Summary: We will not investigate a council and care homes over the care of Mr X, Mrs X’s husband. Mrs X says the faults in care led to her husband’s death and for distress for her. There were faults admitted by the council and care homes. However, both organisations have taken action to prevent the faults happening for other care home residents. An investigation would be unlikely to find the faults caused Mr X’s death or achieve more for Mrs X than the work the council and care homes have already carried out.

The Ombudsmen’s role and powers

1. We 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)
2. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they could add to any previous investigation by the bodies.

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

3. I considered all the information provided to us by Mrs X and the complaint responses from the organisations. I also considered further information about the action Teesside Care has taken since this complaint.
4. I considered the Ombudsman’s Assessment Code.

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What I found

Background

5. Mr X had dementia and in 2024 was in Woodside before moving to Churchview and then Primrose Court. He was admitted to hospital after a fall at Primrose Court and died with the cause of death being pneumonia.

Woodside

6. There were allegations that carers on a night shift abused Mr X causing bruising. Mrs X complained that the manager of Woodside told her that all of the staff on this shift had been dismissed, but they were not.
7. The Council initiated a section 42 of the Care Act safeguarding enquiry after Woodside raised concerns one of its staff had assaulted Mr X.
8. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he cannot protect himself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.
9. The Council visited the home and talked to the Police. The employee in question left employment at Woodside a few days after the incident. Woodside took the action of ensuring all staff reviewed the dementia policy procedure and the positive behaviour support including the challenging behaviour policy and procedures. It also said it would ensure all staff were aware of the residents’ behaviour plans.
10. The Council escalated concerns about Woodside and carried out a quality assurance visit a month later.
11. The Police took no further action.

Analysis

12. Mrs X said that the manager telling her the whole night shift had been dismissed was during a conversation that does not appear to be recorded. Therefore, an investigation would be unlikely to uncover whether the manager told her this information. It also does not appear that there was more than one staff member involved in this incident.
13. In addition, it seems that the Council took appropriate action to assure itself Woodside was not a risk to Mr X or other residents. Therefore, even though this was a serious incident, an investigation by us would be unlikely to achieve more than what the Council has already done.

Churchview

14. There was an incident where Mr X was alleged to have entered another resident’s room and grabbed her, causing a slight injury.
15. Mrs X said there was insufficient proof her husband caused the injury but she bought the resident flowers and apologised and thought the matter was finished.
16. However, a doctor then assessed Mr X and Churchview then gave Mr X 24 hours’ notice to leave.
17. Teesside Care then corrected this to 28 days’ notice, and Mr X moved to Primrose Court.
18. Churchview subsequently found it had not given Mr X his medication for six days in the lead up to the incident.
19. Mrs X felt this could have affected his cognition and behaviour.
20. Churchview contacted the Council when the incident happened and told it that Mr X had not actually had his dementia medication for over a week. Churchview said it was a dispute between the GP and pharmacy that led to the delay but it had not contacted other medical services such as NHS 111 for advice or obtained an emergency prescription.
21. Churchview said that Mr X had now had his dementia medication and his behaviour improved. It also told staff to escalate to management if there are missed medications and that they must contact 111 to request emergency medication.
22. Regarding the doctor, it seems Churchview contacted the Intensive Community Liaison Service who sent an Acting Consultant to assess Mr X’s needs. The Intensive Liaison Service (the Service) provides specialist mental health assessment and care for people who are experiencing mental health issues while in a general hospital setting or in a crisis in the community.
23. The Council said that Mrs X should make a complaint to this service, which is run by the NHS, if she was unhappy with this assessment. As Mrs X has not yet complained to this service, we cannot look at a complaint about it.
24. The assessment stated that Mr X’s needs had increased and so Teesside Healthcare moved Mr X to Primrose Court where it said his needs would be better met.

Analysis

25. An investigation would be unlikely to establish what happened in the incident due to a lack of reliable evidence from the time.
26. Churchview has admitted to faults around medication and the Council has taken action to address this and prevent it from happening again. It also apologised to Mrs X for the failings.
27. Regarding the referral to the Service, the Council found the record keeping around the reasons for this were insufficient and made recommendations in its action plan to improve record keeping. We would be unlikely to find fault with Teesside Healthcare moving Mr X if a doctor had made this recommendation due to his needs changing.
28. Teesside Healthcare said it should not have given Mr X only 24 hours’ notice. Whilst we understand this would have been distressing for Mrs X, the notice was amended to 28 days. In addition, the Council apologised for this error.
29. Therefore, Churchview has stated that it made errors in relation to medication and record keeping, we would be unlikely to add more to the actions taken by the Council and Churchview to prevent this happening to other residents.

Primrose Court

30. Mrs X complained that her husband lost weight and had several falls at Primrose Court. She feels the poor nutrition and the falls he suffered contributed to his death in hospital.
31. The Council carried out a safeguarding enquiry after concerns raised by an ambulance service which took Mr X to hospital. The Council looked for evidence of neglect and a lack of reporting of Mr X’s falls, especially as he was on blood thinners which put him more at risk after a fall.
32. The Council visited Primrose Court, and its enquiry found Primrose Court did not follow protocol by calling 999 after the first fall Mr X suffered but did adhere to protocol following the second fall which led to him being taken to hospital.
33. The Council said that no skull injury was found by the medical examiner and the fall did not cause his death.
34. It found fault and made recommendations for Primrose Court to ensure its policies are followed relating to falls, that a list of all residents on blood thinners was easily available in each nurse’s office and that staff undergo comprehensive falls training.
35. Primrose Court has carried out these actions.
36. In addition, the Council asked Primrose Court about Mr X’s nutrition. Primrose Court provided inadequate records in relation to this, and the Council apologised for this fault.
37. As part of the action plan placed on Teesside Care there was a requirement for it to monitor food and fluid charts and to escalate concerns about nutrition to external agencies if a resident’s nutrition is suffering.
38. Teesside Healthcare admitted that its care fell below its standards and stated it had carried out the action plan to address all of the faults found in this complaint. It also apologised for the distress its faults caused to Mrs X.

Analysis

39. This was a serious situation for Mr X in Primrose Court not phoning emergency services when he fell and not properly managing his nutrition.
40. However, an investigation would be unlikely to find that these faults caused his death as the medical examiner found he died of pneumonia and the nutrition charts would not give enough evidence of how much food and fluids he was taking on.
41. In addition, the Council acted appropriately by investigating Primrose Court, putting in place an action plan and carrying out several unannounced visits to ensure it was complying with the plan.
42. Teesside Healthcare has also taken sufficient action to help prevent this happening to other residents by carrying out the action plan.
43. This was the outcome that Mrs X wanted as a result of the complaint and although she does not accept that the actions have taken place, we have seen what we consider adequate evidence of the actions. An investigation by us would be unlikely to achieve more for Mrs X.

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Decision

44. An investigation by the Ombudsmen would be unlikely to add to the actions carried out by the Council and Teesside Healthcare and so we will not investigate this complaint.

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Investigator's decision on behalf of the Ombudsman