Church Street Medical Centre (17 017 711b)

Category : Health > General Practice

Decision : Upheld

Decision date : 24 Jul 2019

The Ombudsman's final decision:

Summary: Ms P complained that a care home and GP practice failed to properly respond to her father Mr D’s ill health, which put him at unnecessary risk. On another occasion, a nurse at the care home failed to call an ambulance in time, reducing his chance of surviving the infection he died of. Further, that a council failed to carry out safeguarding investigations adequately. The Ombudsmen find some fault with the response of the GP practice and care home in the first incident, which caused Ms P distress. In the second incident the nurse failed to call an ambulance in time which reduced Mr D’s chance of surviving. The Ombudsmen recommend action to address this. They find no fault with the safeguarding investigations.

The complaint

  1. Ms P complained about Moorlands Care Home (the Home), which is run by Regal Care Trading Ltd., Church Street Medical Centre (the Practice), and Nottinghamshire County Council (the Council). She said:
      1. In April 2017, the Home took too long to seek medical attention for her father Mr D, which caused a delay in his admission to hospital for treatment. This put Mr D at risk, and caused his condition to become life threatening. It caused significant distress to her.
      2. A GP at the Practice did not review her father face to face, which contributed to the delay in his admission to hospital. The GP refused to discuss this with Ms P after she went to the surgery later that day.
      3. The Council’s safeguarding investigation into this incident was biased, did not allow her to have enough input, and did not identify the failings in care.
      4. In August 2017, the Home again took too long to seek medical attention for Mr D, and a nurse did not call an ambulance despite being advised to by the 111 service because of suspected sepsis. This prevented Mr D from having the best opportunity to survive.
      5. The Council’s safeguarding investigation into this did not adequately consider the role of the nurse at the Home the day before Mr D’s hospital admission.
      6. In mid-June 2017, Mr D developed bowel problems but the Home failed to send a stool sample to the Practice for testing.
      7. Ms P is unhappy with the way her complaint was handled. In particular, she did not receive an adequate response to her complaint about the Home’s actions, and the response she received was significantly delayed.
  2. Ms P says these events caused her significant stress, distress, and caused her ill health to worsen. She seeks better explanations about what happened, an acknowledgement of what went wrong, apologies, and changes to practice and procedures.

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Parts of the complaint I investigated

  1. I investigated all the complaint except part f. I have explained why at the end of this statement.

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The Ombudsmen’s role and powers

  1. 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)). If it has, they may suggest a remedy. 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.
  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. (Local Government Act 1974, section 25(7), as amended)
  3. 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 for both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA)
  4. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
  5. The Ombudsmen 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 the decision was reached. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
  6. 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 information provided by the parties to the complaint, including relevant health and social care records from the Home, the Practice, the hospital to which Mr D was admitted, the 111 service, the out of hours GP service, and the ambulance service. I took account of relevant policy, law and guidance. I took clinical advice from an experienced GP, and a senior nurse with expertise in the care of older people.
  2. I shared a draft of this decision with the parties to the complaint and considered their comments.

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What I found

Legal and administrative context

Safeguarding

  1. The safeguarding responsibilities of local authorities and their partners are set out in the Care Act 2014 and the accompanying statutory guidance. 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.

Fundamental Standards of Care

  1. 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.
  2. Regulation 12 says care must be delivered safely. Providers must minimise risks to a person as much as reasonably practicable. People providing care must have the appropriate skills.

The Code for Nurses and Midwives

  1. The Nursing and Midwifery (NMC) issued The Code in 2009 (updated 2015). This sets out standards of conduct, performance and ethics for nurses and midwives. It says clear and accurate records should be kept of discussions, assessments, treatment and medicines given, along with how effective these have been. Nurses and midwives must “accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care”. They must promptly refer a person to another practitioner when necessary for care or treatment.

Background

  1. Mr D lived in a nursing home (the Home). He had a range of health problems, including swallowing difficulties, weakness on one side of his body, and confusion.
  2. In the evening of 25 April 2017, Mr D was admitted to hospital with aspiration pneumonia (a chest infection caused by inhaling something rather than swallowing it) and hypoactive delirium (a condition where a person who is unwell becomes unusually sleepy and withdrawn). Ms P complained to the Council that the carers at the Home had not sought medical attention for him soon enough. The Council investigated under the safeguarding process but concluded that Ms P’s concerns were not substantiated.
  3. In the morning of 20 August 2017, Mr D was admitted to hospital after becoming unwell overnight. He sadly died on 25 August.

