Summary: The Ombudsmen found fault with the care provided to an elderly man by a care home acting on behalf of the Council. The Council agreed to apologise for this fault and pay a financial sum in recognition of the distress this caused. The Ombudsmen were satisfied a GP Practice and Trust that were also involved in the man’s care acted without fault.

The complaint

1. The complainant, who I will call Mrs B, is complaining about the care and treatment provided to her husband, Mr B, in 2018. Mrs B complains that:

• The Leys Health Centre (the Practice) discontinued Mr B’s laxative medication in August 2018, despite him requiring this medication on a long-term basis;
• Oxford University Hospitals NHS Trust (the Trust) failed to make clear that Mr B’s bowel function needed to be monitored and that he required ongoing treatment with laxatives following a hospital admission in September 2018; and
• Brookfield Care Home (the care home) failed to maintain bowel charts or food and fluid balance charts for Mr B and did not monitor his bowel function appropriately.

2. We have powers to investigate adult social care complaints under Part 3 of the Local Government Act 1974. This section of the Act covers complaints where local councils arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can, by law, treat the actions of the care provider as if they were the actions of the council in those cases.
3. Mr B’s placement at the care home was arranged by Oxfordshire County Council (the Council). This means we consider the care provided to Mr B during his time in the care home to have been provided on behalf of the Council.

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The Ombudsmen’s role and powers

4. 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).
5. 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.
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

7. In making this final decision, I considered information provided by Mrs B and discussed the complaint with her. I also considered comments and documentation (including the care records) from the Council, Trust and Practice.
8. In addition, I obtained clinical advice from a nurse with relevant qualifications and experience. I invited comments on my draft decision statement from Mrs B and the organisations she is complaining about and took the information they provided into account.

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What I found

Relevant guidance and legislation

Nursing care

9. The Nursing and Midwifery Council (NMC) is the regulatory body for nurses in England. It publishes guidance for nurses entitled The Code: Professional standards of practice for nurses, midwives and nursing associates (2015). This is commonly known as ‘the Code’.
10. The Code emphasises the importance of robust assessment and care planning in person-centred care. Section 13.1 of the Code says nurses must “accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care”.
11. Good record-keeping is an essential part of the care planning process. Section 10.2 of the Code says nurses must keep clear and accurate records “to identify any risks or problems that have arisen and the steps taken to deal with them”.

Care home regulations and guidance

12. In 2008, the government introduced the Health and Social Care Act 2008 (the Act). This Act created a new regulator of health and social care services in England. This is the Care Quality Commission (CQC).
13. This led to the introduction of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Care Regulations). The Care Regulations set out the fundamental standards those registered to provide care services must achieve and below which care must never fall.
14. The CQC provides guidance for care providers on how to meet the fundamental standards of care. This is entitled Guidance for providers on meeting the regulations (2015) (the Guidance).

Nutrition

15. Section 14(1) of the Guidance accompanying the Care Regulations states that any assessment of a service user’s care needs “should include risks related to people’s nutritional and hydration needs.” The Guidance emphasises the importance of accurate nutritional assessment in ensuring that a service user is provided with an appropriate diet.

Key facts

16. Mr B had been a resident in the care home since June 2018. He had a history of gastrointestinal problems, along with other long-standing health conditions. Mr B was considered to be at high risk of constipation and took regular laxative medication.
17. On 22 August 2018, a GP from the Practice carried out a routine visit to the care home. Following a conversation with two nurses, the GP discontinued Mr B’s laxative medication on the basis that he was having regular bowel movements.
18. Mr B became unwell and was complaining of pain and nausea. He was reluctant to take his medication and sometimes refused food and drink. A GP from the Practice noted that he appeared confused.
19. Mr B was admitted to hospital on 12 September with a suspected respiratory tract infection. The clinical team found him to be constipated and treated him with an enema. Mr B was discharged back to the care home later that day with antibiotics to treat the infection.
20. On 9 November, Mr B reported pain and discomfort when passing stools. Care home staff also noted blood in Mr B’s stools. Following discussion with the care home, a GP and a visiting nurse practitioner, the care home arranged for Mr B to be admitted to hospital for further investigation.
21. Clinicians noted Mr B was suffering from hypothermia and dehydration. A Computed Tomography (CT) of Mr B’s abdomen revealed he had severe faecal impaction. Clinical staff also noted Mr B was experiencing significant rectal bleeding. However, he was too unwell to tolerate further investigations.
22. Mr B’s condition deteriorated and he died on 16 November.

