The Ombudsman's final decision:
Summary: Mrs V complains about the care of her late husband by a care home and a GP Practice in the last months of his life. We have upheld some of Mrs V’s complaints about the Home’s care of Mr V and its complaint handling. We have also upheld some of Mrs V’s complaints about the GP Practice’s handling of end of life medication and complaint handling. Bupa, the Council and the GP Practice accept our recommendations. We have therefore completed our investigation.
- The complainant, whom I shall call Mrs V, complains about the care provided to her late husband, Mr V, at Meadbank Nursing Centre (the Home, operated by Bupa) between May and November 2017. London Borough of Wandsworth (the Council) and Wandsworth Clinical Commissioning Group were responsible for Mr V’s placement at the Home. NHS South West London Clinical Commissioning Group (the CCG) took over responsibility from Wandsworth Clinical Commissioning Group from April 2020. The Knightsbridge Medical Centre provided GP services to Mr V while he was at the Home.
- Mrs V complains that the Home failed to:
- properly manage Mr V’s risk of falling and provide an accurate complaint response on this issue;
- adequately supervise another resident, leading to an assault on Mr V which Mrs V believes could have been avoided;
- take adequate steps to get Mr V’s arm weakness/paralysis investigated; and
- ensure Mr V was taking all his prescribed medications.
The Ombudsmen’s role and powers
- 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)
- 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, the Ombudsmen may 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.
- The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
- 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)
- Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
How I considered this complaint
- I have considered the following evidence as part of my investigation:
- information provided by Mrs V in writing and by telephone;
- written information provided by the CCG, Council, Home and Practice;
- relevant law and guidance; and
- clinical advice from a registered nurse and a GP, with relevant knowledge and experience but no previous connection to this complaint.
What I found
Key background summary
- Mr V moved to the Home on 28 April 2017, following a hospital admission. He had significant health problems including mixed dementia and a severe cognitive impairment. The Council and CCG were jointly accountable for his care there under section 117 of the Mental Health Act 1983.
- Mr V suffered several falls in June and July 2017. In July 2017, the Council carried out a safeguarding enquiry after another resident attacked and injured
Mr V. The Council completed the enquiry in late July 2017 and wrote to the Home to ask it to take actions to safeguard Mr V. Mr V remained in the Home. Although no further incidents with other residents or falls were recorded after the end of July, Mrs V was dissatisfied with the way the Home managed Mr V’s medication. She was also dissatisfied with the way the Home and the GP Practice dealt with the worsening weakness in Mr V’s arm.
- Mr V’s health deteriorated rapidly around 25 October 2017. By 27 October, a Friday, doctors felt he was approaching the end of his life and it was the time to agree end of life care for him. The GP Practice issued a prescription for ‘anticipatory medication’ [medication kept in case it is needed to relieve symptoms at the end of life] for the weekend, to be delivered using a syringe driver [a small pump used to give medicine continuously under the skin over a period of time]. There was a delay in Mr V receiving this medication. He received some injections that weekend and the syringe driver was set up the following Tuesday. Mr V died on 1 November 2017.
Care by the Home – falls
- 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 says that care must be provided in a safe way for residents. This includes: assessing and as far as possible mitigating risks, safe care planning, ensuring premises and equipment are safe and safe management of medicines. Regulation 17 is about good governance. This includes maintaining accurate and complete records.
- The Home acted within its policy to assess Mr V’s risk of falls at the time of his admission and on five more occasions until October 2017. It identified Mr V was at high risk of falls from the time he started living there. He remained at high risk of falls throughout his time at the Home. All the risk assessments concluded he was at high risk of falling and should have had a falls care plan and checks every two hours at night. There was no fault in the way the Home assessed Mr V’s risk of falling and planned his care to reduce that risk.
- Mr V’s moving around plan dated 28 April 2017 said he should have been accompanied when walking short distance, in a wheelchair for longer distances and had a floor sensor mat. A falls sensor mat activates the call system when a person steps on it, alerting staff to residents’ movements. A falls diary records five unwitnessed falls between 20 June and 30 July 2017, four of them in the night and one at about 6pm. Another fall on 31 July was witnessed by staff who said Mr V had lost his balance. Mr V sustained cuts and bruises. The Home asked a GP to see Mr V following each of those falls. There was nothing physical to explain why Mr V was falling frequently. The GPs who saw Mr X ordered blood tests and asked his psychiatrist to review his medication.
