Summary: There is no evidence of fault in the treatment of Mr A by the commissioned care provider, or the way in which the Council conducted the safeguarding enquiry.

The complaint

1. Mr X (as I shall call the complainant) complains about the care and treatment of his late father Mr A in the care home commissioned by the Council. He says the failure of the care home to monitor his father’s fluid intake led to severe dehydration. He complains of other failures in the care home, including failure to allow him (Mr X) access to his father’s notes, providing unnecessary laxatives, forcing Mr A to shower instead of his preferred strip wash, and giving medication contrary to his health conditions.

Back to top

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’. (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, section 30(1B) and 34H(i), as amended)

Back to top

How I considered this complaint

4. I considered the information provided by Mr X and by the Council and care home. All parties had an opportunity to comment on an earlier draft of this statement and I considered their comments before I reached a final decision.

Back to top

What I found

Relevant law and guidance

5. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
6. Regulation 9 says care must be appropriate and meet people’s needs.
7. Regulation 10 says care provider staff must respect people’s preferences, lifestyle and care choices and treat people with care and dignity.
8. Regulation 14 says the nutritional and hydration needs of service users must be met. It says hydration intake should be monitored and recorded to prevent unnecessary dehydration.
9. The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 and came into force on 1 April 2009. The safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative.

What happened

10. Mr A had dementia. He was deemed to be at high risk of falls and at risk of constipation. He had poor mobility and needed the assistance of two staff to transfer. He was also registered blind.
11. Mr A was subject to a DOLS authorisation and to a Court of Protection order which named Hazelgrove as the place he should reside. Mr X held Power of Attorney for his father’s health and welfare except in respect of his place of residence.
12. Mr A went to live in Hazelgrove on 28 July 2020. A handover note from the previous care home said “known CKD [chronic kidney disease] but keeping him hydrated is the key to avoiding AKI [acute kidney injury]”. His care plan was annotated NKDA (no known drug allergies). His care plan noted he was on a regular diet with thin fluids, and that fluids should be encouraged. Mr X has provided copies of notes from the previous care home showing how frequently staff encouraged Mr A to take fluids.
13. Staff at Hazelgrove recorded periods of agitation from the start, usually – but not always – associated with personal care.
14. The Council says Mr A was not described as incontinent by his previous care home but the notes for Hazelgrove state he was incontinent. The Council also notes Mr A’s condition was said by the previous care provider to have deteriorated after a fall on 9 July.
15. Mr X emailed the care home manager on 3 August asking her to email his father’s care records, MAR charts and any incident reports so he could see them before his planned visit to Mr A on 5 August. The manager contacted the Council for advice. She said she had not been asked this before and considered it an unreasonable request, as Mr X could view the documents whenever he visited Mr A. The care home manager emailed Mr X saying “Regarding emailing you the care plan etc we are consulting with the local authority about the ongoing disclosure of records”.
16. The Council responded there was nothing in the Court order requiring the notes to be sent to Mr X. An officer from the local NHS Trust responded: “With regards to him accessing the care documents, we are not stopping (Mr X) reading the documents when he visits his dad, but realise that this is not what he is requesting and that his expectation for you to send him weekly copies of all documentation is not realistic. Is there a way that his visiting time could be increased by half an hour to enable him to read through the documents when he visits?” She added that Mrs A was happy with Mr A’s placement at Hazelgrove.
17. The care home manager explained to Mr X she would make the notes available to him when he visited Mr A. Mr X replied that would not be good use of his time and he expressed concern she had refused. He said it prohibited him working in his father’s best interests. He also raised concerns that it had taken several carers to encourage his father to shower and that Mr X was said to be agitated afterwards. He asked again for the care records to be emailed prior to his visit.
18. The care home manager spoke to Mr A’s social worker. She said Mr A was now doubly incontinent. She said he was accepting of personal care in the mornings but became more agitated as the day went on, to the extent that on one occasion it had taken four staff to provide personal care and reassurance to him. She said behaviour charts were in place and being completed but she was requesting additional funding to provide 1:1 care in the afternoons. She had asked the GP to check whether Mr A was in pain and that was causing his agitation: she stated the GP had prescribed Zapain instead of paracetamol and Mr A appeared to be coping better with it.
19. When Mr X visited on 5 August he did so with his partner, although the care home regulations at the time under Covid 19 restrictions only allowed for one visitor. The care home manager subsequently emailed the social worker again and said on this occasion she had allowed both visitors. She said Mr X was unhappy his father was not available to be seen when he arrived at 10.30: she said this was because Mr A liked to sleep in until 11. She said she had told Mr X he could have an additional half an hour visiting time after his planned visit to view the records. Mr X declined.
20. Mr X was so concerned about what he considered to be a deterioration in his father’s condition that he called an ambulance. The care home manager told the social worker Mr A’s condition had not changed since he was admitted to the home a few days previously. Mr X says he declined to view the records as he was only offered visibility of the care-plan and his repeated requests to view the care-notes while he waited for the ambulance were both ignored and declined
21. The Council’s records show Mr A was severely dehydrated when he was admitted to hospital. He was prescribed antibiotics for a possible chest infection. Hospital records provided by Mr X show the clerking doctor’s diagnosis of sepsis and “AKI due (to) dehydration”.
22. On 10 August Mr X raised a safeguarding concern about Mr A’s care and treatment at the care home. He said Mr A had been subjected to “severe, undetected dehydration” at the care home; that the care provider had denied him (Mr X) access to his father’s care notes, that the care provider had given his father high levels of laxatives despite his diarrhoea, that his father had been forced to shower despite his preference for a strip wash. He said there had been a substantial decline in Mr X’s health in the space of 8 days and he did not consider the care home was a safe environment for Mr X.
23. Mr X also sent a copy of the safeguarding concern to the care provider. The care home manager emailed the social worker and said she intended to give notice to Mr A. She said the home could meet Mr A’s needs but would not be able to permit Mr X to continue to visit which would impact on Mr A’s rights to a family life.
24. Mr A was said to be medically fit for discharge back to Hazelgrove on 12 August but his condition deteriorated before an alternative placement could be found and he died on 1 September of aspiration pneumonia.

