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Rushall Medical Centre (17 003 159b)

Category : Health > General Practice

Decision : Not upheld

Decision date : 08 Feb 2018

The Ombudsman's final decision:

Summary: The Ombudsmen found fault with the Trust and Council’s communication with Mr X, when his mother, Mrs Y, was at a care home for rehabilitation after suffering a stroke. The Council and the Trust have provided a suitable remedy for the distress that Mr X and the family suffered.

The complaint

  1. Mr X said his mother, Mrs Y, was given nearly no rehabilitation by both Trust and care home staff during a two week stay at a care home commissioned by the Council.
  2. Mr X said that care home staff:
    • took his mother off fluid intake monitoring after two days. He said she was not monitored for fluids at all in her last week at the care home, despite increased confusion and her kidneys failing. As a result, Mrs Y suffered dehydration on admission to the Trust, acute kidney injury and her death was potentially avoidable.
    • left to clear up her own diarrhoea
  3. Mr X said that a GP misdiagnosed his mother with scabies which meant she was left unattended by staff and led to falls
  4. Mr X also said that both the Council and the Trust’s communication with the family was poor.
  5. Mr X said the Council and the Trust’s actions caused Mrs Y and the family significant distress.
  6. Mr X would like an apology, improvements to their service and a financial remedy for distress.

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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. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. In this case, the care home was commissioned by the Council and therefore acting on its behalf. (Local Government Act 1974, section 25(7), as amended).
  3. 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).
  4. 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.
  5. 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. I considered the documentation provided by Mr X and I have also spoken to him by telephone.
  2. I asked the Trust and the Council to comment on the complaint and provide supporting documentation.
  3. I have taken relevant law and guidance into account before coming to a view.
  4. I also sought clinical advice from an independent GP.
  5. I invited Mr X, the Council, the Trust and the Practice to comment on my draft decision. I received comments which I considered before making my final decision.

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What I found

  1. The National Institute for Health and Care Excellence’s (NICE) Clinical Knowledge Summaries provide GP’s with a summary of practical guidance and best practice in respect to over 330 common and/or significant conditions including scabies.

Fluid monitoring

  1. The Hospital Hydration toolkit (Royal College of Nursing and National Patient Safety Association, 2007) provides practical advice for health care staff in England and Wales on how to lessen the risk and potential harm that dehydration can cause. It states there is no agreed daily intake level for water in the UK.


  1. The Code (Nursing and Midwifery Council, 2015) states that nurses should be open and candid with all service users about all aspects of care and treatment, including when mistakes or harm have taken place. Specifically: “explain fully and promptly what has happened, including the likely effects, and apologise to the person affected and, where appropriate, their advocate, family or carers”.

Key facts

  1. On 25 July 2016 Mrs Y suffered a stroke caused by bleeding on the surface of the brain. She was treated in hospital and on 5 August the Trust transferred her to a care home for rehabilitation.
  2. On 19 August 2016 Mrs Y was admitted to hospital after she had fallen and hit her head at the care home. Her condition gradually declined, and on 19 September, she sadly passed away.



  1. Mr X said his mother was given nearly no rehabilitation by either the Council or the Trust.
  2. The Trust and Council records show that during Mrs Y’s stay at the care home, a physiotherapist and occupational therapist from the Trust (both part of the stroke rehabilitation team) visited Mrs Y five times (between 5 and 16 August 2016) to practice mobility exercises.
  3. The Trust’s records show that on 10 August 2016 the physiotherapist developed a Care Plan for the care home staff. It said Mrs Y should mobilise and shower with the close supervision of one person and sit in an upright chair if tolerated. The next day, the physiotherapist added that standing exercises should be repeated daily.
  4. The Care Plan shows that on 11 and 12 August 2016 staff practised mobilising with Mrs Y. After this point Mrs Y was regularly checked by care home staff and her mobility was good. However, they would have to prompt Mrs Y to call the bell when no staff were present to help her mobilise.
  5. On 18 August 2016, after a visit to see Mrs Y, a senior physiotherapist at the Trust sought advice from a geriatrician by email. The senior physiotherapist was concerned Mrs Y’s bleed (from the stroke) may have extended, and she did not want to provide further therapy until this was clarified. The senior physiotherapist was worried this was the cause of Mrs Y’s confusion and a recent fall. The geriatrician booked a brain scan for Mrs Y.
  6. I am satisfied the Trust and Council took appropriate steps to rehabilitate Mrs Y. Trust staff visited her at the home and put a care plan in place. Care home staff also tried to help Mrs Y mobilise regularly. When Mrs Y tried to mobilise without support of staff, they showed her how to use the call bell for help.

Misdiagnosis of scabies

  1. Mr X said a GP misdiagnosed his mother with scabies, and as a result she was isolated and unattended by staff which led to falls.
  2. On 8 August 2016, a GP visited Mrs Y to assess a rash on her head. The GP also found Mrs Y’s skin was worn from scratching her back, left arm and lower legs. The GP noted that scabies was possibly the cause of her symptoms. Therefore, the GP prescribed both permethrin (treatment for scabies) and betnovate (treatment for eczema), and she began treatment on 13 August.
  3. On 23 August, a consultant dermatologist diagnosed Mrs X with a specific type of eczema.
  4. At the time, the GP’s provisional diagnosis of scabies was in line with the NICE guidelines (paragraph 16). Mrs Y had an itchy rash in several places, and there had recently been an outbreak of scabies at the care home.
  5. Clearly, the diagnosis of scabies was subsequently found to be wrong, but this was not due to any fault by the GP. The incorrect diagnosis also had no impact on Mrs Y. The GP prescribed treatments for both scabies and eczema, which the Trust later diagnosed Mrs Y with. I consider the GP prescribed the correct treatment for Mrs Y’s eczema in August 2016.

Fluid monitoring

  1. Mr X said his mother was taken off fluid intake monitoring after only two days at the care home (on 7 August 2016). She was not monitored for fluids at all in her last week at the care home, despite increased confusion and her kidneys failing.
  2. The records show that, on 5 and 6 August 2016, Mrs Y had 700mls and 1000mls of fluids respectively. Staff then decided to stop fluid charts after this, as they did not have any concerns.
  3. After 7 August 2016 staff did not record they had any concerns about Mrs Y’s fluid intake.
  4. When the Trust discharged Mrs Y, it did not state any concerns about her fluid intake.
  5. When the care home stopped monitoring Mrs Y’s fluids, there is no evidence staff were concerned about Mrs Y’s fluids intake afterwards. On many occasions staff noted that Mrs Y had a good fluid intake in the daily care record. Also, a blood test on 12 August showed that Mrs Y was not dehydrated. This indicates her fluid intake was good then. The decision to stop monitoring Mrs Y’s fluid was taken properly.


  1. Mr X said that his mother was left to clean up herself when she had diarrhoea.
  2. On 17 August 2016 staff found Mrs Y and faeces on the floor after she had attempted to go to the toilet through the night. Therefore, staff helped Mrs Y and changed her clothes and bedsheets.
  3. The Council has provided evidence to show that staff helped Mrs Y when they found her on the floor. The records show that staff cleared up the faeces from the floor and helped her to change.


  1. Mr X said that communication with the family was incredibly poor, both by care home staff and Trust staff.
  2. There is no evidence of communication with the family in the care home records. The daily care records only show that Mrs Y had visitors.
  3. Mrs Y fell on two occasions on 15 and 18 August 2016. National guidance (paragraph 18) says that, when harm has taken place, staff should contact the family to explain what has happened and to explain the likely effects. There is no evidence of any conversations with the family about either the falls or when Mrs Y was subsequently admitted to hospital. I have not seen any evidence that either the Trust or care home staff kept Mr X updated on the progress of his mother’s rehabilitation.
  4. Overall, the issue of how much information staff should share is a matter of professional judgement. However, the Council’s and Trust’s actions were not in line with the NICE guidance. Therefore, I find fault with both the Trust and the Council. I appreciate the lack of communication would have been distressing for Mr X and the family.
  5. The Trust and Council provided a joint response to Mr X’s complaint when he complained to them. They apologised that communication with the family was not good enough regarding numerous aspects of Mrs Y’s care.
  6. They detailed improvements to their services around communication:
    • Both the Trust and Council will ask relatives if they require progress meetings to request information
    • The Trust’s Community Stroke Therapy team will introduce a rehabilitation record which is communicated to families.
  7. Taking these service improvements into account, I am satisfied that the Trust and Council have remedied the injustice that Mr X and the family suffered. I will not be making any more recommendations to the Trust or the Council.

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Final decision

  1. I find fault with the Trust and the Council’s communication with Mr X and the family during Mrs Y’s period of rehabilitation at the care home. The Trust and the Council has already suitably remedied the distress that Mr X and the family suffered. I have not found fault with the rehabilitation, fluid monitoring, diagnosis of scabies or personal care offered to Mrs Y.

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Investigator's decision on behalf of the Ombudsman

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