Lakeview Health Care Ltd (23 009 054a)
The Ombudsman's final decision:
Summary: We found fault with the falls care provided to Mr X when he was resident in a care home. We also found fault with the safeguarding enquiries carried out by the local safeguarding authority. The organisations involved will apologise to Mr X’s daughter, Ms Y, and explain what action they will take to prevent similar problems occurring for other service users. They will also pay Ms Y a financial remedy in recognition of the distress these events caused her.
The complaint
- The complainant, who I will call Ms Y, is complaining about the care provided to her father, Mr X, by Lakeview Care Home (the care home - operated by Lakeview Health Care Ltd). This placement was commissioned by Salford City Council (Salford Council).
- Ms Y complains that:
- the care home failed to properly manage her father’s risk of falls. She says falls documentation at the care home was inaccurate and that staff failed to update her father’s care plans or contact relevant professionals when he refused to transfer;
- care home staff failed to support her father to transfer safely, causing him to fall and bang his head. She says this situation was made worse as staff gave contradictory accounts of what occurred;
- care home staff delayed in obtaining emergency clinical care for her father and this placed him at greater risk of harm; and
- the care home manager failed to inform her that her father may be suffering from cancer.
- Ms Y complains that subsequent safeguarding enquiries undertaken by Wigan Metropolitan Borough Council (Wigan Council) were inadequate and failed to identify inaccuracies and omissions in the records. As a result, she says she cannot be assured that similar problems will not occur for other residents of the care home.
- Ms Y says these events have been extremely distressing for her and that this is compounded as she cannot be sure what happened on the day of her father’s fall.
The Ombudsmen’s role and powers
- 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.
- When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened.
- 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
- In making my final decision, I considered information provided by Ms Y and discussed the complaint with her. I also considered relevant documentation from Salford Council, Wigan Council and the care home. I took account of relevant legislation and guidance. I invited comments from all parties on my draft decision statement and considered the responses I received.
- Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
What I found
Relevant legislation and guidance
Fundamental Standards of Care
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards which care must never fall below.
- Regulation 12 relates to safe care and treatment. It says care providers must assess the risk to the health and safety of a service user of receiving care and treatment and must take measures to mitigate this risk. This regulation also sets out that care providers must ensure any equipment used when supporting a service user is safe and used in a safe way.
- Regulation 17 relates to good governance. This includes the maintenance of “accurate, complete and contemporaneous” records for each service user.
- Regulation 20 relates to the duty of candour. This sets out that all health and social care providers have a duty to be open and transparent with people receiving care and treatment from them.
Care Act 2014 – Safeguarding
- Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.
Stroke care
- The National Institute for Health and Social Care Excellence (NICE) publishes guidance for clinical professionals on the management of stroke. This is entitled ‘Stroke and transient ischaemic attack in over 16s: diagnosis and initial management’ (the clinical guidance).
- The clinical guidance emphasises the importance of prompt recognition of symptoms and diagnosis for people who are suspected to have suffered a stroke. This is because certain stroke treatments are time sensitive.
Deprivation of Liberties Safeguards
- The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 that 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 other less restrictive alternative.
Background
- Mr X moved into the care home in March 2019 after a lengthy period of inpatient care. The placement was arranged by Salford Council. Mr X lacked capacity to make decisions about his care and was subject to DoLS as he required treatment in his best interests.
- Mr X suffered a fall in the bathroom in July 2021 and suffered severe bleeding. He was taken to hospital for treatment. This led Ms Y to request a full review of Mr X’s care needs and the equipment he was using.
- Five days after his discharge, Mr X fell again and received further treatment in hospital.
- The care home said that, in July 2021, it made a referral for Mr X to the local falls clinic. The clinic has no record of having received the referral. However, Mr X’s GP submitted a further referral on 5 August 2021.
- In September 2021, the Council completed a review of Mr X’s care and support needs. This noted that Mr X had a history of falls and was at high risk of falling when moving around with his walking frame.
- In February 2022, Mr X underwent a sigmoidoscopy (a scan to check the lower part of the large intestine for abnormalities). This did not reveal any abnormalities.
- On 11 May 2022, Mr X was transferring from his armchair to his wheelchair when he suffered a further fall and struck his head on the base of his bed. A nurse examined Mr X and found no visible injuries. She noted he was alert and responsive. The nurse also took Mr X’s clinical observations, which were in the normal range. However, Mr X was unable to get to his feet.
- The nurse called 999 at 12.59pm as Mr X was unable to stand and was also taking blood-thinning medication. The nurse was advised that there would be a five to six hour wait for an ambulance and to call back if Mr X’s condition changed.
- Shortly after the call ended, Mr X lay down and became unresponsive. He subsequently vomited and his breathing became erratic. The nurse called 999 again at 1.09pm. A rapid response unit arrived at 1.16pm, with an ambulance attending at 1.21pm.
- Mr X was taken to hospital by ambulance where he was found to have suffered a traumatic subdural haematoma (a bleed on the brain). Mr X died in hospital on 14 May.
- Ms Y submitted a safeguarding referral to Wigan Council. This was the local authority with responsibility for safeguarding in the area in which the care home was located.
- Wigan Council made Section 47 enquiries and determined that the care home had acted appropriately with regards to Mr X’s falls management.
My analysis and findings
Falls management
- Ms Y complained that the care home failed to properly manage her father’s risk of falls. She said falls documentation at the care home was inaccurate and that staff failed to update her father’s care plans to reflect his changing needs after his fall in July 2021.
- The care records show Mr X was at high risk of falls. Salford Council completed a care and support plan for Mr X in March 2019. This recorded that Mr X had suffered a stroke in 2018 that had reduced the strength down one side of his body. As a result, the care plan recorded that Mr X needed support to move around using a wheeled walking frame, and when showering, to reduce the risk of falls. The care plan also set out that Mr X would need to be reviewed by a physiotherapist.
- A physiotherapist from the local falls clinic assessed Mr X in May 2019 and continued to support him until August 2019, when the service discharged him. At that stage, the physiotherapist noted that Mr X was able to move around well with a wheeled walking frame.
- Mr X experienced a fall in the shower on 17 July 2021 and suffered a serious wound to his lower torso that required hospital treatment. In response to Ms Y’s concerns, the care home agreed to carry out an immediate review of Mr X’s care plans and risk assessments. The care home also said it would arrange for an Occupational Therapist (OT) to review Mr X’s equipment.
- Following this fall, Mr X’s GP made another referral for him to the falls clinic. The GP made the referral in early August 2021. The falls clinic did not receive the referral.
- In September 2021, the care home reviewed Mr X’s needs. It completed a falls care plan. This stated that Mr X was at high risk of falls. The plan recorded that Mr X could move short distances with his wheeled frame but required support from staff to move longer distances. The plan said Mr X should be reminded to transfer slowly and carefully and request assistance if necessary. The plan also said that care staff should check Mr X’s walking frame to ensure it was in good working order.
- A hospital consultant subsequently submitted a further referral to the falls clinic in January 2022.
- In March 2022, a physiotherapist visited Mr X at the care home. However, Mr X declined any physiotherapy input. The physiotherapist spoke to care home staff and recorded that they did not need any additional support or advice in terms of managing Mr X’s mobility needs. However, the physiotherapist recommended that Mr X’s wheeled walker needed to be replaced.
- I have reviewed the records that were in place at the time of Mr X’s fall in May 2022 and have identified potentially significant concerns about the adequacy of this documentation.
- In May 2022, Mr X’s falls risk assessment recorded that he was at risk of falls. Despite this, the same risk assessment noted that Mr X needed no assistance with standing or mobilising. This was incorrect. The records suggest the care home reviewed Mr X’s falls documentation several times between September 2021 and April 2022. These reviews did not identify this discrepancy, which had been evident in the records in July 2019.
- Mr X was at high risk of falls. His falls care plan from September 2021 noted staff should remind him “to transfer slowly and carefully and to request assistance from staff if he is feeling tired or unwell.” However, the care home acknowledged in its complaints responses that Mr X was unwilling to transfer in a way that would have allowed a member of staff to support him. I found no evidence in the care records to suggest the care home reviewed the care plan considering this. This was a significant omission given Mr X’s history of falls and the fact he was refusing to transfer safely.
- Furthermore, Mr X’s clinical records show he had limited movement and some contraction in his right hand. This would have further impaired his ability to transfer safely without support from a member of staff. This was not reflected in Mr X’s care plans at the care home.
- The records show Mr X was subject to DoLS. This should have led care home staff to assess Mr X’s capacity to make decisions around transferring. It should further have led the care home to refer Mr X to Salford Council’s DoLS team for review. I found no evidence to show this happened. Nor did the care home contact Mr X’s family for input.
- The evidence I have seen suggests the falls documentation for Mr X did not accurately reflect his care needs and his risk of falls. In addition, care home staff did not properly consider Mr X’s capacity to make decisions as required by the DoLS. This was fault by the care home and Salford Council.
- There is no way of knowing whether Mr X’s fall might have been prevented if improved care documentation had been in place. Nor is it possible to say whether input from other professionals or the family would have altered the outcome. Indeed, it is important to be clear that it is not possible to entirely eliminate the risk of falls for somebody like Mr X, who was considered to be at high risk.
- However, this has left Ms Y with uncertainty around whether the outcome of Mr X’s care might have been different with improved falls management.
Fall on 11 May 2022
- Ms Y complained that a care worker failed to support her father to transfer safely, causing him to fall and bang his head. Ms Y said that, to transfer from his chair to his wheelchair safely, Mr X needed a care worker to stand to his side to assist him. She said Mr X was unable to transfer without this support as a previous stroke had affected his hand function. In addition, one of his hands was contracted, which affected his grip.
- Ms Y said that, on this day, the care worker had placed Mr X’s wheelchair directly in front of him and stood behind it. This meant Mr X was left to transfer himself and had fallen as a result.
- In its complaint response, the care home Mr X ordinarily transferred using a wheeled frame, with the support of one member of staff. The care home said the healthcare assistant who was supporting Mr X when he fell was experienced in doing so. The care home went on to say that it had utilised this method of transfer regularly in the past and that Mr X often refused to transfer using the method Ms Y described.
- As I have explained above, the falls risk documentation and moving and handling plan for Mr X did not accurately reflect his needs. They lacked detail and contained significant errors. This potentially placed Mr X at increased risk.
- We are unable to say, even on balance of probabilities, whether Mr X’s fall would have been avoided if a different method of transfer had been used. Nevertheless, Ms Y has been left with significant distress and uncertainty as to what might have happened.
Emergency care
- Ms Y complained that care home staff delayed unnecessarily in obtaining emergency clinical care for her father and this placed him at greater risk of harm. Ms Y said staff failed to inform emergency call operators that they thought Mr X may have suffered a further stroke. Ms Y pointed out that stroke care is time-critical, and that staff should not have waited 18 minutes to call an ambulance.
- Following Mr X’s fall at around 12.40pm, the healthcare assistant fetched a nurse and nursing assistant. The nurse recalled that she checked Mr X for injuries and found no marks or injuries. She noted that Mr X was “talkative and alert” and that his clinical observations were normal. The nurse noted Mr X had a history of stroke. She recalled that Mr X started to make efforts to stand before lying back down and indicating he would need help.
- The nursing assistant said Mr X had complained that his head hurt when she and the nurse entered the toom. She recalled having checked Mr X and found no visible sign of injury. However, she asked Mr X to point to where his head hurt. Mr X pointed to the front-left part of his head. The nursing assistant remembered the healthcare assistant telling her Mr X had banged the back of his head.
- At 12.59pm, the nurse called 999. She reported that Mr X was awake and breathing but that “he would not even attempt” to get up and “was choosing not to answer” when she asked him questions. The nurse reported Mr X was on blood-thinning medication. The call operator advised that it might be over five hours before an ambulance could attend. As the nurse was speaking to the call operator, Mr X vomited. The call operator told the nurse to call again if Mr X’s condition deteriorated.
- In the meantime, the nursing assistant spoke to one of the care home’s clinical nurse managers. The manager advised that it was appropriate to call 999 as Mr X was on blood-thinning medication due to his previous stroke.
- The nursing assistant noted Mr X was lying in the recovery position and was complaining repeatedly of pain in his head. She noted that he then slumped to the floor before vomiting. Both the nurse and nursing assistant recalled that Mr X then became unresponsive.
- The nursing assistant pressed the emergency call button for assistance and a healthcare assistant attended.
- The nurse called 999 again at 1.09pm. She reported that Mr X was no longer awake and that his breathing was loud and gurgling. The nurse said Mr X had previously suffered a stroke and that she was concerned he may have suffered another one. The 999 call operator advised the nurse to fetch a defibrillator. The nurse asked the healthcare assistant to get this. A rapid response unit arrived at 1.16pm, at which point the nurse ended the call.
- An ambulance arrived at 1.21pm. The attending paramedics recalled that Mr X was lying on the floor. They recalled care home staff telling them that Mr X had fallen while using a standing aid and banged his head on his bed first and then the floor. The paramedics also remembered care home staff telling them Mr X was not complaining of any pain and had been sat in his chair having a drink and talking with them. The paramedics took Mr X’s clinical observations and found these to be normal. They checked Mr X and found no obvious sign of injury.
- The ambulance subsequently transported Mr X to hospital. He was found to have suffered a traumatic subdural haematoma. Mr X died in hospital on 14 May.
- There was a period of around 19 minutes following Mr X’s fall before the nurse called an ambulance. During this period, the healthcare assistant who had witnessed the fall had to fetch the nurse. The nurse then had to examine Mr X and take his clinical observations. At that stage, Mr X was complaining of pain, but his observations were normal, there was no visible sign of injury and the nurse recorded that he was alert. Nevertheless, the nurse called 999 as she was aware that Mr X was taking blood-thinning medication.
- In her complaint, Ms Y says the nurse should not have waited this long before calling 999.
- NHS guidance advises highlights certain risk factors that should lead someone who has suffered a head injury to attend A&E. These risk factors include the taking of blood-thinning medication. The guidance recommends calling 999 if the person who has suffered the injury cannot be transported to A&E safely.
- The evidence I have seen suggests the care home staff were initially planning to assist Mr X back to his feet. However, when this was not possible, the nurse called 999. Taking everything into account, while I accept there was a period of around 19 minutes before the nurse called 999, I do not consider this to warrant a finding of fault.
- There do appear to have been some disparities between the recollections of the professionals caring for Mr X on that day. We cannot now resolve these inconsistencies in the absence of any further independent evidence.
- However, it is concerning to see that the recollections of the attending paramedics differ significantly to the accounts provided in the statements of the nurse and nursing assistant. This included the paramedics’ recollection that they had been told Mr X had been helped to sit in his chair and was drinking and talking with staff. It is unclear who gave the paramedics this information and I found no evidence in the records to support this account.
- It is my view that, on balance of probabilities, this information was provided to the paramedics by a member of care home staff. This is because it would be otherwise unclear how the paramedics would have come by this information. This information did not accurately reflect the records or Mr X’s condition following his fall. This was fault by the care home and Salford Council.
- This has caused Ms Y significant distress and uncertainty as she cannot now be certain about how events unfolded on the day of Mr X’s fall.
Communication
- Ms Y complained that the care home manager failed to inform her that her father may be suffering from cancer. Ms Y said the manager told her that Mr X’s sigmoidoscopy procedure was routine when, in fact, it was a fast-track referral for suspected cancer.
- In September 2021, a GP made a referral for Mr X to the local endoscopy team. This referral noted that there had been a change in Mr X’s bowel habits and that blood had been found in his stools. The referral noted “suspected lower gastrointestinal cancer”.
- On 5 October, Mr X was seen at an outpatient clinic. The reviewing surgeon noted that Mr X had scored very highly on a bowel cancer screening test. Mr X underwent a Computed Tomography (CT) scan. This revealed some abnormalities that required further examination via a sigmoidoscopy.
- A clinician contacted the care home to ask whether there had been any changes in Mr X’s bowel habits.
- On 18 December, another clinician from the colorectal team contacted the care home again to explain that Mr X would undergo a sigmoidoscopy.
- On 1 February, Ms Y contacted the care home manager. She said Mr X had advised her that he was due to undergo a sigmoidoscopy. Ms Y queried whether this was correct and asked why Mr X needed this procedure.
- The care home manager responded to Ms Y on 3 February. He said he had spoken to health colleagues “and they have stated that the [sigmoidoscopy] is for a routine check and not related to anything adverse.”
- Ms Y responded the same day. She asked whether Mr X’s CT scan had revealed any abnormalities. She did not receive a response.
- The sigmoidoscopy took place later that month. This did not reveal any abnormalities. A subsequent biopsy proved negative. Ms Y said she did not become aware that Mr X had been treated for suspected cancer until after his death.
- In its response to my draft decision statement, the care home referred me to two clinic letters (from the local hospital’s CT Department and General Surgery Department. The care home said neither of these letters included reference to a possible cancer diagnosis.
- I accept the letters in question make no reference to cancer as a potential diagnosis. However, this ignores other interactions between care home staff and the clinical team at the hospital. In September 2021, a GP made a referral for Mr X due to there being blood in his stools and a change in his bowel habits. My understanding is that care home staff would have taken the stool sample and made this available to the GP. This strongly suggests that care home staff would (or should) have made enquiries as to why Mr X was being sent for further investigations.
- In October, another member of the team recorded that he had spoken to care home staff about Mr X as he was concerned about his elevated risk of colorectal cancer. The GP records show Mr X was also seen within a fast-track clinic on 28 October with suspected colorectal cancer. My understanding is that care home staff accompanied Mr X to this appointment.
- In December, a surgeon had a further conversation with the care home and explained that Mr X would require a flexible sigmoidoscopy procedure.
- On balance of probabilities, I consider it likely that care home staff were aware that Mr X was potentially suffering from colorectal cancer and that the sigmoidoscopy procedure was intended to explore this.
- My understanding is that the care home manager was advised by health colleagues that the sigmoidoscopy was routine. It is possible there was some confusion here as I found no evidence to support this.
- The fundamental standards place a duty of candour on care providers. The failure to share information about Mr X’s condition with his family was evidence of fault by the care home and Salford Council.
- This caused Ms Y significant distress when she later obtained copies of Mr X’s care records.
Safeguarding
- Ms Y complained that the safeguarding enquiries undertaken by Wigan Council were inadequate and failed to identify inaccuracies and omissions in the records and correspondence that she had identified.
- In its response to my enquiries, Wigan Council said it was satisfied its enquiries were thorough and based on the evidence that was available at that time. However, Wigan Council also acknowledged that it had failed to respond to some of Ms Y’s further correspondence regarding the outcome of the safeguarding enquiries.
- I have detailed my concerns regarding the falls documentation for Mr X above. This information was available to Wigan Council at the time of the safeguarding enquiries and should have led it to conclude that this documentation did not accurately reflect Mr X’s needs. This likely placed him at increased risk of falls. The failure to identify this represented fault by Wigan Council.
- This was compounded as Wigan Council failed to respond to Ms Y when she raised concerns about the outcome of the enquiries. This represented a missed opportunity to make further enquiries if necessary. Again, this was fault.
- This caused Ms Y further distress as she was left with the view that her concerns had not been adequately investigated.
Agreed actions
- As Salford Council was responsible for commissioning the care home placement for Mr X, it shares responsibility for the fault I identified. However, I made only one recommendation to Salford Council. There are two reasons for this. Firstly, Salford Council was not involved in the day-to-day management of falls at the care home. Secondly, this was an out-of-area placement and Salford Council is not involved with monitoring of care home placements in that area.
- For these reasons, I directed most of my recommendations to the care home and Wigan Council.
Care home
- Within one month of my final decision statement, the care home will write to Ms Y to apologise for the distress caused to her by:
- the inadequate falls documentation for Mr X and the likelihood this placed him at greater risk of falls;
- the failure to properly assess Mr X’s capacity or refer him to Salford Council’s DoLS team for review;
- care home staff sharing inaccurate information with the attending paramedics regarding Mr X’s condition following his fall in May 2022; and
- the failure of the care home manager to share accurate information with her regarding the sigmoidoscopy procedure undergone by Mr X in February 2022.
- Within one month of my final decision statement, the care home will also pay Ms Y £500 in recognition of the distress caused to her by the fault I have identified.
- Within three months of my final decision statement, the care home will write to the Ombudsmen to explain what action it will take to:
- ensure care home staff maintain “accurate, complete and contemporaneous” falls documentation for each service user. This documentation should properly reflect the needs of each person in keeping with the requirements of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014; and
- ensure care home staff are familiar with the provisions of the Deprivation of Liberties Safeguards and local DoLS policies and procedures.
Salford Council
- Within one month of my final decision statement, the Salford Council will write to Ms Y to apologise for the distress caused to her by the fault I identified in the care provided to Mr X in the care home, for which it shared responsibility.
Wigan Council
- Within one month of my final decision statement, Wigan Council will write to Ms Y to apologise for the distress caused to her by:
- the failure of the safeguarding enquiry to identify potentially significant omissions and discrepancies in the care home’s falls documentation; and
- its failure to respond to Ms Y’s concerns about the outcome of the safeguarding enquiry.
- Within one month of my final decision statement, Wigan Council will also pay Ms Y £100 in recognition of the distress caused to her by the fault I have identified.
- Salford City Council, the care home and Wigan Council will provide us with evidence they have complied with the above actions.
Final decision
- I found fault by the care home and Salford Council with regards to the falls care provided to Mr X in the care home. I also found fault by Wigan Council with regards to its subsequent safeguarding enquiries.
- I am now proposing to complete my investigation on this basis.
Investigator's decision on behalf of the Ombudsman