The safeguarding investigation

25. A social worker emailed Mr X on 11 August and said she would be investigating his concerns in a safeguarding investigation. Mr X responded, saying there had been ‘great resistance’ from the care home to giving him access to his father’s records. He also said he believed a safeguarding alert had been raised by the paramedics who took his father to hospital.
26. The social worker contacted the hospital ward for details of Mr A’s condition on admission and the extent of any kidney damage as reported by Mr X. She asked whether he had been able to drink, and what his continence level was. She also reviewed all the care home files and sought information from the paramedics who had taken him to hospital. In addition she sought information from Mr A’s previous care home.
27. The hospital safeguarding lead responded that Mr A was doubly incontinent. He was on antibiotics but the source of the infection had not been established. The IV fluids he had been given had been discontinued and the kidney damage was “resolving”. She added that he became agitated when staff tried to carry out personal care.
28. The ambulance service confirmed its staff had not made a safeguarding referral. Mr X says the ambulance crew informed him they could raise a concern but he was best placed to raise concerns (as an informed caregiver)..
29. The Council produced its safeguarding report on 26 October 2020. It said the records showed Mr A’s “presentation had sadly been deteriorating for some time. There is evidence to suggest that some aspects of his presentation were consistent across settings, including episodes of incontinence and sleepiness. These needs were being met in a similar way both in the community and in hospital, with multiple members of staff required for example. It should also be noted that some deterioration in presentation is to be expected, following a change in accommodation.”
30. The report noted that Mr A was dehydrated on admission to hospital but not to a level which either the ambulance staff or the hospital staff considered merited a safeguarding alert. It said the care home’s records of fluid intake and output could not provide evidence that Mr A was receiving the 1500ml per day that was recommended in his care plan, although the care provider said he would have consumed other fluids as well as those recorded. The care home agreed to improve its record-keeping in this respect. The report stated there was no evidence to suggest Mr A had received more than the necessary amount of laxatives as Mr X had suggested.
31. The report noted the care home had give full access to Mr A’s records at the home but had not, after consultation with the Council, agreed to Mr X’s request to email him all records on a weekly basis.
32. Mr X says (and the MAR charts record) the care provider administered paracetamol to Mr A for one day at the same time as it administered Zapain, despite the information readily available on the Zapain information leaflet that “patients should not take any other paracetamol containing medicines whilst taking Zapain Capsules”. He says this was an overdose of paracetamol and the care home did not take action to obtain medication to mitigate it. The local NHS trust wrote to Mr X, “When (the dementia liaison nurse) spoke to the care home staff on 30th July 2020, the manager and nurse both indicated that they thought your father was in pain especially in in his legs and that they felt the prescribed analgesia was not effective. (The nurse) advised them to discuss this with the GP. (He) is not a Nurse Prescriber and did not advise Hazelgrove staff to ask for a particular analgesic to be prescribed. This is the responsibility of the GP, therefore (the) advice to seek a medical opinion was appropriate. “
33. The safeguarding report noted, “staff had care plans in place which were being kept under review. Additional advice was being sought from professionals where necessary and that guidance implemented, with a plan for increased care and a recent medication change. Some of this guidance (ie: around family access to care plans and the prescription of pain relief) directly informed some of Hazel Grove's actions or was outside of their decision-making responsibility. Hazel Grove cannot reasonably be held accountable for this.”
34. The report concluded that the intention of the care home to monitor more thoroughly the fluid intake of residents would reduce any possibility of risk to other residents.

The complaint

35. In March 2021 Mr X contacted the Council. He was unhappy with the outcome of the safeguarding enquiry. He was concerned the social worker had not contacted him directly at the outset of the enquiry. He still had concerns about the cause of his father’s dehydration, the use of laxatives, the way he had been showered instead of washed, the failure to allow him (Mr X) both access to Mr A’s records and private time with his father, and the significant decline in his health in the eight days he was resident at Hazelgrove. He also raised another concern about the use of Lorazepam to sedate his father.
36. The Council’s service manager apologized that the social worker had not communicated to Mr X her view that because the matter of Mr A’s residence had been subject to Court of Protection proceedings it was better to have all communication in writing.
37. The service manager apologised it had not been possible to find a definitive cause for Mr A’s dehydration but said there appeared to have been several contributory factors. He reiterated Mr X had been able to access his father’s notes although not in the manner he wished. In respect of the concern about visits not being private, he said Mr A had needed support to use the phone (as he sometimes threw it to the floor) and that on one occasion a nurse had entered the room to offer any assistance but had left when asked.
38. The service manager said there had been no concerns expressed by the hospital that Mr A suffered diarrhoea and no evidence that his condition had declined substantially over the period of residence in Hazelgrove as Mr X said. He also said there was no record of anyone being told at Hazelgrove that Mr A preferred strip wash to a shower.
39. The service manager also said the other concern Mr X raised – about the prescription of Lorazepam – was outside the scope of the safeguarding enquiry. The local NHS Trust responded to Mr X about the administration of Lorazepam. It said all changes to medication had been made by Mr A’s GP. In respect of the administration of Zapain, which Mr X says was contraindicated for his father because of his severe kidney disease, Mr X says his father’s GP confirms he did not assess Mr A but had “placed his trust in the local mental health team whom Hazelgrove had assured had reviewed Mr A and they wished for a strong Co-Codamol to be prescribed”.
40. Mr A remained unhappy with the Council’s response. He wrote again to the Council and complained to the Ombudsman. He said there had been abuse and neglect which had led to Mr A’s hospitalisation.

Mr X’s response to my draft decision

41. Mr X has provided evidence of some discrepancies in the care home records which suggest Mr A consumed less fluids than recorded: for example,

“28th July, records 200ml of Tea @ 7:00am, but he didn’t arrive until midday.

5th August, records 200ml of Juice @ 9:00am, but the RN Daily Documentation records he didn’t wake until 10.30am.

5th August, records 200mls of Tea @22:00, but he is in hospital.”

42. Mr X also says, “from 1st August onwards records show a noticeable decline in food intake. HG’s records reflect no attempt made to provide alternative food options to encourage eating or when food presented was in contravention to my father’s recorded food preferences”.
43. In response to my draft decision Mr X said the evidence shows the care home manager was only prepared to let him have access to his father’s care plan, not the entirety of the notes. He says in several emails she refers directly only to the “care plan”. The records I have seen from the care home and the Council refer however to the “care plan etc” or the “care documents” and are not in my view limited to discussion of the care plan alone.
44. Mr X expresses concern about the way the care provider administered Zapain for which there was no justification and failed to act when it also administered prescribed paracetamol. He has provided a letter from his father’s GP which says “It is common practice within the NHS for other teams to request GPs to prescribe medication on their behalf…..we have to trust our colleagues that these requests are reasonable …I therefore provided that medication on behalf of the mental health team”.
45. Mr X also continues to express concern about the care provider’s unjustified use of laxatives which he believes contributed to his father’s dehydration.

Analysis

46. The Council arranged the placement of Mr X in Hazelgrove following a Court of protection hearing which deemed he should be placed there. Mr A was subject to a DOLS authorisation while he was in the care home.
47. The Council’s and care home records do not provide any evidence to suggest Mr A’s care and treatment in the home was not appropriate to his needs. On the one occasion he was showered in the home he became agitated and needed the attention of several staff (as he also did when receiving other personal care, and in hospital). There is no record of any information being passed to the care home about Mr A’s preference in that respect. There is no evidence the staff failed to treat him with dignity.
48. Mr X was given the opportunity to have full access to Mr A’s notes. I explain above that references made to the care plan etc or the care plan documents do not imply Mr X was only to be shown the care plan itself. I have not seen any evidence that Mr X was caused injustice as a result of the care provider’s actions.
49. The care home noted some but not all fluid intake and an outcome of the safeguarding enquiry was its agreement to improve its monitoring of fluid intake.
50. The prescription of drugs was not the remit of the care provider or the Council but the responsibility of Mr A’s GP. The MAR charts show that on one day the care home administered the prescribed paracetamol as well as Zapain. As that was not known at the time of Mr A’s admission to hospital there is no evidence of consequent injustice.
51. The safeguarding enquiry was conducted in a thorough and timely way,

Back to top

Final decision

52. I have now completed the investigation on the basis there is no evidence of fault on the part of the Council.

Back to top

Investigator's decision on behalf of the Ombudsman