Complaint about the events of April 2017

  1. Ms P said:
  • She went to the Home in the late morning of 25 April because the GP said they would visit to review Mr D’s medication at lunchtime. However, the GP did not come to Mr D’s room, and Ms P found out in the early afternoon that the GP had left.
  • When she entered Mr D’s room, she found him not alert, with noisy, gurgling, breathing and unable to eat or drink. Two carers told her they’d heard a problem with his breathing, and also told the Home’s senior care worker (the Senior Carer) this. However, the Home did not act on this, and the nurse did not see that he was unwell.
  • Ms P said she spoke with the Senior Carer about Mr D’s breathing, who said she would contact the Practice for a home visit. Then Ms P went to the Practice to express concerns about Mr D. The Practice receptionist said the GP was busy so they took Ms P’s details, but no one called her back.
  • The Home did not seek medical attention for Mr D until that evening, when he was very poorly. This delay meant Mr D’s condition became life threatening.
  • When the Home called out of hours health services, it gave incorrect information about Mr D. It said he’d only had breathing difficulties for the last twenty minutes, disregarding the problems earlier that day. This made it harder for the out of hours service to diagnose the problem.
  • When she phoned the Home around 16:00 that day, the Senior Carer said she was waiting for the doctor to get back to her, but the Practice said this was not correct.
  • The safeguarding investigation did not take into account that: the Senior Carer’s statement said Mr D had been struggling to breathe, which she did not tell the out of hours medical service; no one called the GP when Mr D was seen to struggle to breathe in the afternoon; the Home did not tell the out of hours services that Mr D had a history of chest infections; and parts of the Senior Carer’s statement were inaccurate.
  • The social worker who completed the safeguarding investigation did not take proper account of the information from Ms P, and clearly believed the Home.
  • The social worker told Ms P she would organise a meeting at the Home to discuss Ms P’s concerns, but the social worker did not do this.
  • If the safeguarding investigation into the April events had been upheld, the events of August may have been avoided.

The records

  1. The Home’s records of 25 April say Mr D ate all his breakfast, and drank fluids that morning. Staff provided personal care in the morning and had no concerns about him.
  2. The Practice’s records show that a receptionist sent a message to the GP at 15:09 to say Ms P attended and said she had sat in Mr D’s room for three hours waiting for the GP. Ms P said two carers noticed that morning that Mr D was wheezing, and asked whether the GP knew this, since the carers did not tell the nurse on duty (Nurse B). The GP replied to the receptionist at 15:31 to say the carers had not mentioned Mr D wheezing or said he needed to be seen. She asked the receptionist to check with the Home whether he needed a visit.
  3. At 15:27, the Senior Carer recorded that after the GP left Ms P said Mr D sounded chesty and wheezy, so she would phone the GP if they saw any further wheeziness. Carers noted at 15:30 that Mr D drank coffee and ate most of a snack. At 17:16, carers recorded that Mr D ate most of his evening meal and drank all his drink.
  4. At 18:38, carers recorded that they provided personal care to Mr D and his breathing seemed strained and he was in pain. They told Nurse B and the Senior Carer.
  5. Nurse B told the 111 service at 18:46 that care staff had just reported that Mr D was very chesty and wheezy, but he had been fine that day. She had just been to see Mr D, and he was chesty and wheezy.
  6. The out of hours service recorded that Nurse B said she had seen Mr D a few times that day, and neither she nor the care staff had noticed any problems. He had been eating and drinking. Now, he was chesty and wheezy and had a cough. The Senior Carer took over the call. She said Mr D had had breathing problems in the past. Earlier that day Ms P said Mr D was very chesty and she wanted him to see the GP, but the GP had left. The Home’s staff had seen him since, and he was “not too bad”, but he now sounded “quite bad” and did not look comfortable. The out of hours doctor said it sounded like the start of a chest infection and they would visit within two hours.
  7. Before the out of hours doctor arrived, the Home called an ambulance for Mr D. The out of hours doctor visited at 20:07. They recorded that Mr D became “very chesty” that evening, with a raised temperature of 39. He ate dinner about 17:00 that day, with no coughing or choking. The doctor felt he probably had aspiration pneumonia. While the doctor was present, the ambulance arrived to take Mr D to hospital.
  8. The hospital records show that Mr D was diagnosed with aspiration pneumonia and hypoactive delirium. A doctor recorded that his prognosis was uncertain. He could “take a turn for the worse”.
  9. At 09:35 on 26 April the Practice’s receptionist messaged the GP to say they had checked with the Home whether Mr D needed a visit, and the staff from the Home said they would let the Practice know when they had spoken with the Senior Carer.
  10. The Council’s records, following discussion with the Home, say Ms P’s concerns were resolved by the meeting with the GP and the Home on 12 May.
  11. A social worker called the Home on 24 May. The Home said Mr D was usually wheezy. Staff on duty on 25 April did not consider that he was more wheezy than normal until later in the day. The Home said it told Ms P when they met that if she had concerns about Mr D that morning she should have told the nurse in charge.
  12. The social worker decided that since Ms P had met with the Home to discuss her concerns and the issue may have been “lack of communication” between Ms P and the Home, the matter did not need a safeguarding investigation.
  13. Ms P contacted the Council again in early June. She said she was not satisfied with the meeting in May. She was not happy that the Home told the out of hours services Mr D did not have a history of chest infections, when he did. It did not say that carers saw Mr D struggling to breathe. She said the Home should have called the GP sooner, and that if the Home gave the correct information to the out of hours services they would have called an ambulance straight away. The Council decided it would conduct a safeguarding enquiry.
  14. The social worker visited the Home on 9 June. They reviewed Mr D’s care plan, care logs, statements from staff, and spoke with the Home’s manager and Nurse B. Nurse B wrote a statement that staff had seen Mr D throughout the day and they were not concerned about his breathing until teatime. The social worker also got the records from the 111 and out of hours service.
  15. The Home’s manager said Mr D was often deeply asleep over meal times, so his meals were kept for when he was awake. Ms P felt his deep sleep was of concern, when it was not. Care staff said Mr D was often short of breath following personal care, and it was at this time that Ms P told staff she was concerned about his breathing. The social worker noted that the transcript of the out of hours call said the staff said Mr D did not have frequent chest infections. The Senior Carer and nurse said they thought they had said that he had a history of chest infections.
  16. The social worker concluded that they could find no evidence of neglect. They noted that whether staff gave incorrect information about Mr D’s history of chest infections did not affect the fact that emergency services were called.
  17. The social worker called Ms P on 11 July and explained they found no evidence that the care staff acted inappropriately. Ms P said she appreciated that there was a lack of evidence, but she felt strongly that the Home did not get Mr D to hospital quickly enough.
  18. Ms P called the Council on 21 July. She said she was not happy with the outcome of the safeguarding investigation. The social worker agreed to contact the Home. On 24 July the social worker spoke with the Home’s manager. The Home’s records say the social worker would meet with Ms P and the Home to discuss various concerns (related to the way Ms P fed Mr D), but he was admitted to hospital before this happened.
  19. On 15 August the Council recorded that Ms P called to say she understood the social worker may not want to pursue the safeguarding investigation further, but she considered that her concerns were justified. She said she did not want to make a complaint or further action to be taken.

Findings about the Home

  1. Ms P said the Home’s carers told her they heard a problem with Mr D’s breathing in the morning. The Home provided a copy of statements by the carers who saw Mr D that morning. One said Mr D was quite wheezy, which they had mentioned to Ms P, but this was normal for him in the morning and he did not seem worse than he did at other times. The other also said that Mr D was a little chesty in the morning, but this was normal for him and they did not worry because they knew once he was sitting correctly it would settle down.
  2. Having considered the evidence, I find that there was no reason for the Home to seek medical attention for Mr D based on the observations of the carers in the morning.
  3. The Senior Carer documented in the Home’s records at 15:27 that Ms P said Mr D sounded “chesty/wheezy” so she would phone the GP if they saw further wheeziness. Ms P says the Senior Carer told her she would call the GP for a home visit, and that when she rang the Home later in the afternoon the Senior Carer said she was waiting for the Practice to get back to her. The accounts of this discussion conflict. I cannot resolve these two differing accounts without any additional evidence, and there is no such evidence available. In these circumstances, I cannot establish that there was fault here.
  4. Mr D was at significant risk of aspiration because of his medical conditions, and aspiration does not always cause coughing. Therefore, the Home needed to be alert to possible signs of aspiration. The Senior Carer should have reported Ms P’s concerns to Nurse B, which should have prompted Nurse B to monitor Mr D’s respiratory rate, temperature and oxygen saturation levels to check for signs of aspiration.
  5. In its comments on a draft of this decision, the Home told me the Senior Carer did report Ms P’s concerns to Nurse B, who carried out physiological observations, but they did not document this. Based on the evidence I have seen, I am not persuaded by this.
  6. I find that the Home failed to properly respond to Ms P’s concern by ensuring that the nurse was aware of Ms P’s observation and that the nurse monitored Mr D’s physiological signs as a result. This was fault, and was a potential breach of the fundamental standards of care.
  7. The records say the Home’s staff saw Mr D several times during the afternoon and did not see cause for concern about him, which indicates that they did not witness the abnormal sounds Ms P heard.
  8. Signs of aspiration pneumonia can develop very quickly, and we do not know at what time during that day Mr D’s physiological observations would have become abnormal. Therefore, it is possible that if a nurse had checked them soon after Ms P reported her concerns to the Senior Carer they would have been normal. Therefore, I cannot say that the Home would have found cause to seek immediate medical attention for Mr D were it not for the fault. This means I have not found that the Home’s fault affected the course of Mr D’s illness or put him at increased risk.
  9. When the carers saw that Mr D seemed unwell in the evening, the Home promptly sought medical assistance for him. Ms P complained that the Home did not tell the out of hours service that he’d had breathing difficulties earlier that day. But the records show that the Senior Carer told the out of hours service that Ms P said he was chesty earlier in the day. I have not seen evidence of fault with the way the Home responded after staff saw that Mr D was unwell.

