NHS Barnet Clinical Comissioning Group (19 021 064b)

Category : Health > Community hospital services

Decision : Closed after initial enquiries

Decision date : 15 Feb 2021

The Ombudsman's final decision:

Summary: Mr B complains about the care and support provided to his wife’s late cousin, Miss J, while resident in a home partly funded by the Council and the Clinical Commissioning Group. Mr B says Miss J suffered continuous weight loss and was unlawfully strapped to a chair for long periods by the Home during the last six months of her life. Mr B also complained about the decision to discharge Miss J from hospital and a failure to readmit her to hospital. Mr B’s complaint to the Ombudsmen is late and it is unlikely we can add to the previous investigation completed by the Council or achieve the outcome he wants.

The complaint

  1. The complainant, who I shall refer to as Mr B, complains about the actions of London Borough of Barnet (the Council), Barnet Clinical Commissioning Group (the CCG) and Carlton Court Nursing Home (the Home). He said while his wife’s late cousin, Miss J, was resident in the Home from May 2018 to June 2019 she:
    • suffered continuous weight loss due to the lack of provision of sufficient food and drink and no doctor treated her for this condition.
    • experienced severe discomfort during the last six months of her life because she was strapped to a reclining wheelchair for up to 12 hours daily.
    • she was discharged from hospital too soon and was denied readmission to hospital despite requiring medical care and treatment.
  2. Mr B said the concerns led to Miss J’s premature death and he says he is seeking justice for Miss J as an outcome for his complaint. He did not define this specifically but said he wanted the people involved to be punished.

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The Ombudsmen’s role and powers

  1. 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)
  2. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
  3. 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 would find fault, or
  • the fault has not caused injustice to the person who complained, or
  • it is unlikely they could add to any previous investigation by the bodies, or
  • they cannot achieve the outcome someone wants.

(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

  1. I have considered information provided by Mr B with his complaint and information provided by the Council and the CCG to the Ombudsmen. Mr B has been given an opportunity to respond to a draft of this decision.

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What I found

Legal and administrative context

  1. The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 and came into force on 1 April 2009. The safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no less restrictive alternative. The legislation sets out the procedure to follow to obtain authorisation to deprive an individual of their liberty. Without the authorisation, the deprivation of liberty is unlawful. It is the responsibility of the care home, hospital to apply for authorisation.

Background

  1. Miss J was resident in the nursing home from February 2015 to June 2019 following a move from the community. Mr B said that although Miss J was over eighty years old, she was physically fit and well and mobile.
  2. Mr B complained to the Council and the CCG in February 2019 about the care and support Miss J was receiving in the Home.
  3. The CCG responded to the complaint and said it was not providing care directly to Miss J. It confirmed it had contacted the Home and was assured Miss J had access to a doctor who Mr B could complain to. The CCG also said it was a clinical decision for Miss J to be discharged from hospital and the use of the restraint strap was in line with the authorisation in place.
  4. The Council responded to Mr D’s complaint in April and said officers had been to visit Miss J on separate occasions and established that she spent no more than two hours at a time strapped in her chair. A risk assessment was in place as well as a DoLS authorisation. The Council’s safeguarding officer also witnessed staff helping Miss J to mobilise.
  5. It also said the Office of the Public Guardian had met with the Home and Mr B, and did not have any concerns about the use of the restraint to help manage Miss J’s safety.
  6. The Council also said it had completed a safeguarding enquiry into the concerns raised about Miss J’s discharge from hospital in November 2018. The safeguarding investigation had established Miss J was medically fit for discharge. It also said ambulance staff had made the medical decision not to admit Miss J to hospital after visiting her in the home.
  7. In response to Mr B’s complaint about Miss J’s weight loss the Council said the Home was managing her weight closely and she had been eating and drinking.
  8. Mr B wrote to the Council again in June 2019 to escalate the complaint. The Council responded in September and apologised for its delay in replying. It reiterated what it had said in its earlier response and added that a speech and language therapist and a dietician had provided advice to the Home about what Miss J should eat. Miss J had gradual weight loss and the Home had taken appropriate action. It also said the DoLS authorisation permitted the care home to use the restraint strap for up to two hours daily. This was the least restrictive option to manage Miss J’s risk of falls.
  9. Mr B complained to the Ombudsmen in September 2020.

Findings

  1. Mr B’s complaint to the Ombudsmen is late. He was aware of the issues he complained about from 2018 and raised a complaint in early 2019. There was some delay by the Council in responding which I have considered. Nevertheless, Mr B has taken more than 12 months to complain to the Ombudsmen from the date he was aware of the issues.
  2. We have discretion to investigate late complaints. Based on the evidence available now, we should not do so as it is unlikely we can add to the previous investigations already completed. An investigation would involve a review of the care and records held by the Home. Mr B believes these documents would have been manipulated to cover up fault. He also disagrees with the opinion of clinicians that Miss J was medically fit for discharge from hospital. On balance, it is unlikely the Ombudsmen would find fault just because Mr B disagrees with medical opinion.
  3. Mr B does not claim a personal injustice but says he wants justice for
    Miss J. He has not defined what he means by justice but said he wants the people involved to be punished for what he feels was Miss J’s premature death. The Ombudsmen could not achieve the outcome Mr B wants.

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Final decision

  1. We should not investigate Mr B’s complaint as it is late, and we cannot add to the previous investigation completed or achieve the outcome he wants. I have closed the complaint.

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Investigator's decision on behalf of the Ombudsman

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