Norfolk Community Health & Care NHS Trust (16 016 347d)

Category : Health > Community hospital services

Decision : Upheld

Decision date : 28 Mar 2018

The Ombudsman's final decision:

Summary: Mrs X complains the organisations involved in this complaint did not do enough to diagnose her husband, Mr X’s brain tumour. She also says the Council did not offer enough support for Mr X’s social care needs. There is some evidence of fault in the actions of a matron employed by the Norfolk Trust as she failed to properly record how she assessed Mr X. However, this has not caused an injustice. There is no evidence of fault in the other parts of the complaint.

The complaint

  1. Mrs X complains about the failure to diagnose and support her husband, Mr X. In summary:
    • In November 2015, Mr X went to the Practice and was referred for cognitive behavioural therapy (CBT). He attended the Practice regularly between November 2015 and April 2016. Mrs X considers the Practice should have investigated more thoroughly at the outset as she considers it could have detected he had a brain tumour. Mr X attended the Practice again on 6 April 2016. He was given blood tests and referred to a community matron at the Norfolk Trust.
    • Mrs X contacted the Council to request assistance in April 2016. She says the Council simply determined Mr X had assets over the relevant threshold so did not qualify for assistance. She considers the Council should have signposted her to available services. She is also concerned about a capacity assessment the Council completed.
    • Mrs X considers the Ambulance Service and the Wellbeing Service failed to take any action to investigate Mr X’s condition.
    • A community matron from Norfolk Trust assessed Mr X on 6 April 2016 but this did not result in assistance with funding the placement which he eventually took up. Mrs X says these assessments were repetitive.
    • On 8 April 2016 Mr X attended the accident and emergency department of the QEHKL Trust. Mrs X is concerned Mr X was not given a computed tomography (CT) scan (an x-ray and computer scan used to create detailed images of the inside of the body) or any other neurological investigations.
    • Ultimately Mrs X was compelled to place Mr X in a residential home which she funded privately at £100 per day. She is concerned Mr X may have been eligible for financial support with the placement. Mrs X also commissioned two scans privately, at the cost of £1,700 which she says was a result of the Practice failing to visit Mr X at the placement.

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The Ombudsmen’s role and powers

  1. 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).
  2. 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.
  3. 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

  1. I have considered a written complaint from Mrs X and I have discussed the matter with her. I have made enquiries of the organisations complained of and considered the responses with supporting documents. I have taken relevant guidance into account.
  2. Before coming to a view, I have sought advice from a general practitioner, emergency department consultant, nurse and mental health nurse.
  3. I have issued a draft decision on the complaint and invited comments from all the parties.

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What I found

  1. Mr X attended the Practice on 11 November 2015 with what it described as a ‘stress-related problem’. The Practice recommended CBT. It signposted Mr X to the Wellbeing Service and Mr X contacted the service directly on 10 December 2015 to begin CBT.
  2. On 4 April 2016, Mr X fell and Mrs X called an ambulance. The paramedics who attended did not take Mr X to hospital but recommended he visit the Practice. He did so on 6 April 2016. The Practice ordered blood tests and referred Mr X to a community matron for an assessment.
  3. On 8 April 2016 Mr X attended the emergency unit of the QEHKL Trust. He was discharged the same day.
  4. On 12 April 2016 Mrs X contacted the Council and requested an assessment. The Council determined Mr X had assets over the threshold for eligibility for care services.
  5. In late April 2016 Mr X was diagnosed with an aggressive brain tumour.

Relevant law and guidance

Social care

  1. Sections 9 and 10 of the Care Act 2014 require local authorities to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to all people regardless of their finances or whether the local authority thinks an individual has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.

Mental capacity

  1. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
  2. A person must be presumed to have capacity to make a decision unless it is established that he or she lacks capacity. A person should not be treated as unable to make a decision:
  • because he or she makes an unwise decision;
  • based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
  • before all practicable steps to help the person to do so have been taken without success.
  1. The council must assess someone’s ability to make a decision, when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
  2. An assessment of someone’s capacity is specific to the decision to be made at a particular time. When assessing somebody’s capacity, the assessor needs to find out:
  • Does the person have a general understanding of what decision they need to make and why they need to make it?
  • Does the person have a general understanding of the likely effects of making, or not making, this decision?
  • Is the person able to understand, retain, use, and weigh up the information relevant to this decision?
  • Can the person communicate their decision?

Analysis

The Practice

  1. The guidance on brain tumours in adults sets out the symptoms a person might have that require further investigation to determine whether he or she has a brain tumour. The guidance says:

‘Anyone presenting with new, unexplained headaches or neurological symptoms needs a thorough neurological history and examination. The presentation will depend on location and rate of growth but includes features of a space-occupying lesion and raised intracranial pressure (ICP):

    • Headache, which is typically worse in the mornings.
    • Nausea and vomiting.
    • Seizures.
    • Progressive focal neurological deficits - eg, diplopia associated with a cranial nerve defect, visual field defect, neurological deficits affecting the upper and/or lower limb.
    • Cognitive or behavioural symptoms.
    • Symptoms relating to location of mass - eg, frontal lobe lesions associated with personality changes, disinhibition and parietal lobe lesions might be associated with dysarthria.
    • Papilloedema (absence of papilloedema does not exclude a brain tumour).’
  1. I have reviewed Mr X’s medical records. When Mr X visited the Practice in November 2015 he complained of anxiety and poor sleep. He again approached his GP in December the same year with similar concerns explaining that his stress was worse. His GP signposted him to the Wellbeing Service for CBT and prescribed propranolol which blocks the symptoms of anxiety.
  2. On 6 January 2016, the Wellbeing Service wrote to Mr X’s GP. It explained Mr X had taken a patient health questionnaire. He scored 18 which indicated he had moderately severe depression. Mr X also took an anxiety test which showed he had severe anxiety. Both these factors indicated Mr X had mental health, rather than neurological difficulties and therefore neurological investigation was not carried out. There is therefore no evidence of fault in the Practice failing to consider neurological investigations at this point.
  3. In February and March 2016 Mr X visited the Practice twice and his notes show his stress was improving with the CBT. The Practice prescribed medication for anxiety to further correct the imbalance in his mood. I therefore do not consider there was evidence of fault at this point as Mr X appeared to be improving as a result of the CBT and medication changes.
  4. Mrs X contacted the Practice the day the Ambulance Service visited, on 4 April 2016. However, Mr X’s usual GP was on annual leave. The Practice said it offered Mr X an appointment with another GP but Mrs X declined this offer. However, Mr X visited the practice two days later.
  5. The National Institute for Health and Care Excellence (NICE) issued clinical guidelines known as ‘Suspected Cancer: recognition and referral’. The guidance says that for brain and central nervous system cancers, a CT scan should be performed within two weeks in adults with progressive, rapid loss of neurological function.
  6. Mr X attended an appointment on 6 April 2016. The notes from the day record a thorough investigation. Mr X’s GP queried whether he had Parkinson’s disease or a neurological problem. He ordered blood tests and referred Mr X to the community matron. Mr X’s blood tests came back two days later. Our GP advisor confirmed the results were essentially all normal and there was nothing to indicate a neurology referral was appropriate at this point.
  7. The notes record Mr X’s GP had a discussion with the community matron on 12 April 2016. The notes say the family was ‘…anxious/wondering about [a] referral to [a] neurologist to be assessed…’
  8. The notes go on to say the Practice made a referral two days later. Based on the records, I cannot conclude the Practice should have made a neurology referral sooner. There was nothing in Mr X’s physical presentation or blood tests that indicated that neurological investigation was indicated. Indeed, the Practice appears to have eventually made the referral based on the family’s wishes. This is appropriate as patients and their families have the right to be referred privately but this will usually require a letter from a GP. I therefore do not consider there is evidence of fault in the Practice failing to identify Mr X needed neurological investigation sooner.

The Ambulance Service

  1. Mr X fell on 4 April 2016 and Mrs X called an ambulance. The paramedics did not take him to hospital, but gave him a copy of the documentation from the visit to take to the Practice.
  2. The paramedics visited again on 7 and 8 April 2016, when Mr X was taken to a QEHKL Trust hospital.
  3. NICE also issued clinical guidelines known as ‘Head Injury: assessment and early management’ (the Head Injury Guidance). The Head Injury Guidance sets out the expectation for a paramedics’ initial assessment. It says paramedics should use the Glasgow Coma Scale (GCS, a tool used to assess the level of consciousness in patients with an acute brain injury).
  4. The GCS guidance says observations should be performed and recorded on a half-hourly basis until a score of 15 has been achieved.
  5. I have reviewed the paramedics notes from the visits and noted the following:
    • On 4 April 2016 Mr X’s GCS score was 15 on the first recording. The paramedics monitored Mr X for around half an hour and his score remained the same. The paramedics advised Mr X to see his GP.
    • On 7 April 2016, the paramedics monitored Mr X for half an hour and recorded his GCS score at three intervals. Each time the score was over 15. The paramedics noted Mr X was due to see his GP the following day.
    • On 8 April 2016, the paramedics recorded Mr X’s GCS score at 15 on two occasions and noted his GP had begun investigations. However, he was transported to hospital.
  6. I can find no evidence of fault in the way the paramedics assessed Mr X. On the three occasions he was seen, the paramedics assessed him in line with the Head Injury Guidance. Each time his GCS score was 15 or above. The paramedics made a clinical decision to transport him to hospital on the third occasion.