Analysis

Practice

23. Mrs B complained about the Practice’s decision to cease Mr B’s laxative medication in August 2018.
24. The Practice said a GP made this decision following discussion with nursing staff at the care home. The Practice said nurses advised the GP that Mr B was having regular bowel movements without the use of laxatives and felt this was no longer required as a regular medication.
25. In response to my enquiries, the Practice added that the GP advised care home nurses to monitor Mr B’s bowel activity carefully as he was at risk of constipation. The Practice said a GP could have reinstated Mr B’s laxative medication at any time if the care home had informed it that Mr B’s bowel activity had reduced.
26. The Practice’s clinical records show a GP visited Mr B at the care home on 22 August 2018. The GP noted that she had spoken to two nurses at the care home and that there was “no need for reg [laxative medication] as bowels open reg”. The GP also noted “bowel chart being kept”.
27. I found no note of this conversation in the records supplied by the care home. Nevertheless, I am satisfied, on balance of probabilities, that the discussion took place as recorded by the GP. This is because the GP’s note is a contemporaneous record and refers to the care home nurses by name.
28. It is important to note that laxative medications can have unpleasant side-effects for users. For this reason, laxatives should not ordinarily be taken once a person’s constipation has improved. The GP’s records show she was advised by care home nurses that Mr B was opening his bowels regularly without the use of laxatives. In the circumstances, I consider the GP’s decision to discontinue this medication to have been appropriate. I found no fault by the Practice on this point.
29. However, Mr B remained at risk of constipation. This meant it was particularly important for the care home to monitor his bowel function on an ongoing basis. Despite what is recorded in the GP’s note, I found no evidence to suggest the care home was maintaining a bowel chart for Mr B at that time. I have commented on this in further detail below in my consideration of Mrs B’s complaint about the care home.

Trust

30. Mrs B said she was told by a clinician during Mr B’s brief admission in September 2018 that he would require ongoing treatment with laxatives. Mrs B complained that the Trust did not make the care home or Practice aware of this.
31. The Trust said clinicians did consider prescribing laxatives for Mr B. However, the Trust said there was no clear history of chronic constipation. In addition, the Trust said Mr B was taking antibiotics for his infection and, as these can cause diarrhoea, the clinicians felt it would not be appropriate to prescribe laxatives. The Trust said it would have expected the care home to monitor Mr B’s bowel function as a matter of course following his discharge from hospital.
32. Mr B was first admitted to hospital on 12 September 2018 with a suspected respiratory tract infection.
33. The assessing clinician examined Mr B’s abdomen. He found this to be soft and non-tender and noted there was no distension. In addition, the clinician noted normal bowel sounds. However, further examination revealed that Mr B had a “full rectum with firm stools.”
34. The clinical records show the assessing clinician spoke to Mr B about his clinical history. He also spoke to the care home and accessed Mr B’s GP records electronically.
35. The clinician found no evidence of chronic constipation in Mr B’s clinical history and felt his constipation may be related to his recent infection. As a result, he prescribed a course of antibiotic medication to treat Mr B’s respiratory tract infection.
36. In addition, the clinical team treated Mr B’s constipation with an enema. This resulted in him opening his bowels three times prior to his discharge back to the care home later that day.
37. It is important to note that diarrhoea is a common side effect of the antibiotic medication (co-amoxiclav) prescribed to treat Mr B’s infection. In this clinical context, I am satisfied the decision not to prescribe laxative medication was based on appropriate evidence and in keeping with good clinical care. I found no fault by the Trust in this regard.
38. In my view, it would have been helpful if the Trust’s discharge summary had explicitly recorded the need for ongoing monitoring of Mr B’s bowel function. Indeed, the Trust acknowledged this in its response to Mrs B’s complaint and apologised that this was not communicated clearly to the care home.
39. Nevertheless, the discharge summary made clear that Mr B was constipated on admission to hospital on 12 September. Furthermore, the care home’s records show it already considered Mr B to be at high risk of constipation. In my view, this information should have led the care home to introduce a process for monitoring Mr B’s bowel function. I found no evidence that it did so. Again, I have commented on this in more detail below.