- Records indicate Mr V did not have a floor sensor mat in his room before 14 July 2017. The documentary evidence does not record whether the Home checked on Mr V every two hours at night. Failure to install a sensor mat despite Mr V’s moving around plan saying he should have one was fault. It was also fault not to document whether staff checked Mr V every two hours at night. This was contrary to Regulations 12 and 17. We cannot say that Mr V would not have fallen even if the mat had been there, or if there were documentary records of Mr V being monitored every two hours at night. But the flaws have led to a lost opportunity to prevent some of Mr V’s falls, and a justifiable and distressing doubt for Mrs V that some of her husband’s falls could have been avoidable with better care. I have made recommendations below for Bupa and the Council, to remedy Mrs V’s injustice and to put service improvements in place to prevent similar faults causing problems to others.
- The Council wrote to the Home in late July 2017 asking it to consider making the sensor mat in Mr V’s room larger and to place padded cot sides on his bed. It also asked the Home to consider a toileting regime. The purpose of a toileting regime would have been to ensure Mr V has opportunities to be supported to go to the toilet at night, rather than feeling the need to get out of bed on his own. The Home installed cot sides on 30 July 2017. The Home did not put in place a toileting regime or a larger sensor mat. However, Mr V did not have any falls after the end of July 2017. I consider the Council took appropriate action to check the Home had taken enough steps to prevent further falls.
Care by the Home – assault by another resident
- Mr V had mixed dementia with severe cognitive impairment and displayed challenging behaviour before he moved into the Home. Mr V preferred to move around independently and could become irritable if others tried to help. He could also on occasion enter others’ rooms and display challenging behaviour, which could trigger a response from the other residents. The Home was aware of this around the time of Mr V’s admission. However, it did not have a behaviour management plan in place for Mr V.
- Mr V was assaulted by another resident on 13 July 2017. The Home’s records indicate this happened when Mr V had entered the other resident’s room. The GP who examined him after the assault noted:
- Mr V had sustained facial injuries which needed to be cleaned and dressed;
- the assault had happened when all the carers and nurses were busy doing personal care leaving no staff free to monitor the corridors and other residents;
- she raised concerns with the Home’s manager that the staff levels on the floor were not enough to adequately supervise residents who had a history of wandering or aggression;
- the Home’s manager’s response was that the levels were adequate because they met guidelines.
- an incident such as the one where another resident attacked Mr V was predictable;
- despite this, the Home did not have a behaviour management plan in place for Mr V; and
- at the time the incident happened, there were not enough staff to provide adequate supervision on the floor where Mr V lived.
- it was providing further staff training on how to support people with challenging behaviours; and
- it was ensuring the senior nurse and managers are adequately coached in dealing with challenging behaviours.
Care by the Home – medication other than end of life medication
- Mr V had MDS [myelodysplastic syndrome, one of a group of rare blood cancers where the body does not make enough healthy blood cells]. Mrs V says that Mr V’s blood test results in late September 2017 led the hospital haematology department [department for treatment of diseases of the blood] to suspect he may not be taking his prescribed medication for this condition (Anagrelide). The haematologist’s letter to Mr V’s GP confirms this.
- Mrs V also expressed concerns in September and October 2017 that carers did not always apply Mr V’s prescription creams or bathe his eyes as frequently as they should.
- Nurses are permitted to transcribe instructions for supplying or administering medication, for example from a label on pharmacy supplied medication to a medication administration record (MAR) chart. “NMC 2007: Standards for medicines management” says that nurses:
- are responsible for ensuring that what they write is legible;
- must make a clear, accurate and immediate record of all medicine administered, intentionally withheld or refused by the patient; and
- where a nurse or carer omits prescribed medication, they must state why they did this.
- manage medicines properly and safely (Regulation 12); and
- keep accurate records (Regulation 17).
Arm weakness/paralysis – investigation by GP Practice
- Mrs V says that:
- during an appointment with Mr V’s haematologist on 1 September 2017, she expressed concern that Mr V’s right arm had appeared paralysed for some time;
- the haematologist wrote to Mr V’s GP the next day and advised them she had sent Mr V for a review at the A&E department because of the concerns about arm weakness;
- the A&E department carried out a CT scan [a scan that can give good pictures of soft parts of the inside of a body that do not show on ordinary X-ray pictures] of Mr V’s head and told Mrs V to ask his GP surgery to arrange an urgent scan of Mr V’s neck and shoulder. Mrs V says she asked the GP surgery for an urgent neck and shoulder scan, but the GP practice did not arrange it;
- the haematologist wrote to Mr V’s GP on 3 October 2017 following another appointment where she and Mrs V remained concerned that Mr V was not using his right arm;
- Mrs V followed this up with a GP who had visited Mr V in the Home and he told her he would speak with a neurologist [a doctor that specialises in disorders affecting the brain, spinal cord and nerves] the next day and get back to her;
- the GP did not contact Mrs V as agreed, and Mr V received a non-urgent neurology appointment for February 2018.
1 November 2017. In relation to Mr V’s right arm, the GP Practice’s records show the following.
- A GP saw Mr V on 19 July 2017, a few days after he had been assaulted, and noted he was reluctant to use his right arm, which was bruised and painful when he tried to use it. The GP noted the arm felt hard and tender to touch. The GP was concerned about a possible fracture, so sent Mr V for an x-ray which was done the same day. The x-ray revealed formation of new bone over an old fracture but no new fractures.
- The Home asked a GP to examine Mr V on 29 August 2017 because he had a pain in his right arm. Mr V wanted to go to the toilet at the time of the GP’s visit, so the GP did not examine him then. The GP noted Mr V was using his right arm to hold the carer, the x-ray results from the month before, and that Mr V did not appear unwell, so decided to examine him the next day instead.
- The same GP examined Mr V’s right arm the next day and noted he seemed to be using it less than his left arm. The GP also considered Mr V did not show signs of pain when she touched the arm and that he had reduced power in his right hand but not his whole arm. The GP noted no obvious redness or swelling of the arm or hand and no neck pain. The GP considered the symptoms may be related to the bruising following the assault of July and/or a soft tissue injury, so she arranged for a visit from a physiotherapist. The Practice says that the GP would have chased this up had she known about delays and would have reviewed Mr V’s arm again had she been aware that Mrs V was concerned about a worsening of the symptoms before the visit to the haematologist.
- The GP practice says that the GP who saw Mr V on 12 September 2017 was unaware of the CT scan performed in A&E on 1 September, so did not examine his arm again.
- Mrs V met with a GP at the Home on 3 October 2017 to discuss Mr V’s worsening arm weakness. The GP examined Mr V and concluded the arm weakness was more likely to have a neurological cause than being related to bones, joints or muscles. The GP did not chase up the physiotherapy service because he considered Mr V was unlikely to benefit from it because of his inability to remember and perform exercises. The GP discussed Mr V’s arm weakness at a Practice weekly clinical meeting, which agreed Mr V needed an urgent neurology referral. The GP wrote a referral letter on 5 October 2017 asking for an urgent neurology appointment. The Practice chased up the referral on 10 October to ensure it had been received.
- the referral to a physiotherapist on 30 August 2017 was in accordance with General Medical Council (GMC) guidance on providing a good standard of care;
- Mr V’s haematologist and the hospital A&E had arranged a CT scan and the GP Practice took note of the results in October;
- the hospital did not ask the GP Practice to arrange any further scans; and
- having reviewed Mr V’s arm problems and decided that physiotherapy was unlikely to be of benefit to Mr V, the GP Practice made an urgent referral for a neurology appointment.
Arm weakness/paralysis – care by the Home
- Mr V’s GPs and hospital were involved in investigating the cause of his arm weakness. In those circumstances, there was nothing extra the Home should have done to investigate the weakness or paralysis in his arm. Therefore, the Home did not act with fault in leaving the investigation of the cause of Mr V’s arm problem to his doctors.
- Mrs V’s diary of events records that:
- Mr V’s weak arm became trapped between the bed and guard rail on 4 September 2017;
- nobody at the Home responded to his calls for help with this happened;
- she found him in his bed, stuck between the mattress and the guard rail, crying and shouting, with carers walking past the door; and
- Mr V’s arm was injured as a result.
- it has no record of Mr V’s arm becoming trapped in his bed rail and the resultant injury; and
- since Mrs V’s complaint, it has worked with staff to improve body mapping, care planning and recording and implemented a “robust daily clinical risk review each morning throughout the home”.
End of life care by the Home and GP Practice
- Mrs V says that:
- the GP practice made an inadequate referral to a hospice, resulting in the hospice declining to admit Mr V because the referral did not indicate that he was ill enough;
- a GP never explained to the family what would happen at the end of Mr V’s life;
- the GP practice and Home failed to ensure Mr V received end of life medication via a syringe driver over a weekend, despite a hospice sending a faxed prescription to the GP practice at 1pm on Friday 27 October 2017;
- the nurses on duty at the Home on the Saturday knew nothing about the arrangements for a syringe driver;
- a nurse at the Home initially refused a request for a second injection of a medication that would calm Mr V and only gave this to him after Mrs V sought advice from a hospice.
- The GP Practice’s complaint response to Mrs V dated 9 November 2018 states that the Hospice assessed Mr V earlier in October 2017 and considered he was not approaching the end of his life then. However, there is no documentary record of the GP Practice making a referral to the Hospice in early October 2017. The GP Practice’s response to our enquiries confirms it did not refer Mr V to the hospice until 27 October 2017. I will deal with the GP Practice’s complaint handling below.
- There are not enough records for us to establish who referred Mr V to the hospice in early October and whether the referral was flawed. However, a hospice is unlikely to accept a patient until they are in the last few days of their life. The records the Home and the GP Practice have provided describe the state of Mr V’s health in October. Based on those records, I consider it unlikely that a hospice would have admitted Mr V in early October 2017.
- Whether or not the hospice accepted a referral had no bearing on the GP Practice’s ability to prescribe anticipatory end of life medication. The GP Practice could have done this independently of any referral and assessment by the Hospice, whenever a GP considered it appropriate. I will deal with the GP Practice’s prescribing of end of life medication below.
- The GP Practice made a referral to the hospice on 27 October 2017. The referral was to request a recommendation for end of life medication. The records indicate that the GP Practice made the referral having consulted Mrs V. I have found no fault in the way the GP Practice made this referral because it was made at the appropriate time and in consultation with Mrs V.
Explanation of what happens at end of life
- Not all relatives of terminally ill patients will want to know this information, as some people may find it distressing. Mrs V says that the GP only spoke with her about resuscitation and who to call if she had concerns about care out of hours. The GP Practice’s records say that a GP discussed Mr V’s deterioration with
Mrs V on 27 October 2017. The records are brief and do not indicate that the GP explained the process of dying or what would happen to Mr V in the last hours of his life. However, there is also no indication that Mrs V asked for this information at the time. I therefore consider that the GP Practice did not act with fault in relation to this part of the complaint.
End of life medication
- Information provided by Mrs V, the GP Practice and the Home indicates the following happened.
- A GP (GP A) examined Mr V on 25 October and noted he had deteriorated rapidly, became bed-bound, had no communication and was eating very little. The GP started a course of antibiotics in case an infection was causing the deterioration and arranged to see Mr V the next day to review him.
- The following day GP A reduced some of Mr V’s other medications that could have been making him more drowsy. GP A advised the Home to continue Mr V’s antibiotics.
- On 27 October (a Friday), another GP (GP B) examined Mr V and decided that it was the right time to confirm end of life plans with Mrs V.
- GP B then contacted the hospice and at about 1pm received a faxed drug chart from the hospice, recommending end of life medication to be used in a syringe driver. The GP Practice faxed a copy of the drug chart to the Home but did not fax a prescription to Pharmacy A, the Home’s usual pharmacy. As a result, the drugs were not dispensed. Neither the GP Practice nor the Home checked whether Pharmacy A had received the prescription.
- GP B telephoned the Home just after 4 pm and from that conversation understood the Home had received the medication and would administer it.
- On Saturday 28 October, the Home’s nursing staff telephoned GP C to advise him they had not received the end of life medication.
- GP C issued another prescription to enable Pharmacy B (a pharmacy that deals with urgent prescriptions) to dispense the end of life medications that day.
- The Home received the medication at about 6pm on Saturday 28 October.
- On 29 and 30 October, Mr V received a medication called Midazolam [used in end of life care to relive symptoms of restlessness or fitting, it causes sleepiness and decreases anxiety] by injection. This would have reduced his anxiety. He also received Buscopan by injection. This would have reduced secretions.
- On 30 October, GP D saw Mr V. GP D noted Mr V had started receiving end of life medications by injection, and that he received those as he needed them.
- On 31 October, GP C saw Mr V and realised that the syringe driver had not been started yet. The Home told GP C that there was no nurse on duty that weekend who was qualified to set up the syringe driver. The Home set up the syringe driver that day. Mr V received Morphine Sulphate (strong pain relief), Haloperidol (used to relieve nausea, agitation and delirium), Midazolam and Buscopan from 10:45 on 31 October until he died at about 06:00 on 1 November.
Complaint handling by Bupa
- Bupa received Mrs V’s complaint on 14 February 2018. It acknowledged her complaint on the same day and sent her a formal written response on 4 April 2018. Mrs V replied on 17 April to say she was dissatisfied with the response because it did not resolve all her complaints. Bupa sent a further complaint response on 15 June, which relayed the original responses with some further explanations. The responses offer apologies for poor documentation, inadequate support around grooming, the attack on Mr V by another resident, the delay in starting a syringe driver and incorrect information about 1:1 care. Bupa also offered to reimburse Mrs V for a damaged chair and explained what it was going to do to improve record keeping and staff training.
- Mrs V and her son attended a complaint meeting with the Home after receiving the written responses. Mrs V says her son left a list of written questions with the Home, which the Home agreed to answer but never did. Bupa cannot find this list of questions, although Mrs V was able to show us a copy.
- I consider there were flaws in Bupa’s complaint handling, for the following reasons.
- Bupa did not acknowledge errors by the Home around falls management, supervision of residents and end of life medication as part of its own investigation.
- The complaint responses do not provide a factually accurate explanation of what happened with Mr V’s end of life medication.
- Bupa’s complaint responses place the responsibility for the delay in setting up a syringe driver with the hospice. However, Bupa was responsible for providing and setting up syringe drivers and there is no documentary evidence that the Home contacted the district nursing or out of hours services for help having noticed a shortage of equipment or qualified staff.
- I consider it more likely than not that the Home did agree to answer a list of questions at the complaint meeting. Having made that commitment, the Home should have answered the questions or explained to Mrs V and her son why this was not possible.
Complaint handling by the GP Practice
- Mrs V complained to the GP Practice on 17 September 2018. The Practice replied in detail on 9 November 2018. The response included details of every GP appointment Mr V had at the Home. The GP Practice’s response also apologised for: delay in its complaint investigation, not keeping Mrs V informed of all treatment plans for Mr V, the delay in end of life medication being available for Mr V, Mrs V feeling that GP C was not caring when he spoke to her on 28 October 2017 and Mrs V’s difficulty in chasing up a physiotherapy appointment.
- The complaint response incorrectly states that the GP Practice faxed a prescription to Pharmacy A in the afternoon of 27 October 2017. The GP Practice did not realise until our investigation that it had not faxed the prescription to Pharmacy A that day. This was fault in the GP Practice’s complaint handling. This meant the GP Practice could not provide a factually accurate explanation of what happened with Mr V’s end of life medication.
- As a result, Mrs V was put to avoidable time, trouble and distress in trying to get her complaint resolved by having an accurate understanding of what happened to her husband at the end of his life. I have made recommendations below for the GP Practice to apologise to Mrs V and review its complaint handling.
- The CCG has committed to sharing learning from this investigation with the GP that currently works with the Home, as well as the falls prevention and integrated care teams that work closely with care homes in its area.
- Within one month of the date of our final decision, the Council, Bupa, and GP Practice will write to Mrs V to acknowledge and apologise for all the faults identified in this decision, and their impact on Mr and Mrs V.
- Within three months of the date of our final decision, Bupa will send the Ombudsmen evidence that it has reviewed the Home’s processes for:
- checking that the recommendations from risk assessments and care plans are being implemented;
- ensuring the Home is adequately staffed, including with nurses qualified to set up syringe drivers;
- records of medication given;
- planning and implementing end of life care in a way that is coordinated with all relevant professionals; and
- complaint handling.
- that staff at the Home have had training on how to support people with challenging behaviours;
- that the Home’s senior nurse and managers have been coached in dealing with challenging behaviours; and
- that the Home has worked with staff to improve body mapping, care planning and recording and implemented a “robust daily clinical risk review each morning”.
- a change in practice to ensure it telephones pharmacies twice: to check receipt of prescriptions for end of life medication and to check the medication has been dispensed;
- weekly meetings to discuss patients with end of life care plans; and
- monthly multidisciplinary meeting involving all health care professionals involved in end of life care.
- Mrs V complained about the care of her late husband by a care home and a GP Practice. She also complained about complaint handling by the care home and GP Practice. The Ombudsmen have upheld some of Mrs V’s complaints about the Home’s care of Mr V, relating to falls, assault by another resident, record keeping, end of life medication and complaint handling. The Ombudsmen have also upheld some of Mrs V’s complaints about the GP Practice’s handling of end of life medication and complaint handling. Bupa, the GP Practice and the Council accept our recommendations. We have therefore completed our investigation.
Investigator's decision on behalf of the Ombudsman