The QEHKL Trust

  1. Mr X attended the QEHKL hospital accident and emergency department on 8 April 2016. Mrs X believes the QEHKL failed to diagnose Mr X’s brain tumour on this day.
  2. The Head Injury Guidance says that patients with a high risk of brain injury should have a full clinical assessment to determine whether a CT scan is needed.
  3. Mr X’s clinical records from the day show he was admitted because he had fallen the previous evening. He had no loss of consciousness, headaches or nausea. Mr X had a history of unsteadiness on his feet, however, our advisor confirmed there was nothing in his initial assessment to indicate he needed an urgent CT scan that day.
  4. An occupational therapist assessed Mr X and decided he was not safe at home as the family were not coping. Therefore, the emergency department consultant considered whether Mr X should be admitted to hospital for social, rather than health-related reasons. However, at this point Mrs X had arranged a respite placement for Mr X.
  5. Hospital admission is generally avoided for elderly patients due to the risk of hospital-acquired infections. Therefore, given that any admission would have been for social reasons, it was appropriate that Mr X was discharged to the placement in the circumstances.
  6. Mr X had a CT scan later the same month which showed he had a very large, advanced tumour.
  7. As people age, the brain gradually shrinks which leaves a surrounding space. Any additional mass in an older person, for example, a blood clot or tumour, may not cause the same effects as it would in a younger person and the physical signs of such a mass may not be readily apparent. Therefore, while the evidence suggests Mr X’s tumour may have been present for some time, there was a lack of physical evidence to suggest the tumour was present.
  8. Further, when taking a decision to request a CT scan, the likelihood of identifying a problem must be weighed against the risks of the procedure. Risks include allergy to the contrast material and the brain’s exposure to radiation. Given these risk factors and the lack of physical symptoms indicating a scan was necessary, I do not consider there is evidence of fault in the QEHKL Trust failing to request a CT scan.

The Norfolk Trust

  1. The Norfolk Trust is responsible for the actions of the community matron. In response to my enquiries, the Norfolk Trust explained it received a referral on 6 April 2016.
  2. Community matrons assess people with high needs with a view to avoiding hospital admission. Their role involves assessing people and making appropriate referrals, for example to a physiotherapist.
  3. The community matron assessed Mr X the same day. She concluded Mr X’s main issues were with mobility and falling as well as cognitive and neurological problems. She referred Mr X for physiotherapy services but concluded he did not have any rehabilitation needs.
  4. The record of the assessment is brief, considering the matron spent some time with Mr X. She identified Mr X had lost a lot of weight and she should have undertaken a formal malnutrition risk assessment. This may have resulted in a referral to a dietician. However, in terms of Mr X’s medical needs, the matron was unable to act until the GP had completed his medical assessment. As discussed above, ultimately Mr X’s blood tests showed nothing unusual. Therefore, it is unlikely that, had the matron had this information, the outcome would have been different.
  5. The record-keeping around the assessment is poor and this is evidence of fault. There should have been a comprehensive record of the assessment and it is therefore difficult to see how the matron concluded Mr X did not have a health or rehabilitation need. This is evidence of fault. However, our advisor has confirmed that this does not mean Mr X should have been assessed for health funding.
  6. Mrs X essentially complains that Mr X’s respite placement should have been funded. However, based on the matron’s conclusions, she determined that the physiotherapist referral was adequate and I cannot conclude the outcome would have been different had the matron had access to the information from the GP about his medical condition. I therefore cannot conclude she would have determined Mr X should have been assessed for health funding for the respite placement and there is therefore no injustice.

