Summary: The Ombudsmen find fault in the way a Care Home monitored and recorded the condition of a resident’s foot. However, the Care Home has already accepted this failing and taken suitable action to improve its practice. The Ombudsmen has not found fault in the Care Home’s actions during a week in late October 2018 as there no clear indications it should have escalated the resident’s care during that time.

The complaint

1. Dr Y complains that, between 18 and 26 October 2018, Alexander Court (the Care Home) failed to notice or act upon a significant and life threatening deterioration in the condition his father’s, Mr X’s, foot and health. Dr Y said staff should have arranged for an urgent escalation in Mr X’s care.
2. Further, Dr Y complains the Care Home acted inappropriately, unprofessionally and obstructively when he asked for an emergency hospital admission on 26 October 2018.
3. Dr Y said Mr X was allowed to have a festering foot ulcer deteriorate to such an extent that he had overwhelming unrecognised sepsis by the time he was taken to hospital. Dr Y said his condition was so advanced that the only options were a course of antibiotics and then, when they failed, an amputation which still did not save him.
4. The London Borough of Newham (the Council) funded Mr X’s placement at the Care Home. Mr X also received Funded Nursing Care (FNC) contributions for the care he needed from registered nurses. The Local Government and Social Care Ombudsman (LGSCO) investigates whichever local authority is ultimately responsible for a person’s care, regardless of whether it arranges that care through a contract with a private provider. In contrast, the Parliamentary and Health Service Ombudsman (PHSO) investigate the providers of NHS services directly. As such, this investigation is of the Council as well as the Care Home and was conducted as a joint investigation because of the intertwined nature of these responsibilities.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA,as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. 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) 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.
7. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
8. The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
9. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
10. 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

11. I read the correspondence Dr Y sent to the Ombudsmen and spoke to him on the telephone. We wrote to the Council and Care Home to explain what we intended to investigate and to ask for their comments and copies of relevant records. I considered all the comments and records they provided. I also wrote to several other organisations to ask for copies of their records, which I considered. In addition, I considered relevant legislation and guidance and took advice from a practicing nurse and a vascular surgeon with relevant experience and no conflicts of interest.
12. I shared confidential copies of my draft decision with Dr Y and the organisations under investigation to explain my provisional findings. I invited their comments and considered those I received in response.

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What I found

Guidance on care home standards

13. There are standards for safety and quality care providers need to meet: The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations). The Care Quality Commission (the CQC) has written guidance to help care providers meet these standards: Guidance for providers on meeting the regulations (March 2015) (the Fundamental Standards).
14. Under the Regulations and Fundamental Standards, care providers need to make sure:

• They provide people with appropriate care, personalised to their needs. As part of this, care providers need to make sure assessments are regularly reviewed (Regulation 9)
• People are kept safe from avoidable risk and harm, and from unsafe care and treatment. This includes assessing risk and making plans to manage it. Care providers also need to make sure staff are appropriately trained, and that equipment is suitable and available (Regulation 12).

15. The Nursing and Midwifery Council (the NMC) produces The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates (the Code). The sets out the standards that nurses must uphold.
16. This includes guidance, at 13.2, that nurses must make timely referrals to other practitioners when any action, care or treatment is needed.

Background

17. Mr X had diabetes, high blood pressure and end stage renal failure, for which he had dialysis three times a week in hospital. In late August 2018 he went into the Care Home, funded by the Council. Later in the placement Mr X began receiving FNC contributions.
18. On his arrival at the Care Home staff completed an assessment and noted that both of Mr X’s big toes were necrotic. It started wound assessment charts for both feet. A couple of days after his admission the Care Home received a call in the evening from the hospital Mr X attended for dialysis. They said the Care Home should put a dry dressing on Mr X’s left big toe. It did so the following day. On the next day the Care Home completed a care plan for Mr X’s feet. It noted they would need regular assessment and said staff were aware of this.
19. At the start of September 2018 Dr Y called the Care Home and asked it to refer Mr X to a Tissue Viability Nurse (a TVN), in relation to his feet. The Care Home did so the next day. A TVN saw Mr X the following day. They told the Care Home to leave Mr X’s right big toe exposed and to monitor it, and to put a non‑medicated ointment dressing on the left big toe. They said they would review things again if asked to do so.
20. Just over a week later the TVN asked Mr X’s GP to refer Mr X to the Vascular service for advice on the management of his feet. The GP made this referral.
21. In the middle of September 2018 the Care Home called an ambulance as Mr X’s blood sugar was very low. It took him to hospital which admitted him. During the admission the hospital noted some signs of an infection but without a clear source and noted Mr X was not feverish. It discharged him back to the Care Home two days later.
22. On his return the Care Home completed a body map. It noted the area of necrosis to his left foot may have spread but was dry.
23. A Vascular Surgeon reviewed Mr X in early October 2018. They noted Mr X was unable to say how long his toe had been black and said it was intermittently painful. The Surgeon suggested an angiogram of the left leg along with ‘angioplasty of the popliteal artery for limb salvage’ (a procedure to widen a narrowed artery in the leg to improve blood flow with the intention of saving the use of the limb). They said they would discuss this with the multi-disciplinary team and then saw Mr X in clinic again.
24. On 14 October 2018 the Care Home called an out of hours GP owing to concerns that Mr X seemed generally unwell. A GP saw Mr X but did not prescribe any new medication or suggest any changes to his care.
25. A Vascular Surgeon saw Mr X in clinic again on 18 October 2018. They noted the plan was the same as discussed at the start of October and said the operation should happen in the next two weeks.
26. Mr X attended hospital for dialysis three times over the next seven days. On each occasion he returned to the Care Home.
27. On 25 October the Care Home received a call from a hospital to say that Mr X would have angioplasty on his legs on 2 November.
28. On 26 October Mr X’s wife and one of his son’s visited him and helped make arrangements for planned visits to hospital on 29 October and 2 November. During their visit the bedsheet came off and Mr X’s son was shocked at the sight of his father’s foot. He took a picture on his phone and sent it to Dr Y (who lives in a different country).
29. Dr Y called a Renal Registrar at the hospital Mr X attended for dialysis. Dr Y said the Registrar said Mr X should go to A&E as soon as possible.
30. Dr Y called the Care Home and asked them to arrange to transfer Mr X to hospital immediately. The Care Home did not agree to this request. It noted Mr X was due to go to hospital for treatment on his feet within the next week and said it would need an instruction to admit Mr X to hospital from a professional involved in his care.
31. After several calls the Care Home took Mr X’s observations and found them to be within normal ranges. It then wrote a referral to Mr X’s GP noting that Mr X appeared to be weak, was complaining of pain in his leg and his family were concerned about the state of his foot.
32. Dr Y also contacted Mr X’s GP. The GP agreed that Mr X should go to hospital. The GP then called the Care Home and said it should call 999 for an ambulance to take Mr X to hospital. The Care Home did so and an ambulance arrived about an hour later.
33. Mr X initially went to Queen’s Hospital. It noted signs of an infection and started antibiotics. On 27 October 2018 a consultant reviewed Mr X and felt he may have sepsis and that it could be related to his feet. Mr X transferred to the Royal London Hospital later that day.
34. The Royal London continued to treat Mr X with antibiotics and completed investigations to try to locate the source of the infection. Doctors noted it may have related to one of Mr X’s feet but were not sure.
35. On 6 November 2018 a scan showed clear signs of infection in Mr X’s foot which required urgent surgery. Medics spoke to Mr X’s family who agreed to an above knee amputation. Mr X had surgery later that day.
36. Mr X’s health deteriorated in the following days and he sadly died on 9 November 2018. Medics determined the cause of death was sepsis secondary to osteomyelitis (an infection of the bone).

Complaint to the Care Home

37. Dr Y complained to the Care Home in March 2019. The Care Home replied at the end of April 2019. It said its staff had checked on Mr X’s feet on a regular basis. However, it acknowledged its records should have been more detailed about the progress of the wound. In addition, the Care Home said it recognised that a further referral to the TVN would have been good practice.
38. In terms of the events on 26 October 2018 the Care Home said its decisions had been reasonable but acknowledged the calls could have been handled better.

Safeguarding investigation

39. In August 2019 the CQC passed a safeguarding concern to the London Borough of Barking and Dagenham (B&D Council). It made enquiries and produced a report in early December 2019. B&D Council partly substantiated the concern and concluded that:

• There was poor communication and recording of wound management as per the Care Home’s own Wound Management Protocol,
• There was no evidence the family were kept informed of any deterioration in the foot,
• There was no record of when staff noted a deterioration in the foot, and
• There was no evidence of follow up with other professionals – i.e. GP or TVN.

