Summary: Mr D complains about the care provided to his grandmother, Ms E, before her death. He complains the organisations who provided her care failed to keep her safe or recognise how vulnerable she was. I find no fault with the actions of the organisations and do not uphold the complaint.

The complaint

1. Mr D complains about the care provided to his grandmother, Ms E, by Surrey County Council (the Council), The Ashford & St Peters Hospital NHS Trust (the Trust), CSH Surrey (the Hub) and Sunbury Health Centre Group Practice (the GP Practice) after she was diagnosed with dementia.
2. Mr D complains there was a lack of coordination which led to her not receiving appropriate care as her mental and physical health deteriorated. Specifically, he complains:
• The Council failed to safeguard Ms E despite multiple agencies, including the police, reporting her concerning behaviour.
• The Council, the Trust and the Hub failed to consider whether Ms E had lost the ability to make decisions which would keep her safe.
• None of the organisations undertook a mental capacity assessment when the family and the police raised concerns about her behaviour.
• The Council, the Trust and the Hub did not inform the family of its thinking and expected Ms E to be able to explain to her family what was happening, despite her inability, at times, to remember where she was.
• The Trust asked Ms E to sign a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) when her family were not present. Mr D only found out when his grandmother showed him a copy saying she did not know what it was but signed it anyway as she felt she had to.
• All organisations took what Ms E was saying at face value without verifying information with her family, had this been done the extent of her mental deterioration would have been obvious.
• When Ms E was ready to be discharged from A&E, staff told Mr D it was for him to raise concerns with the Council because she was medically well enough to leave the hospital.
• The GP practice did not help to stop his grandmother from accidentally overdosing on prescription medication which she did multiple times.
• Since her death, Mr D feels the organisation have failed to take accountability for failing to safeguard Ms E and instead implied it was the family’s responsibility to raise safeguarding concerns if they felt Ms E needed more support.
3. Mr D believes the organisations collectively failed to protect his vulnerable grandmother when her diagnosed dementia progressed rapidly. He saw the progression and was involved in her care. He felt pressured by hospital staff to take her home even though he knew her mobility had decreased and she needed more help.
4. Mr D wants an apology, service improvements to ensure other vulnerable adults are not placed in a similar position and financial recompense for the distress in witnessing the events and pursing the complaint.

Back to top

The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended).
7. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended). If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
8. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
9. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended).

Back to top

How I considered this complaint

10. I have considered information Mr D provided in writing and by phone. I also considered documents and comments on the complaint from the Council, the Trust, the Hub and the Practice, as well as Ms E’s records from her time in the Care Centre. I also considered relevant law, policies and guidance.
11. Mr D and the organisations had the opportunity to comment on my draft decision.

Back to top

What I found

Background

12. Ms E had chronic obstructive pulmonary disease (COPD).
13. Ms E was first referred to the Hub in 2020 to help manage her COPD, but she was later discharged as she did not have any sign of cognitive impairment and did not need help at that time. The Hub does not provide direct care, it coordinates care and makes any referrals necessary to manage care more effectively.
14. In March 2024 the Hub received a new referral for Ms E. This was accepted and she was under the care of the Frailty Hub, who have a team of professionals on staff. This team manages patients who have a Rockwood Frailty Scale score of four or more, which classifies the patient as vulnerable.

What happened

15. In August 2024 Ms E’s families were concerned about her behaviour, which had become erratic and she didn’t seem to be able to remember things like she used to. They asked for the organisations to assess her mental health and cognition.
16. A full mental health assessment was undertaken at the Hub, and Ms E was also referred for a CT scan. Ms E did not attend the scan because she forgot about the appointment and her daughter in law, who normally takes her to appointments, did not see the letter.
17. In October 2024, the Hub received an urgent referral to its community response team. Ms E had called the police one night as her alarm was going off and she couldn’t get it to stop. The police also asked for an ambulance, which took Ms E to the accident and emergency department of the Trust to ensure she was well. Ms E stayed in hospital while her needs were assessed by the Hub, the Trust and the Council. Ms E returned home and continued to care for herself.
18. In November and December 2024, Ms E made many calls in the night to her family, as well as to the police and the Council repairs team. She had also started to go outside in the night as she said it helped her breathing. Her family were very concerned for her safety and asked the Council and the Hub for help. They all agreed she seemed to cope well in the day, but at night her behaviour was concerning.
19. In January 2025, the Hub contacted Ms E’s daughter in law to arrange a home visit with her and Ms E to discuss the results of the CT scan. The scan showed a diagnosis of mixed dementia.
20. In late January, Ms E’s daughter in law told the Hub she was concerned as the police had contacted the Council after Ms E had phoned the police in the night and been found in the street. Ms E did not remember doing this, but did admit to going outside as it made it easier for her to breath. The Hub listened to the concerns of Ms E’s daughter in law about her behaviour at night and agreed to escalate a referral for assessment to the Council. Her GP also gave Ms E some antibiotics for cellulitis.
21. Ms E started on medication to help with dementia in February 2025, and in discussion with her daughter in law the dose was increased later in the same month. A mental health practitioner from the Hub spoke to Ms E’s daughter in law who said since Ms E started on the medication there were no further reports of wandering in the night. However at the end of February, Ms E’s daughter in law contacted the Hub to explain Ms E had overdosed twice on her medication and the Hub agreed to change to blister packs to prevent this from happening again.
22. On 5 March 2025 the GP Practice contacted the Hub, it was concerned Ms E was showing ‘sundowning’ symptoms, she became noticeably more unsettled at night and was calling her family many times every night for help. Around the same time, Ms E’s daughter in law contacted the Hub, she was concerned Ms E had stopped showering and was worrying the family with her phone calls. The Hub agreed a home visit with the Council was needed to assess Ms E’s needs, this was booked for 18 March.
23. Ms E fell at home on 7 March 2025 and went to hospital. She did not have any injuries but was dehydrated. Professionals assessed Ms E under the 4As test, which is a tool used to test for delirium and cognitive impairment in older patients. Ms E scored 1, which is the lowest and means she could understand when and where she was, and what was being said to her. She told staff she did not often fall and could make her own meals and look after herself well. Ms E said she wanted to go to her own home.
24. Ms E was passed to the Home First discharge team, who said her mobility was at her baseline and so she was medically fit to go home. Her family spoke to the clinicians treating her and said they were concerned she was not as able to look after herself as she once was. Clinicians recognised the families concerns and agreed Ms E should be further assessed. The Complex Discharge Team (CDT) took over Ms E’s care and assessed her in front of her niece, Ms E again made it clear she wanted to go home. As she was well enough to go home, the team agreed to discharge her and made an urgent referral to the Hub, asking them to expedite the assessment appointment.
25. Ambulance crew raised a safeguarding referral to the Council to get Ms E a personal safety alarm and to have a key safe installed. The Trust has acknowledged it did not raise a safeguarding referral about the same issue and should have done. It will take learning from this investigation to ensure all staff are aware of the importance of escalating safeguarding concerns, even if another organisation has already done so.
26. The Hub received the urgent referral from the Trust about concerns of Ms E’s dementia progressing rapidly. She was phoning some family members many times a night and was not receiving any support. Her family told the Hub they were concerned she was no longer able to look after herself and wanted support from the Council. The Hub contacted the Council to escalate the concerns, the referral noted Ms E lived alone, had reduced mobility and a progressing dementia diagnosis. The joint visit was again agreed with all parties for 18 March.
27. Ms E became unwell and went to hospital on 13 March. During this time, discussions were held with the family who were present about her wishes, including the DNACPR decision. I have reviewed the Trust’s records which confirm a best interest decision was in place not to attempt CPR and the family agreed to the decision. The Trust has also explained the form is digital, and so Ms E would not have been asked to sign anything then, or previously.
28. Sadly, Ms E died on 14 March.

Mr D’s complaint

29. Mr D complains the organisations did not take enough action to protect Ms E, who was vulnerable and lived alone.
30. I have seen evidence from all organisations they were actively seeking to help Ms E and her family. They were speaking with at least one member of her family about her care and the actions being taken at all times.
31. The Mental Capacity Act 2005 says professionals should start with the assumption that the person has capacity and only question it when there is evidence to do so. The organisations informally assessed Ms E’s capacity when she needed to make decisions and despite having dementia, there was no reason to suggest she could not make her own decisions. The organisations did consult family on key issues and took the concerns raised into account when making decisions.
32. I recognise the events surrounding this complaint were very difficult for Mr D and have had a prolonged impact on him. I also understand Mr D may not have been involved in some of the discussions and decisions made, but it would not be practical for the organisations them to speak to every family member about every decision, and we would not expect them to.

Back to top

Decision

33. I do not uphold this complaint, I find no fault with the actions of the organisations.

Back to top

Investigator's decision on behalf of the Ombudsman