Medway NHS Foundation Trust (18 017 295b)

Category : Health > Community hospital services

Decision : Not upheld

Decision date : 19 Dec 2019

The Ombudsman's final decision:

Summary: Mrs D complained about the care of her mother by a Trust, a Council and Community Healthcare Trust. We found some fault with the Community Healthcare Trust, however we consider it took sufficient action to remedy this and the fault did not cause the injustice Mrs D claims.

The complaint

  1. Mrs D complains about her late mother, Mrs E’s discharge from Medway Maritime Hospital (the Trust) to a care home (the Care Home) on 6 December 2016. Mrs D has said the family were told Mrs E would have a suitable bed in the Care Home but this was not the case. This led to Mrs E having to be cared for in her own home.
  2. Mrs D also complains about the home care of her mother by both Medway Council (the Council) commissioned carers and Medway Community Healthcare Trust (MCH) community nurses. Specifically, she has complained about the lack of maintenance of her mother’s hygiene, repositioning and the lack of care of her pressure sores. Mrs E developed sepsis and this led to her hospitalisation. She sadly died in hospital on 2 January 2017 and her death has caused a great deal of distress to the family.
  3. Mrs D would like service improvements and financial compensation for the impact these alleged failings had on her mother and the family.

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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)).
  2. If it has, they may suggest a remedy. 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. We have considered evidence provided by Mrs D, the Hospital Trust, MCH and the Council. We have also considered the relevant law and guidance and taken advice from a Registered Nurse. I shared my draft decision with Mrs D and the organisations complained about. I considered Mrs D’s comments on the draft decision before making my final decision.

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What I found

Guidance

  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.
  2. Where a council has determined that a person has any eligible needs, it must meet these needs. The council should ensure the process is person-centred and must take into consideration the individual’s preferences. The council may take into reasonable consideration its own finances and budgetary position. However, the council should not set arbitrary upper limits on the costs it is willing to pay to meet needs through certain routes. (Care and Support Statutory Guidance 2014).

Background

  1. Mrs E was 85 in late 2016 and had previously suffered two strokes. She also suffered from congestive heart failure and osteoporosis. Mrs E was admitted to hospital on 28 November 2016 after suffering a broken left shoulder from a fall. She was discharged from hospital on 6 December 2016 for a six week rehabilitation at the Care Home. However, there was an issue with the bed that she was provided with at the Care Home and the family decided to take her to her own home.
  2. The Council said the Care Home provided a profile bed as needed but in a shared room. Profiling beds are an electric care bed used in care homes and care at home to assist elderly and disabled users with mobility and their carers with nursing. They also have side rails either side of the mattress platform that can be raised and lowered to help prevent falls from the bed. The Council went on to say that the family did not want a shared room and so decided to take Mrs E home.
  3. When Mrs E returned home the Council put in place a care package with an agency (the First Agency). This was for four half hour daily visits by two carers. This involved getting Mrs E up in the morning, washed and dressed, then making any meals she may want during the day and getting her ready for bed at night.
  4. The Council said Mrs E had two pressure sores on her buttocks on her initial assessment on 6 December 2016. It informed MCH who provided community nurses to support carers with a care plan to try and relieve the pressure sores. Carers were also asked to apply Proshield and reposition Mrs E to ease pressure on the areas at risk of breaking down. Proshield is a skin protectant for use in the prevention and temporary protection of chafed, chapped, cracked or dry skin.
  5. The First Agency said its visits were taking up to two hours a time so the Council on 12 December agreed to extend support to 45 minutes each visit and for carers to seek authorisation on the day if they needed more time.
  6. The First Agency said it had issues providing care to Mrs E in her bedroom due to a lack of space. It asked for Mrs E to be moved to the downstairs lounge to better enable them to deliver care. However, the Council said Mrs E’s son declined this suggestion. The Council said Mrs E needed to be in a care home but when it was planned on 12 December she had a stomach bug so could not be moved. The Council went on to say on 20 December it was trying to organise respite care at a care home but Mrs E wanted to stay at home for Christmas. The First Agency struggled to provide care and their duties were passed to the Second Agency on 20 December 2016.
  7. The Council said on 20 December the Second Agency found Mrs E had three pressure sores. Two were grade 2 (partial thickness skin loss, the sore is superficial looks like an abrasion or blister) and one was necrotic. Necrosis is the death of cells or tissues from severe injury or disease, especially in a localised area of the body. Causes of necrosis include inadequate blood supply.
  8. Carers from the Second Agency said they told the family Mrs E should be lying down, but she liked sitting in her chair. The Council said this can increase the deterioration of pressure sores. The Second Agency said Mrs E did not like to be repositioned regularly as it caused pain in her broken shoulder. It was also difficult to wash Mrs E regularly for these reasons.
  9. On 21 December the Second Agency gave notice to end their care because it felt unable to provide support. The Council said it was the opinion of all professionals involved that Mrs E’s needs could not be met at home and she should move to the care home. However, the Council said Mrs E declined this advice as she wanted to be home for Christmas.
  10. MCH said its Pressure Sore Policy stated that an appropriate dressing should be selected and based on the evidence available and tissue viability advice. MCH also said patients should be referred to the Tissue Viability Service if staff are concerned about a deteriorating pressure sore or if they are not healing after four weeks. It said both of these actions took place as per the policy. It made a referral to a Tissue Viability Nurse on 22 December due to the sores deteriorating.
  11. On 29 December 2016 the Tissue Viability Nurse could not gain entry to Mrs E’s property when she visited. She telephoned the community nurses to explain that she had been unable to assess Mrs E. MCH said if she had been able to gain entry, she would not have been able to assess the pressure damage as two people were required to move Mrs E. MCH said it had raised with the Tissue Viability Nurse’s manager why did she not actively pursue going in to visit Mrs E, even to just talk to Mrs E; this was also shared with the wider team as a lesson learnt.
  12. MCH said it was recorded in Mrs E’s notes on 30 December 2016 that two of her pressure sores were necrotic but there was no indication within the notes of infection.
  13. MCH said there was communication between the Community Nurses and the Tissue Viability Nurses throughout Mrs E’s care. It went on to say community nurses had already put everything into place that was required in accordance with the type of sore. This included advice about not getting out of bed and pressure relieving equipment. MCH said if the Tissue Viability Nurse visited, she would have checked the correct dressings were in place and if there was anything else needed.
  14. MCH said pressure sores are treatable and preventable, but it does require a multitude of factors to all be aligned to make that happen, including factors such hydration, general health and heart disease.

6 December discharge

  1. Mrs D said the bed the Home had promised was not there when they arrived and the one that was offered was not suitable for her mother as she had curvature of the spine so they felt they had no choice but to take her home or take her back to hospital.

Analysis

  1. There is a note in the Trust’s records at this time from a Clinical Sister saying the Care Manager rang to say the family were not happy with the bed and had taken Mrs E home. However, there is insufficient evidence of what bed the Home provided and whether it was adequate to meet Mrs E’ s needs. Therefore, I cannot make a finding even on balance of probabilities as to whether there was fault on the part of the Council or Trust with this discharge.

Lack of care by care agencies and community nurses

  1. Mrs D complained the care package was inadequate to provide proper care to her mother. In addition, carers did not wash her mother regularly, reposition her properly or manage her pressure sores. Furthermore, Mrs D criticised the community nurses in their pressure sore care and the fact the Tissue Viability Nurse did not enter the property to see her mother on 29 December 2016. Mrs D said this lack of care meant the pressure sores got infected, her mother contracted sepsis and had to be taken to hospital on 1 January where she sadly died on 2 January 2017. The death certificate put the cause of death as:
  • ‘Sepsis
  • Infected Sacral Sore
  • Chronic Kidney Disease, Multiple Myeloma, Two previous Myocardial Infarcts’

Analysis

  1. With regards to hygiene, for patients who have episodes of incontinence (such as Mrs E) and wear continence pads; at every positional change the pad should be checked and if soiled, personal hygiene should be provided to the patient.
  2. Regarding the maintenance of Mrs E’s hygiene through regular washing, there is evidence Mrs E was washed regularly although not always daily. It is evidenced she was in pain with her shoulder and was not always amenable to being washed. However, I have not found fault with the care agencies as they did attempt to wash Mrs E regularly. This is also in the context that the carers were struggling to meet all of Mrs E’s needs in the time allocated to each visit. At each visit Mrs E was offered the use of a commode (which she sometimes declined and had the capacity to do so in line with the Mental Capacity Act 2005) and her personal hygiene was attended to afterwards. I have not found fault with these actions as they were within national guidance taking into account the difficulties the carers were experiencing.
  3. The national guidance (NICE CG179 (2014) ‘Pressure sores: prevention and management) states:

“Encourage adults who have been assessed as being at high risk of developing a pressure sore to change their position frequently and at least every 4 hours. If they are unable to reposition themselves, offer help to do so, using appropriate equipment if needed. Document the frequency of repositioning required”.

  1. With regards repositioning it is evidenced from the records there was difficulty in repositioning Mrs E due to the pain she was suffering from her broken arm and the lack of space for a hoist in her room. In addition, there were not enough care visits per day to ensure she was repositioned every four hours. However, I have not found fault with the carers as they attempted to reposition Mrs E but were hampered by a lack of equipment and frequency of visits. In addition, Mrs E did not always want to be moved. MCH nursing records also indicate they advised Mrs E to change her own position if possible in between visits which was appropriate.
  2. With regard to Mrs E’s pressure sore care, she had existing pressure sores prior to carer and district nursing visits. The cause was documented as prolonged sitting. Over the timeframe that care was delivered, Mrs E was sometimes non-concordant with advice, it is documented that “she is unable to change position as often as advised to.”
  3. Pressure area care that is delivered in the home also depends on additional input between district nursing visits. This has to be carried out by carers, family and the patient themselves. There is evidence of education and information sharing from community nurses to carers, Mrs E and her family.
  4. The district nurses delivered care in line with national guidance by ensuring that pressure areas were checked and treated every other day; by providing the family and carers information about pressure sore care and referring Mrs E to the Tissue Viability Nurses due to the severity of the pressure sores.
  5. There is evidence in the notes that the carers regularly applied Proshield and washed the affected areas. Pressure area care was in line with national guidance (NICE CG179 2014) and I have not found fault with this aspect of the complaint. Although the pressure sores deteriorated and became infected, I have not found enough evidence to find this was due to any fault on the part of the community nurses or the carers.
  6. Regarding the Tissue Viability Nurse on 29 December 2016 it was fault on her part that she did obtain the key safe code and at least go in and see Mrs E. However, it did not have a detrimental effect on Mrs E’s condition as the nurse would not have been able to treat her without help from the carers who were not in attendance. In addition, her pressure sores were not showing signs of infection the following day. It is appropriate that the nurse has been spoken to about her conduct and that it was shared for wider learning in the MCH. I would not recommend any further action on this issue.
  7. In relation to Mrs D’s criticism of the care plan, it is the case that several professionals felt Mrs E should have been in a care home. In addition, the Council increased the visit length time and offered to pay for visits that went over the allocated time. When both agencies gave notice to pull out, there is evidence the Council made efforts to find new agencies, and to put support in place so there would be no break in care. Ultimately it was a difficult situation for all involved and the Council found it hard to find agencies that could meet Mrs E’s needs. Taking this into account I have not found fault with the Council with regards the care package and attempts to meet Mrs E’s needs.

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Final decision

  1. This was a difficult situation and it is clear that Mrs E suffered a distressing time towards the end of her life. However, I have not found fault with the Trust or Council and although there was fault on the part of MCH in relation to the Tissue Viability Nurse, it has taken sufficient action to remedy this. In addition, there was insufficient evidence that Mrs E’s death was caused by any actions of the organisations complained about.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman

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