Findings about the Practice

  1. There is no fault with the GP discussing Mr D with the Senior Carer rather than going to see him in his room. It is usual practice for GPs to discuss patients with care home staff and to make decisions based on what care home staff report, without necessarily seeing each patient in person.
  2. When the receptionist told the GP that Ms P was concerned about Mr D wheezing, the GP correctly asked the receptionist to speak with the Home and find out whether Mr D needed a visit. However, reception staff did not do this until the following morning. Further, the GP did not follow up the request that afternoon by asking the receptionist whether the Home said Mr D needed a visit or not. By the time the Practice contacted the Home to offer a visit, Mr D was in hospital. The Practice was at fault here, because it did not follow good practice for the circumstances.
  3. Since the Home was not concerned about Mr D at the time Ms P attended the Practice, it would probably have said he did not need a visit, had the Practice contacted the Home when it should have. Even if the Home had acted without fault and checked Mr D’s observations when it should have, and it had found an abnormality, the Home would then have had to consider contacting the Practice or emergency services itself, rather than waiting for the Practice to call back. Therefore, I have not found that the fault by the Practice caused an injustice.
  4. The Practice completed a significant analysis of this event, but not until December 2018, after Ms P brought her complaint to the Ombudsmen. The analysis is inadequate because it does not contain a thorough review of what went wrong and fully identify what the Practice needed to do to prevent similar incidents.

Findings about the Council

  1. The records show that the safeguarding officer discussed Ms P’s concerns with her and considered what she said. They also considered information from the out of hours services and reviewed the Home’s records. The Council’s records do not suggest it planned to discuss Ms P’s safeguarding concerns with her further at a meeting at the Home.
  2. Having considered the evidence, I can find no fault with the way the Council reached its decision to find that the safeguarding concerns were not substantiated. I have not seen evidence of bias or a failure to take Ms P’s concerns seriously. I have not seen any indication that the Council should have done anything differently which may have prevented the August incident.

Conclusions about the April incident

  1. There was fault because staff at the Home failed to properly respond to Ms P’s concern by ensuring that a nurse monitored Mr D’s physiological observations.
  2. It is not possible to know whether earlier monitoring would have shown signs that Mr D was unwell, so I have not concluded that the Home should have sought medical attention for Mr D earlier. Even if it had, it is likely that Mr D would still have become very unwell and needed an emergency hospital admission for treatment. However, the uncertainty around this is a source of distress to Ms P, and that is an injustice to her.
  3. The Practice is at fault for failing to appropriately follow up Ms P’s concerns, but this did not allow Mr D’s condition to become worse or put him at increased risk.
  4. There was no fault with the Council’s safeguarding investigation.

Complaint about the events of August 2017

Ms P’s complaints

  1. Ms P said:
  • Mr D became very unwell during the morning of 19 August 2017, but the nurse on duty at the Home in the daytime (Nurse K) was not concerned.
  • The local out of hours service told the nurse on duty that night (Nurse Q) to call 999 for an ambulance for Mr D, but she did not.
  • As a result, Mr D lost the chance to survive his illness.
  • No one referred Nurse Q to the Nursing and Midwifery Council (NMC), the professional regulator for nurses, so she had to do this herself.
  • The safeguarding investigation only looked at the actions of Nurse Q. It did not look at the actions of Nurse K, who did not take seriously Ms P’s concerns that Mr D was in an altered state of consciousness and could not swallow pureed food that day.

The records

  1. The Home’s records of 19 August show staff provided care to Mr D throughout the day. He chatted with staff, ate food, drank fluids and passed urine.
  2. At 00:25 on 20 August, a carer noted Mr D was breathing hard, seemed to be in pain, and was not responding. They told Nurse Q.
  3. Nurse Q called 111 at 00:46. She said Mr D was not responding when spoken to, when he was normally alert at night. His blood pressure was a bit high, his eyes were a bit sunken, his breathing was not good and she could hear some bubbling. The 111 service said it would arrange a call back from an out of hours doctor.
  4. The out of hours service called Nurse Q at 00:53. Nurse Q said Mr D did not “look too good at all”. He was lethargic, drowsy, and his breathing was not very good. He had been this way for “about a couple of hours”. At this point the call recording stopped for about 30 seconds. Then, the out of hours service asked Nurse Q whether Mr D had been eating and drinking. She said his intake was quite poor. The out of hours service told Nurse Q she needed to phone an ambulance because Mr D probably had sepsis. Nurse Q confirmed she understood.
  5. The hospital records contain notes provided by the Home. Nurse Q recorded at 01:30 that she was called to Mr D’s room because carers were concerned that he was lethargic, not his usual self, and they had seen him trying to vomit. Nurse Q recorded Mr D’s pulse at 103, blood pressure at 181/72, and temperature at 36.3. She wrote that she called the out of hours service, which advised her to call 999 if his temperature increased. She checked his observations again after an hour. These were a pulse of 101, blood pressure of 161/88 and temperature of 36.7. Mr D appeared settled and asleep.
  6. The out of hours service sent an incident report to the Practice, which said it had advised Nurse Q to call 999. It did not say she should only do so if his temperature increased.
  7. At 07:56 on 20 August, Nurse K rang 999 about Mr D. She said Mr D was “not really conscious”, breathing more deeply than usual, cold and clammy. She had come to work and checked on Mr D, after a report that Mr D was unwell the previous night. She recorded that when night staff called 111: “[111] was a bit busy so they just said to observe him”.
  8. An ambulance took Mr D to hospital. On 21 August, the hospital recorded that Mr D had severe sepsis. The hospital notes of 24 August say Mr D was not responding to treatment for infection, so it started end of life care. He sadly died the next day.
  9. In October, Ms P complained to the Council, which started a safeguarding investigation. Ms P gave the Council a transcript of the call between the out of hours service and Nurse Q, where Nurse Q was instructed to call an ambulance. The social worker visited the Home and found no evidence that the Nurse Q took further action about Mr D’s condition.
  10. In January, Nurse Q contacted the social worker. She said there was a misunderstanding and she thought the advice from the out of hours service was to keep monitoring Mr D’s temperature. The social worker noted that the transcript is very clear that Nurse Q was advised to call 999 and she confirmed she would. There was no record at the Home of the telephone call with the out of hours service, and no ambulance was called until the next morning when another nurse arrived.
  11. On 31 January, the Council wrote to the agency which employed Nurse Q. It explained the findings of the safeguarding investigation about Nurse Q, and asked the agency to report the concerns to the NMC. The social worker noted that he spoke to the Home’s manager on the phone, advised her about the concerns about Nurse Q’s practice and asked the Home not to offer Nurse Q further employment.

Findings about the Home

  1. The Home’s records of 19 August indicate that there was no cause for concern about Mr D that day. Nurse K provided a statement on which she said Mr D did not appear to be ill at any time during that day. She said he took his medication as usual, and conversed with staff before and after Ms P visited. Though Ms P said she told Nurse K that she was concerned that Mr D was very sleepy, I consider that the evidence does not support a view that Nurse K should have sought medical attention for Mr D during the day.
  2. The Home told me that Nurse Q maintains that during the missing section of the transcript of the phone call with the out of hours service, it told her to monitor Mr D’s temperature and call an ambulance if his temperature increased. This reflects what Nurse Q documented in the notes the Home sent to the hospital. However, it does not reflect the content of the incident report the out of hours service sent to the Practice, and it is not consistent with the content of the rest of the transcript of the call.
  3. Regardless, based on her observations that Mr D was less alert, unresponsive to voice, had laboured breathing, was in pain and was attempting to vomit, Nurse Q should have called an ambulance for Mr D by 01:00. Not doing so was fault, and appears to be a potential breach of the NMC Code. This caused a delay of around seven hours in his admission to hospital.
  4. Had Nurse Q called an ambulance when she should have, the possibility that the hospital could have successfully treated Mr D’s infection is slim. Given Mr D’s very poor health, it is very likely that he would have died from the infection even if an ambulance was called at 01:00. Though I find it more likely than not that Mr D’s death was not preventable, the delay did reduce his small chance of surviving the infection. The uncertainty around this caused significant distress to Ms P.

Findings about the Council

  1. Ms P’s complaint to the Council, following which it started the safeguarding investigation, did note that she felt Mr D was in an altered state of consciousness when she visited on 19 April, but she did not say at the time that the Home neglected him during that day. Her letter to the Council of October 2017 said her concern was the failure of Nurse Q to call an ambulance.
  2. Accordingly, I do not find that the Council was at fault for not investigating the events of the daytime. In any case, the evidence from the Home and Nurse K indicates that there was no cause for alarm during that day.
  3. The Council has provided evidence that it asked Nurse Q’s agency to report the concerns about her to the NMC. Its letter contained details of the concerns. The Home said the agency requested documentary evidence of the Council’s concerns and did not receive them, but this is not reflected in the Council’s records.
  4. I do not find fault with the Council here.

Complaint about the complaint handling

  1. Ms P’s key concern here was about the lack of an adequate response to her complaint about the Home’s actions in April 2017.
  2. Ms P wrote to the Home in October 2017 about her concerns, and had no response until March 2018, after she complained again. The Home then told her in May it was investigating her concerns and would write to her, then it refused to do so. This was fault. However, I have not identified an injustice from this, because Ms P’s complaints were investigated by the Council and it is unlikely that a separate investigation by the Home would have made a difference to the outcome.
  3. Ms P complained to the Council in October 2017, and the Council replied that it had reviewed the records of the safeguarding enquiry about the April events, and it considered that this had been handled properly. It explained its reasons for this in detail. The Council was entitled to reach this view, so I do not find fault with it.

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Agreed actions

  1. Within two months of this decision:
      1. the Council will work with the Home to address staffs’ understanding of how they should respond to relative’s concerns, to prevent similar faults occurring in future. It will explain to Ms P in writing how it has done this. It will apologise to her for the impact of the Home’s failure to respond properly to her concerns.
      2. the Home will review its practice and procedures for monitoring the condition of patients who are unwell, or who may be unwell, and seeking medical attention. It will write to Ms P to apologise for the distress caused to her by the failure of Nurse Q to call an ambulance for Mr D and to explain the outcome of its review. It will share a copy of this letter with the Ombudsmen.
      3. the Home will share a copy of this decision statement and its action plan with CQC and the Clinical Commissioning Group which funded Mr D’s nursing care. It will provide evidence to the Ombudsmen that it has done this.
      4. the Home will pay Ms P £500 to acknowledge the distress and uncertainty she was caused by the failure of Nurse Q to call an ambulance for Mr D.

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Decision

  1. I find that:
      1. The Home failed to properly act on Ms P’s concerns about Mr D’s breathing. This was fault, and caused distressing uncertainty to Ms P, which is injustice. I find fault with the Council for this, since the Council commissions social care from the Home.
      2. The Practice failed to respond properly to Ms P’s concerns about Mr D’s breathing. This is fault but did not cause injustice. It also failed to produce an adequate significant event analysis. This is fault but did not cause injustice.
      3. The Home failed to call an ambulance for Mr D when it should have on 20 August. This reduced his chance of surviving his infection and caused significant distress to Ms P. I find fault with the Home for this, as this was a failure of nursing care.
      4. There was no fault with the safeguarding investigations.
      5. The Home failed to properly respond to Ms P’s complaints. This did not cause injustice.
  2. I am satisfied that the agreed actions will remedy the injustice I found. Therefore, I have completed my investigation. We will share a copy of this decision statement with CQC.

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Parts of the complaint that I did not investigate

  1. I did not investigate part f of the complaint, about the failure of the Home to supply a stool sample to Mr D’s GP. There is no evidence that this caused a significant injustice to Mr D. The Home disagrees with the hospital’s note of how frequently Mr D had loose stools when at the Home, and it is unlikely we could resolve this to Ms P’s satisfaction.

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Investigator's decision on behalf of the Ombudsman

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