Summary: Ms A complained about several organisations involved in her father, Mr D’s care, when his physical health and behaviour deteriorated towards the end of his life. Mr D had dementia. Ms A said failings in Mr D’s care meant his family were distressed by his deterioration. We found fault with a Council. and it agreed to take action to improve. We also found fault with an Ambulance Trust, but it has taken appropriate action to address this fault. We did not find fault with the other organisations.

The complaint

1. Ms A has complained about the care and treatment of her late father, Mr D, by Yorkshire Ambulance Service (YAS), the High Street Surgery (the Surgery), Rotherham, Doncaster and South Humber NHS Foundation Trust (RDASH) and the Abbeys Care Home (the Home) arranged by Rotherham Metropolitan Council (the Council). She has also complained about the lack of social care support provided to her father by the Council. Specifically, Ms A has complained

• The Council:
• did not carry out a Care Act assessment or carer's assessment in a timely manner,
• recommended the Home when it was not equipped to care for her father and;
• did not put safeguarding in place for both her father and mother in a timely manner

2. The Home:

• was not properly equipped to look after her father,
• did not properly manage his fluids and food so he did not eat and barely drank for five days,
• did not manage her father's falls risk so he had several falls in a short space of time and;
• did not properly clothe him and left him in a continence aid

3. YAS

• did not take her father to hospital despite him being severely dehydrated

4. RDASH

• did not provide her father with an assessment or consider sectioning him

5. The GP Surgery:

• did not carry out blood tests swiftly to find and treat the infection her father was suffering with.

6. Ms A said the family suffered the trauma of witnessing their father's deterioration and losing their father which has led to her suffering anxiety, depression and ill health.

• Ms A wants the organisations involved to admit their mistakes and put new practices in place to reduce the chance of this happening to other families.

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The Ombudsmen’s role and powers

7. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)

• The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen 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).

8. If it has, they 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.

• If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their 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)

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How I considered this complaint

9. In my investigation I have considered information from Ms A, the Council, the Home, YAS, the GP Surgery and RDASH. I have also taken advice from an independent GP clinical adviser. In addition, I have considered the relevant legislation and guidance. I gave all parties an opportunity to comment on my draft decision before making this final decision.

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What I found

Background

10. In 2020 Mr D was in his 80s, had Alzheimer’s disease and lived with his wife, Mrs D. Alzheimer's disease is a progressive neurological disorder that causes the brain to shrink (atrophy) and brain cells to die. Alzheimer's disease is the most common cause of dementia — a continuous decline in thinking, behavioural and social skills that affects a person's ability to function independently.

• Mr D developed some difficulties in his behaviour in November 2020 and went into the Home. His health deteriorated and he died in a hospice in December 2020.

Council

11. Ms A said at the start of November 2020 she contacted the Council to say her mother was struggling to care for Mr D. Ms A spoke to a social worker (the social worker) who said they were off duty but the best option as Mr D funded his own care was for the family to organise respite care for him.

• Ms A said from that point on the family had no contact from the Council so took the decision to take Mr D to the Home in the hope it would meet his needs.

12. Ms A was unhappy the Council did not carry out an assessment of her father under the Care Act (2014) and a carer’s assessment of her mother after she contacted the Council in early November to see if they could be given more support at home. In addition, she felt the Council should have started safeguarding enquiries to see if her mother was at risk of harm.

• The Care Act assessment is how a Council decides whether a person needs care and support to help them live their day-to-day life. A carer’s assessment is when Councils decide how much support a carer will need in caring for that person.

13. Social care support is means tested, meaning some people will have to pay for this support although the Council can still help organise it.

• The Council said in response to our enquiries that in early November, Ms A asked for a Care Act assessment which was picked up the next day, and the social worker contacted Mrs D and offered to carry out the assessment that day.

14. The Council said Mrs D declined the assessment as her husband was attending an appointment that day but asked for an assessment the following week.

• The social worker put the request through as urgent for the following week and spoke to Ms A and Mrs D about self-funding a care package until the Council could carry out an assessment. The Council said that before the assessment could be carried out the family placed Mr D in the Home on a self-funding basis. The Council also said it had carried out a carer’s assessment of Mrs D in August 2020.

15. Regarding the choice of the Home, the Council said this placement was not arranged or recommended by the Council. The social worker said as the family said they were at crisis point, they advised that the family could organise support themselves. The social worker provided a list of homes including those which had vacancies. The Council said it was still up to the family to make the choice and for the Home to do an assessment to see if it could meet Mr D’s needs. The Council said it followed up with the Home after Mr D had moved there and the Home said Mr D had settled and there were no issues.

• Regarding safeguarding Mrs D, the Council said she did not meet a ‘three-point test’ laid out in Section 42 of the Care Act as she could keep herself safe and could carry out activities independently.

16. The Council said no one raised safeguarding concerns regarding Mr D until later in November. This was when the Home contacted the Council after Mr D had a fall, and the Council was contacted again ten days later by NHS 111 when the Home was finding it difficult to meet Mr D’s needs due to the decline in his health.
17. NHS 111 is a an urgent and emergency integrated care service which can also point people in the right direction to get further assistance.

• Regarding the period after Mr D entered the Home, the social care notes indicate Mr D was initially happy with the placement, but Ms A was already stating that the Home was struggling to care for him due to his behaviour and falls.

18. Mr D suffered an unwitnessed fall at the Home and it made a safeguarding referral. The Council concluded it did not need to take any further action as Mr D was to be kept under close observation for 72 hours, and he had a care plan with regular checks in place.

• I am satisfied the Council at this stage considered the relevant evidence and made the right enquiries before coming to the decision that no further action to safeguard Mr D was needed at that time.

19. A consultant psychiatrist had carried out a Deprivation of Liberty Safeguards (DoLS) assessment and decided Mr D lacked capacity and should be deprived of his liberty at the Home in his own best interests.

• The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 that 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 other less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without authorisation, a deprivation of liberty is unlawful. It is the responsibility of the care home to ensure that any deprivation of liberty is lawful.

20. This assessment also recommended the Council allocate a social worker to the family and suggested the Council make a mental health referral for Mr D. The Council said these actions did not take place as it had not completed the DoLS process off by the time Mr D moved to a hospice and died shortly afterwards.

• As Mr D’s behaviour escalated NHS 111 made a safeguarding referral and the Council began safeguarding procedures. It decided to look into whether a more suitable facility could be found for Mr D as he was at risk of neglect due to staff struggling to meet his needs.

21. The Council held its safeguarding meeting in February 2022 (after Mr D had died), with two of Mr D’s GPs, the Home manager and a social worker.

• It said Mr D had died a week after NHS 111 raised the safeguarding concern. It said there may have been a delay in the mental health and medical support Mr D needed. This safeguarding concern was closed with the action to feedback to the family the about the meeting and that in future a multi-disciplinary meeting should be arranged in these circumstances, to communicate between professionals.

Analysis

22. The social care notes from the initial phone calls with Ms A and Mrs D indicate Mrs D felt she was managing at home with some carer support, but agreed to a carer’s assessment and a care needs assessment for her husband.

• The Council made the referral to a social work team for these assessments and for Mr D to have a mental capacity assessment. When a social worker rang Mrs D later that day to organise these assessments, she asked that they carry out the care assessment the next week.

23. The Council is correct in stating Mrs D asked it to carry out the care assessment the next week, but there is no evidence it arranged for these assessments for the following week. There was a call from both Ms A and Mrs D stating they were struggling but the Council did not come out to assess. Six days later the family decided to place him in the Home.

• It is understandable that the Council agreed to delay the assessments at Mrs D’s request. However, it did not schedule them for the following week and Mrs D continued to have issues looking after Mr D during this time. The notes state that the request for the assessment was closed and this should not have happened.

24. I find it was fault that the request for the assessment was closed. Although it was only a short period before Mr D went into the Home, the failure to arrange the deferred assessments led to a missed opportunity to arrange for support for Mr D, and potentially Mrs D, in their own home. Although the Council had carried out a carer’s assessment in August 2020, Mrs D’s needs had changed since then and needed to be re-assessed.

• Regarding safeguarding, there is mention in the social care notes that Mrs D could be at risk from Mr D. However, the Council did not carry out a safeguarding enquiry in this period before Mr D entered the Home.

25. The Care Act 2014 states a Council must make enquiries if it believes an adult is experiencing or at risk of abuse or neglect.

• Section 14.2 of the statutory guidance to the Care Act says that a local authority’s safeguarding duties apply when an adult:
• has needs for care and support,
• is experiencing, or is at risk of, abuse or neglect; and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect

This is what the Council referred to as the “three-point test” which it did not feel Mrs D’s circumstances met.

26. Mrs D met the first two of these requirements, but the Council concluded she could protect herself. The Council used the available evidence provided by Ms A and her mother to apply these requirements and I have not found fault with how it made this decision not to carry out detailed safeguarding enquiries.

• In terms of possible safeguarding for Mr D during this period, the Council does not seem to have considered safeguarding for him before he entered the Home. He would have met the three requirements outlined above and so it was fault by the Council not to consider making safeguarding enquiries. Mr D was at risk of neglect and a safeguarding enquiry may have meant he was given more support.

