Summary: Mrs X complains the Council failed to safeguard her late mother at Springfield Park Nursing Home and failed to deal properly with her safeguarding concerns. There was a failure to follow the seizure management plan and a delay in calling an ambulance. Although we cannot say this caused harm to Mrs X's mother, the Council needs to apologise to Mrs X for the distress caused and the time and trouble it has put her to.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council failed to safeguard her mother at Springfield Park Nursing Home and failed to deal properly with her safeguarding concerns.

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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 mother, Mrs Y, moved to the residential unit at Springfield Park Nursing Home (Springfield Park) in 2018. She moved there following safeguarding concerns at her previous care home.
7. Mrs Y’s 21 August 2019 care plan for seizures says:
• she can have intermittent seizures lasting 15 seconds or less and be barely noticeable;
• they can present as recurrent eye movements and a vacant appearance;
• they can progress to a much longer and deeper seizure, which may be masked by her sleeping and an inability to respond;
• if she is unresponsive due to this type of seizure 10-minute checks must be in place until it has stopped;
• call the emergency services if she has a seizure for longer than 45 minutes and tell her family;
• if she struggles with secretions, which could cause choking, turn her onto her left to aid the secretion and call an ambulance.
8. Mrs Y’s seizure monitoring chart for 22 August says:
• 11.00-12.00 the hairdresser thought Mrs Y was having a seizure as she was not talking or responding. It says this was more in retrospect, but family witnessed the seizure
• 16.15 – a care worker went to help Mrs Y with a meal
• 19.24 – Mrs Y was in bed having a seizure
• 20.05 – [this appears to have been added retrospectively as it is not on a separate line - only the time is recorded]
• 20.50 – Mrs Y had been sick, having had a seizure but no one knew how long it had lasted
9. Mrs Y’s observation chart for 22 August says:
• 10.15 –with the hairdresser
• 10.45 – in lounge
• 10.50 – in wheel-chair
• 12.00 – in comfy chair for lunch
• 14.56 – in lounge
• 15.30 – bed rest
• 15.56 – bed rest
• 16.15 – having a seizure when a Care Worker arrived with her meal
• 18.44 – took her medication
• 19.25 – Carer Worker repositioned her
• Time illegible – seizures, nurse informed
10. Mrs Y’s daily care notes for 22 August say:
• 19.30 – “[Mrs Y] now has a seizure support plan in place. It was reported on two occasions today that [she] has had a seizure. Staff monitored [her] closely throughout the day. Diet and fluids taken. Personal care and pressure relief given. Medication taken as prescribed.”
• 22.00 – “[Mrs Y] received in bed at start of shift. Reported to have had several[?] seizures today and to keep eyes on her”. [Care Worker] called me at approx. 21.00 that Nurse in Charge wanted to see me. Nurse in Charge reported that [Mrs Y] had had seizures as reported by [two Care Workers]. Both [Care Workers] were with [Mrs Y]. Observed to have vomited, no seizures observed but ? sleeping and unresponsive verbally. Checked over. Baseline observations recorded. Since I am not sure whether she was sleeping after recovering from seizures, [out of hours GP service] contacted first who advised to ring emergency service. 999 call. Help arranged. Next of kin contacted as per plan. Rescue team arrived and ambulance crew followed and the family also in attendance. All along [Care Workers C & B] with her observing her for safety and also gave her hygienic care needs due to vomit and incontinence. Rescue team examined her and later made a decision that she will be taken to hospital ?aspiratory pneumonia. [Mrs Y] left the home with the ambulance crew and her family. Family stated they are making safeguarding issues.”
11. The Ambulance Service’s record says an ambulance was called at 21.43, arrived at the scene at 22.01 and left with Mrs Y at 21.28. It says:
• “GP/family put plan in place for patient to be on 15-minute observations. Daughter left patient at 19.00 and reports x3 seizures throughout the day. Carer reports patient was checked at 20.30 and was settled not seizing, nurse then returned 21.30 to find patient seizing and vomited large amount, called 999.”
• “Bilateral crackles on auscultation ?aspiration.”
12. Mrs Y’s GP wrote a letter to Springfield Park confirming he agreed with the contents of the seizure care plan which it had sent to him. The letter was faxed to Springfield Park on 23 August.
13. The Council has provided statements made by the staff on duty on 22 August.
• Nurse J – around 21.20 Care Worker B said she thought Mrs Y was having a seizure. Nurse J closed the medication trolley and went to Mrs Y’s room. Mrs Y had been sick. They raised headrest a bit to stop her choking. When called, Mrs Y opened her eyes and closed them again. When Nurse K arrived, Nurse J went back to the medication round.
• Nurse K – after starting the shift at 19.30, Nurse K reminded the Care Workers what they needed to do and started the medication round. Care Worker C asked him to check Mrs Y, who had had seizures, vomited and was unresponsive possibly due to sleeping after recovering from the seizures. He quickly checked Mrs Y’s baseline observations, which were normal apart from her oxygen saturation was low at 84%. Out of Hours GP service advised calling an ambulance. Contacted Mrs X while waiting for the ambulance. Rapid response team arrived first, followed by the Paramedics.
• Care Worker B – when starting the shift, she was advised to do 10 minute checks on Mrs Y but to attend to another resident first. When she entered Mrs Y’s room at 20.50, her head was tilted down to the right and she was covered in vomit. Care Worker C fetched Nurse J who said to sit Mrs Y up and fetch Nurse K. They told Nurse K Mrs Y needed an ambulance, but he said he needed to check her first. Nurse K said they needed to clean Mrs Y up and he would sort it out. While cleaning Mrs Y she had two more seizures of about 15 seconds.
• Care Worker C – when she went to her room at 20.50 Mrs Y was throwing up. She went to fetch Nurse J who came and asked her to call Nurse K. Nurse J asked Nurse K to check Mrs Y’s observations and left. Care Worker C checked Mrs Y’s seizure management folder, which said to call an ambulance if she had secretions after a seizure, and showed it to Nurse K who “ignored” her. Nurse K said to leave but Care Worker C said she would stay as she felt uncomfortable leaving Mrs Y while she was covered in vomit and “how she was with her breathing”. Care Worker B told Nurse K he needed to call the out of hours GP service. Nurse K said he would do this after taking Mrs Y’s observations. Care Worker C said they needed to contact Mrs Y’s family and she needed an ambulance. Nurse K said he was sorting it out and they needed to clean Mrs Y and change her. While the Care Workers changed Mrs Y she had three more 15-39 second seizures. When rapid response arrived Nurse K told the Care Workers to get out of the room. Care Worker C wanted to tell them what had happened but Nurse K shut the door on them.
• Senior Care Worker – gave Mrs Y medication at 18.55 with Mrs X present. Mrs Y was fully alert. Checked Mrs Y again at 20.05, before leaving the building, as “she had previously had a seizure around 19.15”.
14. Mrs X reported safeguarding concerns to the Council on 27 August. She said:
• her mother had been admitted to hospital after being sick and had aspiration pneumonia
• Springfield Park had neglected her mother by failing to follow her seizure care plan
• staff should have been checking on her mother every 10 minutes but there had been a gap of 1 ½ hours
• Mrs Y would need nursing support as a residential placement could no longer meet her needs.
15. On 27 August the hospital told the Council Mrs Y had also vomited in the ambulance on the way to hospital, so it could not be sure when she aspirated and if this caused the pneumonia.
16. The Council made enquiries into the safeguarding concerns. It noted there were ongoing safeguarding issues at Springfield Park. Following an inspection in May 2019, the Care Quality Commission had rated it as “inadequate” overall and was working with it to improve its practices. The Council got copies of Mrs Y’s records from Springfield Park.
17. Mrs Y was discharged from hospital for end-of-life care in a hospice, where she died on 3 September.
18. The Council’s safeguarding enquiries decided:
• additional checks should have been put in place earlier after Mrs Y experienced seizures on 22 August
• on the final check before the incident which resulted in Mrs Y going to hospital there had been no seizure activity to justify 10-minute observations
• the Ambulance crew had recorded no safeguarding concerns, nor had the hospital raised any
• there had been no referral to the Coroner’s Office over neglect and the cause of death was recorded as “natural causes”
• no health care professionals, such as a GP, had asked for one-to-one care
• the Multi-Agency Concern protocol had been instigated which discussed ways of improving care at Springfield Park (staffing structure and work allocations for nurses)