Care home

Bowel care

40. Mrs B complained about the decision to cease Mr B’s laxative medication and the care home’s failure to provide appropriate bowel care.
41. The care home said the decision to discontinue Mr B’s laxative medication had been made by a GP from the Practice. The care home said it used the Trust’s discharge summary following Mr B’s admission in September 2018 to assess what follow-up care was required.
42. The Code emphasises the importance of robust assessment and care planning in monitoring a person’s health for evidence of deterioration.
43. In July 2018, around a month after Mr B’s arrival in the care home, staff completed a constipation risk assessment. This found Mr B was at high risk of constipation.
44. This should have led the care home to put in place a care plan setting out what measures it would take to manage this risk. This should include use of a bowel chart to monitor the frequency of bowel activity. I would also have expected to see evidence of the use of a tool such as the Bristol Stool Chart (the BSC) to accurately record the type, consistency and amount of each stool.
45. I found no evidence of such a care plan in the care home’s records. The records do contain a continence care plan, but this makes no reference to the fact Mr B was at high risk of constipation.
46. I note the care home’s daily care records do make some reference to occasions on which Mr B had opened his bowels. However, the entries typically record only “bowels opened” and contain no specific information about the type, consistency and frequency of Mr B’s stools. These records are inconsistent and do not represent an adequate substitute for full bowel and stool charts.
47. In its response to my enquiries, the Council said the care home began to record bowel movements for all residents on one daily list following involvement from the Care Quality Commission (CQC). The Council said Mr B was included on this list from 8 October 2018.
48. The recording of all residents’ bowel movements on one single chart is not in keeping with the requirements of Regulation 9 of the Care Regulations. This sets out that “people using a service have care or treatment that is personalised specifically for them.”
49. Furthermore, I could not review the records in question as I understand the care home only retained them for three months before destroying them. As a result, I am unable to satisfy myself that the care home provided Mr B with appropriate bowel care during this later period from 8 October to his admission to hospital the following month.
50. These are serious omissions that took on even greater significance once Mr B’s laxative medication had been discontinued in August 2018. This was fault.
51. In my view, this is likely to have contributed to Mr B becoming constipated as identified during the hospital admission in September 2018.
52. The clinical evidence also shows that Mr B was suffering from faecal impaction on admission to hospital in November 2018. I understand Mrs B to be of the view that this contributed to Mr B’s gastrointestinal bleeding.
53. Faecal impaction or severe constipation can put a person at risk of stercoral perforation. This is when the contents of the intestines (such as impacted faeces) cause a rupture in the intestinal wall. Similarly, it can increase the risk of stercoral ulceration (an ulcer in the intestinal wall caused by irritation).
54. It is important to note that Mr B also had a history of diverticulitis (an infection of small pockets within the intestines) and oesophageal ulceration (an ulcer in the tube connecting the stomach to the throat). These conditions can also cause gastrointestinal bleeding.
55. In response to my enquiries, the Trust explained that several members of the medical and surgical teams reviewed Mr B on admission. The Trust said they were unable to reach a consensus as to the source of the bleeding.
56. The situation was further complicated as Mr B was too frail to undergo the necessary investigations to diagnose the cause of the bleeding. The Trust explained that a CT scan of Mr B’s abdomen revealed no evidence of stercoral perforation. However, the Trust said clinicians were unable to rule out the possibility of stercoral ulceration.
57. In summary, the evidence does not allow me to reach a robust view on whether Mr B’s faecal impaction was the cause of his gastrointestinal bleeding in November 2018. As a result, I am unable to say whether the outcome of Mr B’s care would have been different even if the care home had provided Mr B with appropriate bowel care.
58. Nevertheless, I consider the care home’s failure to do so placed Mr B at greater risk and is likely to have caused him unnecessary pain and discomfort. This in turn caused Mrs B significant distress and uncertainty.
59. I have addressed this in my recommendations below.

Nutritional and fluid care

60. Mrs B complained that Mr B was dehydrated on admission to hospital in November 2018 and that the care home should have done more to monitor his food and fluid intake.
61. The care home said it monitored Mr B’s food and fluid intake daily following his discharge from hospital in September 2018.
62. Section 14(1) of the Guidance accompanying the Care Regulations states that any assessment of a service user’s care needs “should include risks related to people’s nutritional and hydration needs.” Section 14(2) says the provider must meet a person’s nutrition and hydration needs.
63. When Mr B was admitted to the care home in June 2018, staff completed a Malnutrition Universal Screening Tool (MUST). This is a flow chart consisting of five steps, which are used to identify adults who are malnourished, at risk of malnutrition or obese. The MUST found Mr B to be at medium risk of malnutrition.
64. The care home reviewed the MUST on a monthly basis thereafter. Mr B was noted to be at medium or high risk of malnutrition each time.
65. In addition, Mr B’s high risk of constipation made it particularly important to maintain his hydration levels. This is because dehydration can contribute significantly to the risk of constipation.
66. The care home kept food and fluid charts for Mr B for three periods during his time there:

• A five-day period following Mr B’s admission to the care home in June 2018. This was to establish a baseline for Mr B’s nutritional and fluid intake.
• An 18-day period between 31 August and 17 September 2018. This was when Mr B had lost weight and was acutely unwell with an infection.
• A four-day period prior to Mr B’s readmission to hospital in November 2018. This was when Mr B was again unwell and taking antibiotics.

67. It was appropriate for the care home to maintain food and fluid charts when Mr B’s presentation changed during these periods. In general, the charts show Mr B continued to take on food and fluids, albeit he sometimes refused meals.
68. However, it is of concern that care home staff failed to record Mr B’s urinary output on the charts at any point.
69. It is not usually possible to precisely measure the urinary output of a service user with urinary incontinence. Nevertheless, the food and fluid charts used by the care home contain a box in which staff should record whether the service user’s incontinence pads are wet or dry. The evidence shows care home staff did not complete this section of the charts at all.
70. As a result, the care home failed to keep an accurate record of Mr B’s fluid levels. This meant it could not effectively monitor whether he was taking on too little (or too much) fluid.
71. I do not consider the fluid care provided by the care home to have been in keeping with the Regulations. This was fault.
72. I note Mr B was found to be dehydrated on admission to hospital in November 2018. It is not possible to say whether this would have been prevented if the care home had monitored Mr B’s fluid levels properly. Nevertheless, I consider the failure to do so placed Mr B at increased risk of both dehydration and constipation.
73. Again, I have addressed this in my recommendations below.

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Agreed actions

74. I identified fault by the care home with regards to the care it provided to Mr B. As the care home was providing this care on behalf of the Council, the Council has agreed to take action to remedy the injustice this caused to Mrs B.
75. Within one month of my final decision statement, the Council will:

• Write to Mrs B to apologise for the care home’s failure to provide Mr B with appropriate bowel and fluid care.
• Pay Mrs B £1,000 in recognition of the significant distress and uncertainty caused to her by this fault.

76. In addition, within two months of my final decision statement, the Council will write to the Ombudsmen to:

• Explain what action the care home will take to ensure resident care plans are robust, person-centred and in keeping with the Care Regulations. The Council will explain how the care home will monitor and audit resident care plans on an ongoing basis. In addition, the Council will explain how the care home will ensure relevant care staff are appropriately trained in the completion of care assessments and plans.
• Explain what action the care home will take to ensure it provides nutritional and fluid care that is in keeping with the Care Regulations. This should include action to ensure care staff are appropriately trained to maintain clear and accurate records.
• Explain what action the care home will take to ensure it has a robust records retention policy in place and that staff are appropriately trained in the use of this policy.

77. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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Final decision

78. I found no fault by the Practice or Trust with regards to the care they provided to Mr B. However, I found fault with the care provided to Mr B by the care home. In my view, this caused Mrs B a significant injustice.
79. I am satisfied the actions the Council has agreed to take represent a reasonable and proportionate remedy for this injustice.
80. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman