Summary: Ms X and Mr Y complained a Care Home failed to arrange suitable medical care for Ms X’s father in March 2022. We found no fault in the Care Home’s actions. It sought advice from health professionals and acted on the advice it received.

The complaint

1. Mr A was a resident of Oak View Residential Care Home (the Care Home) in March 2022. Portsmouth City Council (the Council) and NHS Hampshire and Isle of Wight Integrated Care Board (the ICB) (previously Portsmouth Clinical Commissioning Group) jointly funded the placement. His daughter, Ms X, and grandson, Mr Y, complain that:
1. The Care Home failed to arrange a face-to-face GP appointment for Mr A after Ms X first asked for a GP review. She said, instead, the review took place over face time.
2. There was a delay of six days – from 21 March 2022 to 27 March 2022 – in the Care Home asking for further advice from health professionals. Ms X and Mr Y said this was despite Mr A’s health worsening.
3. The Care Home failed to ensure Mr A took important medication properly.
4. On 27 March 2022, during a telephone call, Care Home staff asked the family inappropriate questions, the answers to which they should already have known.
5. On 27 March 2022 Care Home staff could not access key documents about Mr A.
6. On 27 March 2022 the Care Home failed to call Mr A’s family to advise when an ambulance had taken him to hospital, which it had agreed with Ms X it would do.
7. The Care Home lost several of Mr A’s possessions, including his hearing aids and teeth.
2. The complainants said Mr A may have lived longer if he had been treated sooner. Further, they said they felt disgusted by the way the Care Home had acted.

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What I have investigated

3. I have investigated issues (a) and (b), and summarised the complaint as:

Ms X and Mr Y complain about the care the Care Home provided to Mr A in March 2022. They complain the Care Home failed to arrange adequate, timely medical reviews of Mr A between 21 and 27 March 2022 when his health significantly deteriorated. Ms X and Mr Y said Mr A may have lived longer if he had been treated sooner.

4. I have explained at the bottom of this decision statement why I have not investigated the remaining issues Ms X and Mr Y brought to the Ombudsmen.
5. Section 3 of the Mental Health Act 1983 (the MHA) allows people to be detained in hospital for treatment necessary for their health, safety or for the protection of other people. Section 117 of the MHA imposes a duty on health and social services to provide free aftercare services to patients who have been detained under section 3 of the MHA. Councils and ICBs cannot delegate these aftercare duties, regardless of the day‑to‑day arrangements for delivering a person’s aftercare. In view of this the relevant council and ICB will always be included in Ombudsmen investigations about section 117 aftercare. Mr A’s placement at the Care Home was funded through section 117 aftercare funding and, as such, the Council and ICB are included as organisations under investigation.

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The Ombudsmen’s role and powers

6. 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)
7. 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.
8. When considering complaints, if there is a conflict of evidence we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
9. 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))
10. 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

11. I read the correspondence and supporting evidence Ms X and Mr Y sent to the Ombudsmen. A colleague spoke to Ms X on the telephone and I have considered the records of this. I wrote to the Care Home, the Council and the ICB to explain what I intended to investigate and to ask for their comments and copies of relevant records. I considered all the comments and records they provided. I also considered relevant legislation and guidance. In addition, I obtained records from third parties including a GP surgery, an out of hours service, an ambulance service and a hospital. I considered these records as part of the investigation.
12. I shared a confidential copy of a draft decision with Ms X and Mr Y along with the Care Home, the Council and the ICB and invited their comments on it. I took account of the responses I received.

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What I found

Relevant standards and guidance

13. There are standards for safety and quality care providers need to meet: The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations). The Care Quality Commission (the CQC) has written guidance to help care providers meet these standards: Guidance for providers on meeting the regulations (March 2015) (the Fundamental Standards).
14. Under the Regulations and Fundamental Standards care providers need to make sure people are kept safe from avoidable risk and harm, and from unsafe care and treatment. This includes assessing risk and making plans to manage it. Care providers also need to make sure staff are appropriately trained, and that equipment is suitable and available (Regulation 12).
15. The Nursing and Midwifery Council (the NMC) produces The Code: Professional standards of practice and behaviour for nurses, midwives and nursing associates (the Code). The sets out the standards that nurses must uphold. This includes guidance, at 13.2, that nurses must make timely referrals to other practitioners when any action, care or treatment is needed.

What happened

16. Mr A had Alzheimer’s Disease, along with several other long-term health conditions. He moved into the Care Home in early March 2022. The Care Home registered Mr A with the local GP Surgery (the Surgery).
17. Ms X said she visited Mr A on 21 March 2022. She said he was in a wheelchair and in a lot of pain. Ms X said she asked the Care Home to arrange a GP visit. The Care Home’s daily records do not include any reference to this. They list a variety of interventions carer completed throughout the day and recorded that, on average throughout the day, Mr A was content.
18. On 24 March 2022 staff tested Mr A’s urine which suggested he had a urinary tract infection (a UTI). Staff called the Surgery and spoke to a GP in the afternoon. The GP concluded it would be reasonable to treat Mr A for a UTI and prescribed an antibiotic – a tablet to be taken twice a day. The GP told staff they should call the Surgery or 111 if Mr A continued to get worse and his incontinence pad stayed dry. Staff began giving Mr A the antibiotic that evening.
19. Staff from the Care Home called the Surgery again the next day. A GP reviewed Mr A via a video call. The GP felt the antibiotics were working but that it would take some more time until Mr A fully recovered. They advised the Care Home to call 111 if they had any concerns over the weekend. A GP later spoke to Ms X and said Mr A’s observations were normal.
20. In the morning of 27 March 2022 (a Sunday) staff were concerned about Mr A being in pain and called an Out of Hours GP service. The Out of Hours service said it did not feel Mr A needed to go to hospital and said it would arrange for a clinician to come and see him. A Nurse Practitioner from the Out of Hours service came to the Care Home and reviewed Mr A in the middle of the afternoon. Ms X was also there. The Nurse Practitioner said they would arrange for an ambulance to take Mr A to hospital.
21. An ambulance arrived at the Care Home after 8.30pm. The crew also felt Mr A had a UTI and took him to hospital at around 9.30pm. A doctor in the hospital noted they felt Mr A may be dehydrated and may have urosepsis. They prescribed two intravenous antibiotics and intravenous fluids.
22. A Consultant Physician noted a conversation they had with Ms X on 1 April 2022. They noted Ms X was aware that Mr A was very frail and had a poor prognosis. They also recorded that there was nothing that could be done medically to help Mr A improve. Mr A left hospital and went to Ms X’s home later that day. He died a week later.

Analysis

23. The Care Home’s daily records show staff regularly monitored Mr A and performed a variety of care interventions throughout each day. It is clear from these records and Ms X’s recollections that Mr A’s health deteriorated in late March. Staff sought advice and support from health care professionals three times in four days. The Care Home could not make the decision about whether a GP would make a home visit or not; that was for the Surgery to decide. Similarly, it was for the health professionals from the Surgery and from the Out of Hours service to consider Mr A’s observations and history and advise on his care.
24. The evidence shows the Care Home acted on the advice it received, kept things under review and sought more support when Mr A did not improve. In view of this I have not found any fault in the Care Home’s actions. As I have not found any fault in the Care Home’s actions I have not found fault with the Council or ICB as the organisations which commissioned the care.

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Decision

25. I have closed this investigation on the basis that there was no fault by the Care Home, the Council or the ICB.

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Parts of the complaint that I did not investigate

26. In regard to issue (c), Ms X said on one visit to the Care Home she saw Mr A spit something out of his mouth and a staff member threw it in the bin. She said she later learnt this was an antibiotic and this caused her concern that the Care Home did not ensure that Mr A took his medication properly. A failure to ensure Mr A took his medication would amount to fault. However, it is unlikely there would be adequate evidence available for us to make a clear, independent finding about this, even on the balance of probabilities. As such, there was not a realistic chance of the Ombudsmen making a meaningful finding on this issue.
27. In relation to issues (d) and (e), staff asked Ms X about her status as Power of Attorney for Mr A at a time when paramedics were on the scene attending to him. In this context I cannot see that this would be so unreasonable as to constitute a significant service failing. Further, I do not consider the impact of these actions was so serious as to represent a significant injustice. As such, it would not proportionate for the Ombudsmen to investigate these issues.
28. An investigation of issue (f) would need to rely on Ms X’s and Mr A’s family’s accounts of the conversations that took place on 27 March, alongside the Care Home’s accounts. The family’s and the Care Home’s accounts of events are likely to be considerably different and I can see no clear way of reconciling those differences and reaching a meaningful finding.
29. In relation to issue (g), as with issue (c), it is unlikely an investigation would be able to uncover adequate evidence available for us to make a clear, independent finding about this, even on the balance of probabilities. As such, there was not a realistic chance of the Ombudsmen making a meaningful finding on this issue.

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Investigator's decision on behalf of the Ombudsman