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

19. There are some inconsistencies in the accounts of events on 22 August. Some of this can be put down to faulty recollections. Based on the evidence I have seen it seems likely the events were as follows.
20. Mrs Y was in bed having a seizure at 19.24, which meant staff needed to check on her every ten minutes. This was shortly before the day shift ended and the night shift began. The night shift Care Workers were advised to check on Mrs Y every 10 minutes, but this did not happen. It appears the Senior Care Worker checked on Mrs Y at 20.05. Although she did not record Mrs Y’s condition at the time, it seems unlikely she was still having a seizure or had vomited. Nevertheless, the failure to carry out ten-minute observations after 19.24 was fault, for which the Council is accountable (see paragraph 4 above), as was the failure to record Mrs Y’s condition at 20.05. However, assuming Mrs Y was no longer having a seizure at 20.05, there was no longer a need for 10-minute observations.
21. When two Care Workers visited Mrs Y at 20.50 she had had a seizure and was vomiting. They called Nurse J who asked Nurse K to check Mrs Y’s observations. However, according to the Ambulance Service records, it was not called until 21.43. Given that Mrs Y was vomiting and for all anyone knew at the time could have been having a seizure for more than 45 minutes, there was an urgent need to call an ambulance. The failure to do so was fault, for which the Council is accountable.
22. Given the Ambulance Service’s records, it seems likely Mrs Y had aspirated while at Springfield Park. However, I cannot say the outcome for Mrs Y would have been any different were it not for the faults I have identified. Any aspiration is likely to have occurred between 20.05 and 20.50 when there was no need for 10‑minute observations. Besides, 10-minute observations would not necessarily have prevented Mrs Y from aspirating. Nevertheless, the Council needs to apologise to Mrs X and pay recompense for her distress and time and trouble pursuing the complaint.

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Agreed action

23. I recommended the Council within four weeks writes to Mrs X apologising for the failings I have identified and pays her £400 for the distress she has been caused and the trouble she has been put to in pursuing her complaint. The Council has agreed to do this.
24. 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

25. I have completed my investigation, as the Council has agreed to take action which will remedy the injustice caused.

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Investigator's decision on behalf of the Ombudsman