40. The report noted that the two key members of staff no longer worked at the Care Home. It noted the Manager had reported that all staff had received supervision about it and had undertaken wound management training and documentation training. Also, the Care Home said it had started a digitalisation process and staff in all units had electronic devices to record and take pictures.
41. The report noted the Care Home should ensure:

• Staff got specialist training on wound management on a regular basis,
• Pictures and wound measurements were recorded regularly to show improvement or deterioration, and
• Referrals to other professionals should be recorded with the reason for the referrals.

42. In response to my enquiries the Care Home advised that it accepted the safeguarding report’s findings and recommendations. The Care Home said its staff had been to training and its nurses have specialist training. It also said it now takes pictures regularly. Further, the Care Home said it had invested in electronic care plans which, as well as recording information, prompt staff to input required data.
43. The Care Home supplied copies of the types of records it keeps on its new electronic record system, including records for monitoring the status and treatment of wounds. The records include an option to include a photograph and include set fields for describing and measuring the wound. In addition, the Care Home provided a copy of a memo sent to staff in August 2019 detailing mandatory training on wound care to take place that month.

Analysis

44. It has already been acknowledged that the Care Home’s record keeping was poor in relation to the condition of Mr X’s feet. This was outside of good practice and is evidence of fault.
45. In the absence of adequate records, and in consideration of the context and significance of these records, we cannot be satisfied that the Care Home completed the necessary checks and monitoring of Mr X’s feet which it should have done. As such, there was fault with the underlying care and not just the record keeping.
46. The Care Home has accepted B&D Council’s findings and recommendations about this. It has made changes to its practice and provided evidence to show that its recording of wounds is now more comprehensive. As such, I am satisfied that this aspect of the failing in Mr X’s care has been appropriately addressed.
47. In terms of the impact of the failings in Mr X’s care, there is evidence in the Care Home’s notes of if raising concerns with other professionals when it considered this was warranted. The records from the days between 18 and 26 October 2018 do not contain evidence to show a significant deterioration in Mr X’s health and on 26 October his physical observations were within normal ranges. Mr X was still able to visit hospital for dialysis during this time and staff at the hospital did not seek to have him admitted due to concerns about his general health. Further, the Care Home was aware of Mr X’s attendance at the Vascular Clinic on 18 October 2018 and understood it was content to wait until 2 November 2018 to operate and had not asked for him to be admitted sooner. When Mr X was in hospital a Vascular Consultant noted, on 31 October, that he remained without a fever and with normal observations, but with blood results that indicated an infection. In addition, the limited records of Mr X’s foot from the Care Home, alongside information from other sources from before 18 October and after 26 October, does not suggest the presentation of Mr X’s foot changed significantly after the Vascular Clinic appointment of 18 October.
48. Overall, on the balance of the available information, I have not found evidence that Care Home staff failed to arrange an escalation of Mr X’s care between 18 and 26 October 2018. In hospital Mr X was found to have a significant infection that would require an amputation in an attempt to resolve it. However, there is no clear evidence to show the Care Home staff could or should have foreseen this based on Mr X’s recorded presentation during this period. This includes consideration of his continued interaction with other health professionals who did not find cause to urgently admit Mr X to hospital.
49. In terms of the events on 26 October 2018 it is evident that the conversations Dr Y had with the Care Home were frustrating and at times heated and difficult, as well as time consuming. The Care Home has already acknowledged that the calls could have been handled better.
50. Regardless of Dr Y’s profession or background I do not consider it was unreasonable for the Care Home to wait for the advice of a practicing NHS professional who was involved in Mr X’s care before deciding to arrange a transfer to hospital. As such, aside from the frustration Dr Y experienced through these calls, I have not found any other injustice linked to these events. Ultimately, Mr X went to hospital on the same day Dr Y wanted this to happen. Therefore, I am satisfied the Care Home has already provided a proportionate response to this issue.

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Decision

51. I have completed and concluded this investigation on the basis that there was fault which has already been remedied.

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Investigator's decision on behalf of the Ombudsman