27. In relation to the safeguarding referral from NHS 111, it is clear from the evidence Mr D was at risk of neglect and the Council was following safeguarding procedures to address this risk. It was also in contact with the family about their frustrations in getting Mr D the support he needed. The Council was saying his health issues were the most important of those to be addressed. The Council made enquiries of the Home and GP who discussed the issues facing Mr D. Mr D was then moved to a hospice.
28. This was a difficult situation and time-sensitive as Mr D was deteriorating rapidly. The Council did not the complete the safeguarding process in response to the NHS 111 referral before Mr D entered the hospice and was less at risk of neglect.
29. However, it is understandable the Council was trying to carry out enquiries before putting in safeguarding measures and it was trying to involve Mr D’s GP to investigate his health issues. Therefore, I have not found fault with this aspect of the complaint, as the Council’s actions and the timeframe for them appears appropriate in these circumstances.
30. There was a further issue with confusion over the family being invited to the safeguarding meeting in February 2022. The Council has apologised for this error which is reasonable in the circumstances.

The Home

31. Ms A felt the Home tried to help her father but was not properly equipped to do so. This meant his behaviour, his intake of food and fluids, and his risk of falls were not managed effectively. In addition, he was left in a vest and continence aid which affected his dignity.

• The Home said it carried out an assessment over the phone with the family before accepting Mr D as a resident. However, it did not know about some of Mr D’s behaviour and that he had a history of infections.

32. Regarding Mr D’s nutrition, the Home said it did encourage him to eat and drink and recorded his likes and dislikes. However, it could not force him to eat.

• In relation to falls the Home said Mr D was independently mobile and did not need one-to-one support at first. He was directed to a bathroom and he fell. The Home raised a safeguarding referral with the Council, logged the fall and completed an accident report. Regarding a time period when Mr D fell three times in 24 hours the Home said it contacted NHS 111 and a district nurse treated a resulting skin tear.

33. The Home also said in trying to support Mr D it had contact with mental health teams, NHS 111 and the Council.

• The Home said at times Mr D removed his clothes and was sweating. He also lost control of his bowels when he deteriorated so was put in a continence aid.

Analysis

34. The Home has not been able to locate and so has not provided the assessment it said it carried out before Mr D entered the Home.

• Regarding Mr D’s fluid and nutrition, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 14 states people should be given adequate nutrition to sustain life and good health. It also states people should be supported to eat and drink.

35. There is evidence in the Home’s records that Mr D was given adequate fluids and food. However, he did not always drink or eat what he was given. In addition, the records show that staff tried to support him with this but sometimes his behaviour meant he was reluctant or resistant to being supported with eating and drinking. Therefore, I do not find fault with the Home in relation to trying to meet Mr D's nutritional needs.
36. In relation to Mr D’s falls risk, the Home had already put in sensor mats to help reduce his risk before he fell. The Home also raised a safeguarding referral to see whether there was more that could be done to reduce Mr D’s risk of falling again.
37. Mr D suffered further falls and it was obvious staff were struggling to manage his behaviour. However, I have not found fault in the Home’s attempts to reduce his risk of falls and in its reaction to when he did fall.
38. The Home said it would have not taken Mr D as a resident if it had known about his behavioural issues. In this sense it was not equipped to manage his needs. However, it was the family’s choice of home and the Home was not aware of these issues when taking him as a resident.
39. Although the Home has not provided the assessment it says it carried out of Mr D before he entered the Home, the family has also not said it told the Home about the extent of Mr D’s behavioural issues. On balance, I have concluded the Home was not at fault in agreeing to have Mr D as a resident as it thought, after assessing his needs, it could manage them and he would settle at the Home.
40. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 10 states service users must be treated with dignity and respect which includes ensuring the privacy of the service user.
41. At this stage of Mr D’s deterioration, he was resistant to many interventions and I have not found fault with the Home in trying to put some clothes and a continence aid on him to maintain his dignity although this would have been distressing for his family to witness.

YAS

42. Ms A said the Home rang for an ambulance on several occasions and on two of these the paramedics who attended declined to take her father to hospital despite him being very unwell.
43. YAS said the first time it attended after Mr D’s fall, Mr D was fully conscious, eating and drinking normally and engaging with the paramedics. Paramedics examined Mr D and found no injuries. YAS said it assessed Mr D as having a National Early Warning Score (NEWS) of 2. NEWS is a tool which improves the detection and response to clinical deterioration in patients. YAS said a person would need a score of 5 to 6 to be taken to hospital. A score of 2 means a patient can be discharged at the scene.
44. When the ambulance attended nine days later, YAS said the Home told the ambulance crew Mr D kept falling, was very agitated and self-harming. He was also not eating or drinking. The ambulance noted Mr D had three falls in 24 hours and had a skin tear on his arm. YAS said it organised a district nurse visit for the next day to treat the skin tear and there was no clinical need for Mr D to be admitted to hospital. In addition, YAS said it told staff to call Mr D’s GP for help and if he continued to deteriorate to call 999.

• YAS also stated regarding dehydration that although the Home said Mr D had reduced fluid and food intake, he was not showing signs of dehydration or urinary tract infection.

45. YAS reviewed the first two attendances by the ambulances. YAS concluded both crews correctly discharged Mr D from their care to the Home. However, it found the original crew should have referred Mr D to his GP or an out of hours GP for a follow up assessment.

Analysis

46. From the ambulance records I can see the crews carried out the necessary observations on Mr D and the indications were he did not need emergency treatment in hospital. His behaviour was challenging but this on its own would not suggest a hospital admission and their observations of his physical condition were normal.
47. In relation to the first crew not contacting the GP, this was not in line with the YAS guidance and was a fault on its part. It has taken learning and fed this back to the ambulance crew to improve its service from this which is appropriate.
48. The effect on Mr D may have been a lost opportunity to involve the GP sooner to try and help coordinate his care as the GP was not involved until some days later. However, when the GP was involved a video assessment did not identify any further deterioration in Mr D. Therefore, earlier involvement of the GP is unlikely to have affected the amount of support Mr D was getting.

RDASH

49. Ms A complained about RDASH’s response to contacts from the Home and Mr D’s family about mental health support as Mr D was obviously suffering severe mental health issues. He was self-harming and attacking carers and was very agitated.
50. Ms A asked whether her father should have been detained under the Mental Health Act 1983 for his own safety. Someone can be detained under the Mental Health Act if deemed to be a danger to themselves or others.
51. RDASH’s view was that Mr D’s mental health issues such as his agitation were related to a physical problem that had to be diagnosed before it could offer mental health support or treatment. Infection can cause behavioural symptoms and the infection or physical cause of behaviour needs to be ruled out before mental health treatment is provided. RDASH also scheduled a review for a few days’ later, to see whether a physical cause for his behaviours was found in the meantime, but Mr D died before this date.
52. With regard to Mr D not being sectioned under the Mental Health Act, RDASH said it would not look at detaining someone who is suffering poor physical health as it would not allow it to assess their mental health accurately. By the time Mr D was put on end-of-life care in early December RDASH said it would not have been appropriate to assess him under the Mental Health Act as he was very ill from a physical point of view.

Analysis

53. There were several contacts from both the Home and the family to RDASH asking for help. The appropriateness of RDASH’s actions depend on whether a physical cause should be ruled out before carrying out a mental health assessment. In this case the GP had taken blood tests and was waiting to see if an infection was causing delirium.
54. The blood test results showed Mr D had an infection and this could have been affecting his mental health.
55. In this context RDASH was correct in waiting to see if a physical cause was the root of Mr D’s mental health issues.
56. Furthermore, it was appropriate of RDASH not to carry out a Mental Health Act assessment when Mr D was receiving end-of-life care and was very ill from a physical point of view.

GP

57. As it was a blood test which in the end pinpointed the cause of Mr D’s problems(an infection), Ms A questioned whether a blood test could have been carried out earlier to identify and treat her father’s infection before he deteriorated and died.
58. The GP Surgery said it carried out a video assessment of Mr D nearly two weeks after he entered the Home. His dementia had worsened but there were no new issues or concerns.
59. Two days later the family contacted the GP saying Mr D had not eaten for two days and suffered several falls over the weekend. A urine test showed no sign of infection. At this point the GP ordered blood tests to rule out another cause for his confusion rather than consistently worsening dementia.
60. The GP said they also arranged an urgent same day visit from a GP and an urgent request for a mental health team to visit and assess Mr D.
61. A GP saw Mr D the same day and noted that the previous day a GP had put Mr D on antibiotics for a suspected urinary tract infection. The blood results were abnormal and it looked like Mr D had an infection which was being treated with the antibiotics. However, the GP ordered further blood tests to see if Mr D was worsening.
62. The blood tests came back the next day and a GP had a video conference review with Mr D and the Home. The GP changed the antibiotic so it could cover other infections in addition to the possible urinary infection. The GP said at this point they had not been able to prove Mr D had a urinary infection.

Analysis

63. There were difficulties obtaining a urine sample from Mr D due to his behaviour. However, the GP acted appropriately in treating Mr D with antibiotics and taking blood tests when they did.
64. There was no fault in not ordering blood tests sooner so there was no delay in treatment for Mr D. His deterioration took place over the course of three weeks, and the GP put in place appropriate treatment and helped organise a hospice and more medication to help his mood.

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Recommendations

65. I have identified fault leading to some missed opportunities in this case. Therefore, I recommend:
66. By 24 October 2022, the Council write to Ms A acknowledging the faults I outlined in relation to assessment and the missed opportunities for Mr and Mrs D to have more support at home. The Council should explain what action it will take to learn from this and prevent this from happening in future.

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Final decision

67. I find fault with the Council and YAS in relation to the issues I have outlined above. I do not find fault with the Home, GP, or RDASH.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman