving Mr Y paracetamol and asked the ambulance to attend within one hour. The operator could not give medical advice but said they had arranged an ambulance with a one-hour response time.
20. Mr X said the NIC telephoned him just after 5:30am to say Mr Y was unwell, and an ambulance would arrive in about an hour.
21. Mr X told me he attended the nursing home just before 6am. He found Mr Y in bed and unresponsive. He was very hot, his eyes were bulging, his mouth was open, and his right arm was shaking. Mr X considered Mr Y’s condition to be life threatening and went to find help. He brought a care assistant back to Mr Y’s room and insisted they call 999 again. The care assistant said they would tell the NIC.
22. The NIC called 999 again at 7:08am. They said Mr Y had a chest infection, high fever, was shaking, confused, and had slurred speech. They confirmed they were not present with Mr Y and asked if they could give paracetamol. The operator asked if the condition presented an immediate threat to his life. The NIC said it could. The operator confirmed an ambulance would be sent as an emergency response.
23. An ambulance arrived at 7:31am and took Mr Y to Southmead hospital, where he was treated for the onset of sepsis. Sadly, Mr Y did not regain consciousness and died on 4 March 2019, 8 days later.

The Council’s initial investigation

24. The Council received a safeguarding referral from South West Ambulance service on 4 March 2019. It reported concerns about the NIC not recognising possible sepsis.
25. The Council decided it needed to carry out an enquiry under section 42 of the Care Act 2014. It asked the nursing home to carry out an internal investigation. It also told the CQC.
26. Mr X made a safeguarding referral to the Council on 6 March 2019 about the NIC on shift when Mr Y went to hospital.
27. The nursing home manager emailed the Council on 25 March 2019 to say the NIC on shift checked on Mr Y after realising the ambulance had not arrived. The NIC noted Mr Y was trying to form words, but his speech was slurred, and he could not answer questions. She therefore called 999 again.
28. The nursing home accepted the NIC did not follow guidelines and did not repeat observations. The manager told the Council about measures it was taking – including clearer guidelines to support nurses with clinical judgements and sepsis training.
29. The nursing home sent the findings of its internal enquiry to the Council on 1 April 2019. It said staff checked on Mr Y at 4.10am, when he was alert and engaging. On the next round at about 5.30am he appeared unwell and the NIC attended to carry out observations. Mr Y was confused but showed no other trigger signs of sepsis. The NIC therefore called 111 and in line with sepsis guidance was seeking review by a doctor within one hour. The nurse was advised to call an ambulance due to the nature of her concerns. As Mr Y was only showing one moderate risk of sepsis the nurse sought a one-hour response, in line with recommendations. It was the shortest available time, as the NIC did not consider there was a threat to Mr Y’s life, and was suitable at the time.
30. The nursing home said Mr X arrived at about 6:10am. He asked a health care assistant (HCA) about the ambulance at 6:30am. The HCA asked the NIC, who said the ambulance was due any time as it was a one-hour response. Staff told Mr X to ring the bell if he was concerned. The nursing home said Mr X did not ask for the ambulance to be called again. The NIC called at around 7am after realising how late the ambulance was.
31. The Council then contacted the ambulance service to ask for details of the 999 calls, including times, general details of call content, and an overview of how it ranks calls.
32. The ambulance service confirmed the times of the calls, the NIC’s description about Mr X’s condition, and the request for advice about paracetamol. It also confirmed the NIC assessed the time frame of the response.
33. The Council contacted Mr Y’s GP on 11 April 2019. The GP could not give an opinion on whether the nursing home’s actions would have changed the result.
34. Mr X contacted the Council again on 29 April 2019 to say he had the 999 recordings and they show the NIC could not understand key medical terms.
35. The Council replied to Mr X on 30 April 2019. It said the enquiry found the NIC did not follow guidelines about observations, but it could not say this caused or contributed to Mr Y’s death. It said its role was to assess and manage risk, not draw conclusions about neglect. The Council told Mr X it is the role of the coroner to investigate cause of death.
36. The Council closed the enquiry on 2 May 2019 with an outcome of ‘parts of the investigation were substantiated’ as the NIC did not carry out observations as expected. The enquiry could not show whether this would have led to Mr Y’s death. This is a consideration more properly for the coroner. Some areas of the enquiry were inconclusive - such as whether the NIC contacted the ambulance with the correct urgency. The Council said this is because the accounts of Mr Y's symptoms differ between the nursing home and Mr X.

Further investigation by the Council

37. Mr X was not happy with the result. He did not think the care home had been truthful. He told the Council he had listened to recordings of the 999 calls and was alarmed by what he heard. On 9 May 2019, the Council told Mr X it would get the 999 call recordings from the ambulance service and follow up on any concerns with the nursing home.
38. The Council received the transcript of the 999 calls from the ambulance service on 14 May 2019. It highlighted several concerns about the NIC’s lack of understanding.
39. The Council spoke to the care home manager on 15 May 2019 about the 999 call transcripts. The manager expressed surprise and thought the NIC needed more training.
40. The next day, the care home manager told the Council the Nursing and Midwifery Council (NMC) said it was not a reportable incident.
41. The Council visited the care home on 19 June 2019 to review the 999 call recordings with the manager. They agreed an action plan so staff knew the procedure when making a 999 call. The care home said it had supervised the NIC regularly since the incident and was confident in her ability to understand the terms used. It also confirmed the CQC visited on 18 June 2019 and were reassured by the actions taken.
42. The Council contacted the Southmead hospital in July 2019, but no information was recorded on Mr Y’s admission forms about neglect by the nursing home.
43. The Council asked the Clinical Commissioning Groups to report the NIC’s language difficulties and failure to follow correct guidelines to the NMC on 22 July 2019.
44. The Council received notice on 14 October 2019 the NMC did not consider the issues needed further investigation.
45. Following complaints from Mr X, and a meeting with the CQC, the Council asked the CQC to send the 999 audio recordings to the NMC for it to review the matter and offer Mr X complaints channels.
46. Mr X brought his complaint to the Ombudsman on 15 November 2019. He expressed concern at the mistakes throughout the first 999 call. He disputes Mr Y was slurring his words, as the NIC described. Mr X said Mr Y had lost the power of speech. He felt the NIC should not be in a position of authority and lacks the necessary English language skills. He said an ambulance would have come immediately if the NIC had correctly relayed the severity of Mr Y’s condition.
47. Mr X feels Mr Y experienced neglect which led to a delay in proper emergency medical care. This ultimately contributed to Mr Y’s death.
48. The Council received confirmation the NMC would not take action against the NIC on 19 December 2019.

Response to my enquiries

49. The Council told me, because of its investigation, sepsis training started at the care home in June 2019 and further training was planned.
50. An action plan was drawn up for the NIC, including increased supervision, checking, sepsis training, telephone call simulations, and language skills courses.
51. A follow up inspection by the CQC was planned but delayed due to the Coronavirus outbreak.
52. The Council’s initial decision of ‘no further action’ was reviewed when it became aware of the 999 call recordings, but the outcome did not change.

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Analysis

53. The timings of events and the general account of what took place as described by Mr X is disputed by the nursing home. I can therefore understand the Council’s view that some aspects of the investigation were inconclusive, and there was a difference of opinion about the severity of Mr Y’s symptoms.
54. The Council told the nursing home to conduct its own internal enquiry, which it is entitled to do, but I do not consider the Council properly supervised or verified the nursing home’s findings initially.
55. I have listened to the 999 call recordings and they do not tally with what the nursing home said took place. The NIC called 999 because she could not get through to 111, not because she was advised to do so.
56. The nursing home told the Council a one-hour response was suitable at the time of the first call, but there does not appear to be any justification for this. During the call, the NIC could not say what level of threat there was. She also struggled to understand basic questions, about the address, about Mr Y, and some medical terms. I can understand why this was concerning to Mr X.
57. The nursing home also gave the Council different accounts about the second 999 call. It was not clear if the NIC called the ambulance again because she was concerned about Mr Y’s condition worsening, or simply because the ambulance had not yet arrived.
58. The Council could have clarified these issues if it had obtained the 999 call recordings sooner, without having to be prompted by Mr X. This would have allowed the Council to find out a timeline and provide some direction to its enquiries. It would also have avoided some of the frustration Mr X experienced when he read the Council’s initial findings.
59. I have seen the Council’s case notes for the enquiry, and its report sent to Mr X. There is no summary, conclusion, or confirmed findings in the notes and the report is a chronology from the case notes. If the Council had not written to Mr X to explain what the outcome was I would not have known. I do not consider the Council has properly recorded its decision and the actions taken. That was fault. The outcome of the enquiry should be clear.
60. The notes of the initial enquiry show the Council spoke to Mr X, liaised with the nursing home, collected some evidence from the ambulance service, and sought opinion from Mr Y’s GP. While I would not criticise the Council in the main for its enquiry, as it contacted those we would expect, it could have gone further in its investigation. It should have got the 999 call recordings sooner, which would have clarified some of the issues. Timing is crucial in cases of sepsis, so it was vital the Council knew exactly what was said and when. This would best come from the call recordings.
61. Once Mr X told the Council he had the call recordings, the Council sought full transcripts and reviewed the result of its initial investigation. It then took suitable action by liaising with the care home, the CQC, and the CCG. It also ensured the NMC was pressed to investigate. The fact the NMC chose not to take action is not the fault of the Council.
62. I do not find fault with the outcome of the Council’s enquiry. It has identified areas where the nursing home got things wrong and it was satisfied with the actions put in place to prevent similar issues happening again. This included suitable monitoring and training for the NIC.
63. It is not the Council’s role to make findings about cause of death, or the impact of possible neglect. It correctly told Mr X these are matters for the coroner to consider.
64. I have found fault in some aspects of the Council’s initial enquiry. It failed to adequately plan the investigation or maintain oversight. It also failed to properly record the outcome.
65. However, I do not consider Mr X suffered significant injustice as a result. This is because the Council carried out further investigation when it learned Mr X had more evidence. It took suitable steps and the outcome did not change.

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Final decision

66. I have completed my investigation. There was some fault in the Council’s initial safeguarding enquiry and record keeping. There was no fault in the outcome of the enquiry.

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Investigator's decision on behalf of the Ombudsman