The Wellbeing Service

  1. The Wellbeing Service is part of the Improving Access to Psychological Therapies (IAPT) programme. IAPT began in 2008 and aims to implement National Institute for Health and Clinical Excellence (NICE) guidance for people with common mental health problems. IAPT services provide primary-care, evidence-based treatments for people with anxiety and depression and bring them to recovery.
  2. IAPT services receive high numbers of referrals and assessments are therefore focused on psychological therapy and whether this is suitable. IAPT services will also signpost to different services where appropriate. The services do not include multi-disciplinary medical assessments.
  3. IAPT provides ‘stepped care’ as follows:
    • Step 1 – GP-level which includes identification, assessment and active monitoring.
    • Step 2 – Community-based interventions, often in large groups for those with mild to moderate depression, panic disorder and post-traumatic stress disorder, for example.
    • Step 3 – Interventions for those with the symptoms described at step 2 who have not responded. This can include, for example, short-term counselling. This is generally high-intensity therapy usually delivered on a one-to-one basis.
  4. If a patient does not respond at step 3, they are signposted to a higher step or discharged back to a GP. IAPT does not provide neurological assessments but would be expected to signpost to relevant services if this was suspected.
  5. Mr X was offered CBT as part of step 2. The clinical records show he was treated for mixed anxiety and depression. The records do not suggest he had neurological problems. The Wellbeing Service explored the possibility Mr X had depression and his scores in this regard showed improvement.
  6. On 28 April 2016, the Wellbeing Service wrote to Mr X’s GP. The letter outlined the fact Mr X’s symptoms had improved with treatment. However, his cognitive functioning had rapidly declined. The letter explained Mrs X had telephoned and advised Mr X had developed neurological symptoms and suggested Mr X’s GP arrange a mental health assessment.
  7. The letter makes it clear that Mr X was no longer suitable for the Wellbeing Service because his cognition had declined. Mr X therefore no longer had a common mental health problem that could be dealt with in the IAPT service. By asking Mr X’s GP to arrange a mental health assessment when it could no longer undertake psychological therapy, the Wellbeing service acted appropriately. There is therefore no evidence of fault.

The Council

  1. Mrs X believes Mr X should have been diagnosed sooner and therefore entitled to funding for his care. She believes Mr X may have been entitled to a Council-arranged placement. She is also concerned about the Council’s assessment of Mr X’s capacity to decide he wanted to return home.
  2. Mrs X contacted the Council on 12 April 2016 to request an assessment of his social care needs. A Council officer spoke to Mrs X on 18 April 2016. The Council says during this discussion Mrs X confirmed Mr X had assets over the threshold eligible for Council-funded care. It allocated a case worker to help Mr and Mrs X find a suitable placement.
  3. On 18 April 2016, Mrs X contacted the Council again requesting an assessment as she did not consider the respite placement was the right place for Mr X. The Council assessed Mr X on 21 April 2016. The assessment reviewed both Mr X’s social care needs and his ability to make decisions about where he should live. The capacity assessment noted the following factors:
    • The assessor visited Mr X twice. Mrs X was present on the second visit.
    • Mr X was able to tell the assessor details of the placement, including the cost and details of the type of care staff provided.
    • On the second visit, Mr X was able to recall the assessor’s previous visit and the discussion about where he should live. Mr X also recalled previous medical appointments and was able to communicate he had further appointments the following week. The assessor therefore concluded Mr X was able to communicate and retain information long enough to be able to make a decision.
    • Mr X was able to recognise the benefits of being in the care home but said he felt restricted. Mr X was also able to discuss the risks of returning home in terms of using an alarm pendant. He did not want to be in the care home. The assessor therefore concluded Mr X was able to weigh information as part of making a decision.
    • Based on these factors, the assessor decided Mr X had capacity.
  4. There is no evidence of fault in the way the Council assessed Mr ‘s capacity. Mr X had previously been assessed as being able to make decisions. However, the Council still carried out a detailed assessment which included meeting twice with Mr X. The assessor considered all the relevant factors under the Code and reached the view Mr X was able to make decisions about where he should live.
  5. The assessment recorded Mr X’s daughter was arranging a care package at home so Mr X could live with her. The assessment clearly records Mr X had assets above the threshold and his family was arranging care for him at home. I therefore do not consider there is evidence of fault in the Council failing to assess Mr X. It satisfied itself appropriate support was in place, at the home, and arrangements being made for a package of care when he returned to the family home.

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Final decision

  1. There is no evidence of fault in the Practice failing to refer Mr X for neurological investigations.
  2. The Council completed a thorough capacity and social care assessment. There is no evidence of fault in its actions.
  3. Neither the Wellbeing Service nor the Ambulance service are at fault for the actions taken.
  4. There is evidence of fault in the Norfolk Trust’s community matron’s actions. She did not include enough detail in her record of the assessment. However, this did not alter the outcome. There is therefore no injustice.
  5. There was nothing to indicate the QEHKL Trust should have requested an urgent CT scan when Mr X attended on 8 April 2016. There is therefore no evidence of fault.
  6. I have therefore completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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