The Ombudsman's final decision:
Summary: We found fault with the record keeping by the district nurses and the way they ordered dressings. We also found there was a lack of a multidisciplinary team approach to Mr B’s care. We found the Council did not action its safeguarding enquiry immediately and it was not open and honest with Miss A during the complaints process. These faults caused avoidable distress and frustration to Miss A. We recommended an apology, service improvements and financial recompense to address this injustice.
- Miss A complains about the care provided to her father, Mr B, by Central London Community Healthcare NHS Trust (the Trust) between September and November 2020. Miss A also complains about the safeguarding investigation undertaken by London Borough of Wandsworth (the Council).
- Miss A complains:
- The Trust failed to provide Mr B with correct pressure ulcer care. This led his pressure ulcer to worsen significantly.
- The Trust and Council failed to provide effective multidisciplinary care. This led to confusion in the care provided and a disjointed approach which meant they did not refer or escalate properly.
- The Council and Trust failed to fully investigate her concerns about the care provided to her father.
The Ombudsmen’s role and powers
- The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
- 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)
- 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.
- The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
- 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)
How I considered this complaint
- I considered the complaint Miss A made to the Ombudsmen and information she provided on the telephone and by email. I also considered the information provided by the Council and Trust in response to my enquiries.
- I shared a confidential draft with Miss A, the Council and the Trust to explain my provisional findings and invited their comments. I considered these before making a final decision.
What I found
- Mr B had dementia. He lived at home with his wife and received a care package from the Council with carers attending four times a day. Miss A and her brother helped with Mr B’s care.
- Mr B developed a pressure ulcer. Pressure ulcers are injuries to the skin and underlying tissue caused by prolonged pressure on the skin. They are graded using a standard tool from 1 to 4, 4 being the worst.
- Mr B was in hospital and there is a photograph in Mr B’s records from 15 September 2020 which shows a grade 3 pressure ulcer to his sacrum. The hospital discharged him on 24 September.
- The Trust referred Mr B for district nursing home care for the pressure ulcer to his sacrum and noted poor skin quality on both heels. The referral on 24 September states Mr B “has an existing pressure sore – cat 2”.
- Mr B went back into hospital a few days later. He went home on 9 October.
- Miss A worried district nurses were not providing suitable care to the worsening pressure ulcer. She raised a safeguarding concern with the Council on 27 October. The Council opened an enquiry on 9 November 2020.
- Mr B died in late November.
- The Trust explored Miss A’s concerns as part of a Root Cause Analysis (RCA). This is a tool used to help health care organisations retrospectively study events where patient harm or undesired results may have occurred. This allows organisations to identify and address the root causes and make changes, so it does not happen again. The Trust told the Council it was looking at Miss A’s concerns. The Council agreed to wait for the report before continuing with its safeguarding enquiries. The Trust issued the report on 21 December.
- The Council held the Safeguarding Outcome meeting on 22 February 2021 and Miss A attended. She was unhappy with the outcome and made formal complaints to the Council and the Trust. After receiving responses from both, she brought her complaint to the Ombudsmen.
The Trust failed to provide Mr B with correct pressure ulcer care
What should have happened
- A Walsall risk assessment is a tool used by nurses to understand and note the risk of a new pressure ulcer developing or if an existing one could get worse. The Trust’s pressure ulcer care policy states “Walsall risk assessment should be performed:
- At initial assessment to form part of the holistic assessment when the patient is transferred to the community caseload
- All patients who have or are at risk of developing pressure ulcers should be reassessed formally at least monthly and when their condition changes
- If there is a change in carer or care setting
- If the risk status remains high”
- The hospital referred Mr B to the Trust’s district nursing service on 24 September 2020 and told them Mr B had a grade 2 pressure ulcer.
- The service made a mistake when it logged the referral, and this caused confusion to the nurse who assessed Mr B on 25 September. I do not know what happened at this visit because the district nurse did not make notes. The district nurse did take a photo of the pressure ulcer, but this is poor quality and not in line with Trust policy. The same policy states the attending nurse should have completed a Walsall Risk Assessment on Mr B straight after his discharge from hospital. This did not happen.
- Mr B went back into hospital on 29 September. No risk assessment was completed for Mr B until 1 October, when he was in hospital.
- The hospital discharged Mr B on 9 October. The hospital made a second referral to the district nursing service the same date and listed a “chronic grade 3 pressure ulcer to sacrum”. The tissue viability nurse compared Mr B’s admission and discharge pressure ulcer photographs and saw the ulcer got worse in hospital. On 10 October, district nurses completed a Walsall risk assessment and updated Datix. The assessment form was not completed in full and not added to the system until 14 October.
- On 14 October the district nurse recorded an increase in the Walsall risk assessment score, but the form is not complete, so I do not know which part increased or why. The tissue viability nurse asked for a nutritional assessment but one is not recorded. There is no note of ordering dressings, and no handover note provided.
- The records from 15 or 17 October do not show if they ordered dressings, despite evidence the attending nurses knew there was none available in the house. A note on 20 October asks for an urgent follow up for dressings, but I have seen no evidence they chased the order.
- On 24 October, the district nurse completed a wound assessment but did not use clinical language. I do not have enough information to know if the pressure ulcer changed. I also do not know if they escalated the request for dressings. The same day, the district nurse completed an adult safeguarding form with a score of 25. The form recorded “no safeguarding issues” and the district nurse took no further action. The Trust’s policy states a score of 15 or above should trigger a concern. I do not know why the concern was not raised as the district nurse does not record their rationale.
- On 28 October, 30 October and 2 November the district nurse did not complete the Walsall or MUST. The attending nurse ordered dressing from the GP via email. There are no clinical notes about the pressure ulcer.
- On 4 November the records show they still needed dressings, but I do not know if they followed up in a timely way. The district nurse did not complete the MUST on 6 November.
- In summary, I do not have enough clinical evidence to say whether an earlier safeguarding referral could have prevented further decline of Mr B’s sacrum pressure ulcer. However, I can agree this caused unnecessary distress and frustration to Miss A. Firstly, when she was chasing her father’s best interests and secondly when making the complaint. This is an injustice to her.
- In summary, district nurses did not;
- take photographs of the pressure ulcer in line with guidance
- note clinical observations for the pressure ulcer
- provide handover notes
- record whether they had cleaned or dressed the pressure ulcer
- ordered or chased outstanding orders for dressings
- complete Walsall risk assessments and MUST on multiple occasions.
The Trust and Council failed to provide multidisciplinary care
What should have happened
- The Trust’s pressure ulcer care policy states “it is essential that a collaborative, multi-disciplinary, inter agency approach is taken to meet all the needs of a patient with or ‘at risk of’ developing pressure ulcers.”
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 17.2.c states “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.”
- NMC guidance 10 states nurses must “keep clear and accurate records relevant to your practice.”
- Miss A continued to voice her concerns to the carers, the allocated social worker and the district nurses. The notes show the carers also raised concerns with the allocated social worker. The allocated social worker could have called an MDT meeting, they did not. A district nurse can also ask for an MDT meeting if they notice a problem, they did not.
- All the professionals involved in Mr B’s care should have arranged earlier MDT meetings to provide extra support. If they had an MDT meeting when Miss A raised her safeguarding concern, they could have look at the continuing difficulties with Mr B’s care. The Council and the Trust missed an opportunity to address Miss A’s concerns and help Mr B. This is fault.
- There is not enough information in the records. The notes from the carers and the district nurses do not corroborate one another. This is fault by both to keep accurate records and is not in line with guidance.
- The conflicting accounts suggest MDT discussions were taking place, but there are no records of these discussions. Therefore, I do not know what they discussed, if issues remained unresolved, or if escalation should have happened.
- Miss A and her family were frustrated and distressed due to the lack of communication between the different teams caring for Mr B. Miss A felt she had no choice but to raise her concerns with all parties. She felt the organisations were not helping him. This was frustrating and time-consuming for her, especially as she did not live with Mr B. Miss A was further distressed after she saw Mr B’s care records and had more questions than answers. This is an injustice to her.
The Council and Trust failed to investigate her concerns about the care provided to her father.
What should have happened
- Section 42 of the Care Act 2014 says councils must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse.
- The Care Act requires each local authority:
- make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by who.
- set up a Safeguarding Adults Board (SAB).
- arrange, where appropriate, for an independent advocate to represent and support an adult who is the subject of a safeguarding enquiry or Safeguarding Adult Review (SAR) where the adult has ‘substantial difficulty’ in being involved in the process and where there is no other suitable person to represent and support them.
- Miss A raised a concern with the Council on 27 October. The Council passed it to Mr B’s allocated social worker on 30 October. On 2 November, the allocated social worker asked for guidance on the pressure ulcer protocol as they did not know how to continue. The Trust’s safeguarding lead contacted the allocated social worker to explain this was standard practice, and they should assess and let the Trust know the result.
- On 3 November, the allocated social worker replied to the safeguarding lead to say it was not for the Council and they would file. The next day the safeguarding lead contacted the Council’s safeguarding adults coordinator to express concerns about the filing of the referral. On 5 November the coordinator confirmed they would escalate her concern and the allocated social worker would oversee the safeguarding enquiry.
- The Council did not action the safeguarding referral on 27 October. It did not action it until 5 November and only after the Trust’s safeguarding lead intervened with concerns the allocated social worker was not going to progress the enquiry. This is a delay of 9 days. This is fault.
- I know Miss A does not agree with the conclusion reached in the safeguarding investigation. The Local Government Act 1974 states we cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way they reached the decision.
- I found after the enquiry started it followed the correct procedure. Mr B died before the enquiry finished, but all parties agreed to continue.
- The enquiry opened on 5 November 2020 and closed on 4 March 2021. The Council’s policy states it should complete enquiries within three months. The Council did not complete the enquiry within the outlined timescale. I have seen evidence the Council was working with Miss A and kept her updated on the enquiry. This is what I would expect.
- Miss A was distressed when the team said it would not look into her safeguarding concerns. She was frustrated when she found out the allocated social worker did not know the correct procedure. This is an injustice to her. When the Council opened the enquiry, it apologised to Miss A for the delay and the confusion caused.
- I understand Miss A was frustrated because she worried about Mr B. The Council recognised her frustration and apologised. It confirmed the allocated social worker is no longer working for the Council, but others in the same role had received training on the Protocol. I consider this enough to remedy the identified fault.
- After Mr B died, Miss A made a complaint about the district nurses and the result of the safeguarding enquiry. She felt the organisations were not honest with her about what happened and provided contradictory responses which added to her frustration.
- Miss A complained to the Council. She spoke to it on 18 March and agreed what it would investigate. The Council responded on 20 April 2021. It said the Council did not refuse to investigate Miss A’s safeguarding concern but accepted there was a delay.
- Miss A emailed the Council on 22 April to ask it about this and sent it the email from the allocated social worker which said the Council would not investigate. The Council replied on 22 April and said the allocated social worker was clarifying the concern and seeking advice from their supervisor before continuing.
- Miss A responded to the Council on 27 April and explained in the safeguarding meeting, it told her the allocated social worker had not followed the procedure. She queried the dates provided and made it clear she did not believe the Council’s explanation as the dates and information it provided did not match her own version of what happened.
- Miss A complained to the Trust by telephone on 29 October 2020 and sent further concerns in an email on 17 May 2021. The Trust responded on 24 June 2021. It told Miss A it had learnt lessons from the complaint, but it could not say the worsening pressure ulcer was due to failures by the district nurses. Miss A was not happy with the response and had a meeting with the Trust on 4 August. It agreed to provide a further response to her remaining complaints and did so on 3 August 2021.
- The Council told Miss A in its letter of 20 April, and in emails after this, it did not refuse to investigate her safeguarding concern, but this is not correct. I have seen evidence which shows the allocated social worker told Miss A the Council would not investigate. This only changed when the Trust’s safeguarding lead challenged the Council, as discussed in paragraphs 52-54. The Council did not provide accurate explanations when it responded to Miss A’s complaints. In response to our draft decision, the Council explained its complaint manager did not have access to some of the emails between the allocated social worker and the Trust. I acknowledge this would have affected its handling of the complaint but still consider there to be fault as Miss A provided the complaint manager with screenshots of the email in which she was told the Council would not investigate.
- The Council’s email of 22 April also does not explain what happened. The Service Manager told Miss A the allocated social worker was clarifying the concern and seeking advice from her supervisor. As explained in paragraphs 52-54, this is not what happened. Miss A showed them the emails from the allocated social worker and asked for an explanation. This is the second time I found the Council was not clear with Miss A about its mistake.
- I understand Miss A does not accept the explanations provided by the Trust. I have found no evidence it did not try to answer Miss A’s complaint with the information it had.
- Miss A was already distressed when she made a complaint. She has told us she was trying to get justice for her father who she saw in pain before he died. Miss A was upset when pursing the complaint because she was given contradictory accounts by the Council. The Council’s explanation and Miss A’s evidence and experience did not match. This is an injustice to her. The Council has not recognised it has not fully explained its actions to Miss A about what happened when it received her safeguarding concern, this is a further injustice to her.
- I have identified several faults which caused an injustice to Miss A. During the safeguarding investigation and as part of the complaint local resolution process, the Trust and Council recommended improvements.
- The Trust completed its RCA investigation on 21 December 2020. It identified several areas where the care provided was not in line with guidance. It also set out the actions it recommended to prevent reoccurrences.
- The clinician who booked the new assessment as a re-assessment on 24 September has received support and training.
- District nursing team to use Isla Care (image recording software) to support complex wounds
- District nursing team to use Primary Care Network Pharmacist to expedite prescriptions
- District nurses to regularly review complex patients and effectively case manage
- Clinical Operations Manager to flag the prescription issues with the GP federation
- Improved communication between all members of the MDT.
- Improved knowledge across organisations about roles in supporting vulnerable adults, including early MDT meetings with social care primary and nursing.
- Therapy teams to be clear with family/carers/partner organisations about responsibilities.
- Support to ensure Social Care colleagues understand the Pressure Ulcer Protocol Safeguarding process.
- Staff reminded of the need to keep dressings box tidy and disagreements between professionals should not be discussed in front of the patient or their family
- Reminded staff of the need to use MDT meetings when care involved staff from both social and health care organisations
- Fed back to the hospital about the discharge process not being in line with guidance and raised concern about their categorisation of pressure ulcer
- Therefore, the Ombudsmen recommended, and the organisations agreed, within one month of the date of the final decision the organisations will jointly write to Miss A to:
- Acknowledge their responsibility for the faults identified in paragraphs 21-69,
- Apologise for the impact of the faults to Miss A, in terms of the avoidable frustration and distress it caused,
- Provide evidence to the Ombudsmen and Miss A of the completion of the recommendations made in the RCA report and safeguarding enquiry report
- Provide evidence of training to all district nurses on the safeguarding referral process about pressure ulcers
- Provide evidence of training to all district nurses in accurate record keeping and know what they need to record when attending to a pressure ulcer service user
- Provide evidence of training to all relevant staff on the Pressure Ulcer Protocol, ensuring staff know how to process a request when received
- I partly uphold Miss A’s complaint. I found fault which led to an avoidable injustice to Miss A. The agreed recommendations will provide a suitable remedy.
Investigator's decision on behalf of the Ombudsman