Summary: Mrs A complains about a council and care home relating to the care and treatment provided to her mother in 2020. We found fault in fluid management recording and in staff not seeking emergency treatment earlier. The Home has taken appropriate action to address these issues in its care of other residents, but we have recommended it apologises for the uncertainty caused to Mrs B for the delay in seeking emergency treatment.

The complaint

1. Mrs A complains about her late mother, Mrs B’s care at Avon View Care Home (the Home) from January to May 2020. Mrs B was hospitalised in May 2020 and sadly died several days later. Her care at the Home was funded jointly under s.117 of the Mental Health Act (MHA) by Bournemouth, Christchurch and Poole Council (the Council) and Dorset CCG (the CCG).
2. Mrs A has complained the Home did not properly manage her mother’s fluids home leading to severe dehydration, her hospitalisation and later her death.
3. Furthermore, Mrs A complains the Home administered laxatives to her mother despite suffering from vomiting and diarrhoea and this worsened her dehydration.
4. She also complained there was a delay in the Home calling emergency services when her mother was showing symptoms of a stroke which contributed to her mother’s death.
5. Mrs A has suffered distress from losing her mother and not knowing if more could have been done to help her.
6. As a result of this complaint, Mrs A would like the Home held accountable, acknowledge its failings contributed to her mother’s death, apologise and for action taken to prevent this happening again.

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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)
8. 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).
9. 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.
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. When investigating this complaint I considered information from Mrs A, an NHS hospital trust (the Trust) which treated Mrs B, the Council, the Home and an independent clinical adviser.
12. I considered any comments from Mrs A, the Council and the Home on my draft decision before making this final decision.

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What I found

Background

13. Mrs B was in her 80s and the Home cared for her under s.117 of the MHA. S.117 of the MHA imposes a duty on health and social services to meet the health and social care needs arising from or related to the persons mental disorder for patients detained under specific sections of the MHA (e.g. Section 3). Aftercare services provided in relation to the persons mental disorder under s.117 cannot be charged for. This is known as s.117 aftercare.
14. Mrs A was a resident in the Home in the months leading up to May 2020 when she became ill and was admitted to hospital where she sadly died several days later. A postmortem found her causes of death as:
• 1(a) Multifocal Ischaemic Strokes
• 1(b) Clinically Known Hypertension
15. Multifocal ischaemic strokes are a series of small strokes caused by blockages to the blood flow to the brain.
16. Hypertension is high blood pressure and can lead to heart attacks and strokes.
17. Mrs A made a complaint shortly after her mother’s death and the Home investigated the complaint. In addition, Mrs A contacted the Council to make a safeguarding referral related to her mother’s care. Furthermore, the Coroner and Care Quality Commission (CQC) launched investigations.
18. Mrs A went through three stages of the complaint process with the Home and the Council held a safeguarding review meeting in August 2020. The CQC completed its investigation and the Coroner declined to hold an inquest. Mrs A contacted the Ombudsmen in August 2020.

Hydration management

19. Mrs A complained the Home did not properly record her mother’s fluids leading to severe dehydration. She said her mother was extremely dehydrated when she was admitted to hospital in May 2020.
20. The Home found it had not properly recorded Mrs B’s fluid management. It found occasions when her fluid intake was low, but it had not addressed this in her support and care planning. This meant it could not be sure Mrs B’s fluids were properly managed during her stay. As a result of this complaint the Home drew up an action plan to address this and other faults. The actions taken in relation to fluid management were that the Home put in place a system to review progress of patients’ care daily with any shortfalls identified early and that this was recorded properly. The Home and Council monitored recording and said it had greatly improved by September 2020.
21. The Council said it had drawn up the action plan with the Home and considered there were no safeguarding concerns in this case after taking into account evidence from the Home, Trust and the Coroner.
22. I have seen evidence the Home did not properly record Mrs B’s fluid management and she was dehydrated when admitted to hospital. This could indicate that this fault in recording meant the Home did not manage Mrs B’s fluids properly leading to dehydration.
23. However, normally if a patient is not drinking enough and becomes dehydrated, they would have low blood pressure, not high blood pressure which Mrs B was suffering from when admitted to hospital. This would indicate the dehydration was more a consequence of her deterioration rather than the cause of it.
24. Taking this into consideration I do not find the fault of the poor recording of fluid management led to Mrs B’s dehydration, deterioration and her death. In addition, the Home and Council have taken sufficient action to address the fault relating to fluid management.

Laxative administration

25. Mrs A complained the Home gave her mother laxatives for a month before her admission to hospital. This was despite her suffering from vomiting and diarrhoea at times during this period. She complained this led to severe dehydration and her mother’s deterioration and subsequent death.
26. Laxatives when already suffering from vomiting or diarrhoea could exacerbate dehydration. However, there is no evidence in the records that administration of laxatives caused Mrs B’s diarrhoea to get worse and to have a significant effect on her hydration. There is evidence the laxatives improved Mrs B’s bowel movements without causing severe diarrhoea. Therefore, I have not found fault in this aspect of the complaint.

Delay in seeking emergency treatment

27. Mrs A has complained her mother was showing signs of a stroke in the days leading up to her admission to hospital but the staff at the Home did not call an ambulance.
28. She said staff found her mother unconscious the day before she was admitted to hospital, but a doctor was not called. Furthermore, she said her mother was ill for the five days leading up to her admission without staff calling a doctor.
29. The Home’s investigation found staff should have been more active in monitoring Mrs B’s condition during these days and in reporting her worsening condition. It concluded staff should have sought emergency assistance earlier.
30. The Home’s action plan stated it would train staff in noticing the signs of a stroke and escalating health concerns and this training has now taken place.
31. From the evidence I have seen the Home contacted Mrs B’s GP two days before her admission due to high blood pressure and complaining of pain. The GP gave some advice and Mrs B appeared more comfortable later in the day.
32. In the day before her admission Mrs B had a ‘vacant episode’ and was struggling to talk and grip a staff member’s hand. The Home rang the GP, but they could not come to see Mrs B until the following day.
33. On the morning of her admission Mrs B was unresponsive and staff did not seek medical advice although the district nurse visited in the afternoon and took Mrs B’s blood pressure which they fed back to the GP. At around 4pm the GP contacted the Home to tell staff to call an ambulance due to the blood pressure reading taken by the district nurse.
34. The Face, Arm and Speech Test (FAST) states that with a suspected stroke victim one should check for facial or arm weakness and speech problems. If any of these exist, then one should call 999. From the Home records, Mrs B was suffering from speech and arm weakness issues the day before her admission. However, staff did not call 999 although they did contact the GP. Again, the following day when Mrs B was unresponsive staff could have called 999 but did not.
35. However, after staff roused Mrs B, she seemed better, and the district nurse came and checked her blood pressure. In addition, Mrs B’s care plan stated staff should avoid sending her to hospital in addition to the fact staff were trying to keep vulnerable patients away from hospital to avoid the risk of contracting COVID-19. I have considered these mitigating factors, but it was still fault that emergency treatment was not sought the day before or the morning of Mrs B’s admission and the Home has already accepted this in its own consideration of the complaint.
36. With stroke victims it is important to begin treatment as soon as possible. Looking at the impact on Mrs B, even though it is important to get stroke treatment quickly, in this case we cannot say any delay lead to her deterioration and death. This is because even with all the diagnostic equipment and specialists in the hospital, there were no definitive signs Mrs B had had a stroke and treatment did not improve her condition. However, Mrs A has the distress of not knowing if more could have been done to help her mother if staff had sought emergency treatment earlier.
37. The Home has now taken appropriate systemic action in training staff on escalating to medical staff and recognising the signs of stroke.

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Recommendations

38. Due to the uncertainty for Mrs A caused by the fault in not seeking emergency treatment earlier for her mother, I will be recommending that the Home, if it has not already done so, by 28 October 2021, write to Mrs A acknowledging and apologising for the uncertainty and distress caused by the fault of not seeking emergency treatment earlier for her mother.

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Final decision

39. I find although there was fault in how the Home recorded fluid management, the Home and Council put in sufficient measures to prevent this occurring again.
40. There was fault by staff in not seeking emergency treatment earlier, but I do not find this led to Mrs B’s deterioration and death.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman