Summary: West Berkshire County Council carried out a safeguarding investigation into Mrs Y’s weight loss in line with the local procedures. However, a GP at Tilehurst Village Surgery did not monitor Mrs Y’s weight despite agreeing to. That fault caused Mrs Y’s daughter, Mrs X, uncertainty. The GP recognised that fault and has appropriately remedied the injustice to Mrs X and potentially others.

The complaint

1. Mrs X complains that West Berkshire County Council (the Council) and a named GP at Tilehurst Village Surgery (the Surgery) jointly failed to safeguard and support her mother, Mrs Y, between August and September 2019. She says the Council did not robustly investigate her concern that Mrs Y’s husband was not appropriately feeding her, and she had suffered significant weight loss. She says the GP did not properly monitor her mother’s weights.
2. Mrs X also says the GP missed the opportunity to visit her mother at home on 9 April 2020.
3. Mrs X says her mother would be alive if not for the Council and the GP. She says the Council and GP’s actions impacted her mother’s human rights. Mrs X also says it was distressing for the family to witness her mother suffer.
4. Mrs X would like to ensure similar fault does not happen to other families.

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The Ombudsmen’s role and powers

5. 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)
6. 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).
7. 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))
8. 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. 
9. 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

10. I have considered information provided by Mrs X and the organisations. Mrs X, the Council and the Surgery had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Key facts

11. In July 2019, Mrs Y’s husband raised concerns about her weight loss to the GP. Blood tests did not show any markers of malnutrition.
12. Mrs X raised her own concerns to the Council’s Safeguarding Team about Mrs Y’s weight loss on 1 August. Specifically, she said Mrs Y’s husband was not appropriately feeding her. The Council opened a safeguarding enquiry and assigned a Social Worker to Mrs Y. The Social Worker sought information from Mrs Y, Mrs X, the GP, the community matron service and a Day Centre (where Mrs Y attended a few days a week) as part of the safeguarding investigation.
13. The next day Mrs X raised her concerns to the GP. The GP agreed to refer Mrs Y to the community matron service, to weigh Mrs Y and complete the Malnutrition Universal Screening Tool (MUST). The MUST is a flow chart consisting of five steps, which can identify adults who are malnourished, at risk of malnutrition or obese. MUST also contains management guidelines for use in developing care plans to ensure nutritional needs are met.
14. On 12 August, the community matron service noted Mrs Y’s weight was 46.5kg (down from 53kg in 2014). Her MUST score was 2 – which suggested she was a high risk of malnutrition. The community matron service discharged Mrs Y and left it for the GP to decide to refer Mrs Y to a dietician. Instead, the GP decided to monitor Mrs Y’s weights rather than provide nutritional support.
15. On 19 August, Mrs X escalated her concerns to the GP. During a Surgery meeting (three days later), about Mrs Y’s weight loss, the GP noted: “...will arrange to look into this and arrange visit form [sic] CM [community matron] team directly and see if they can get a feel for the situation at home and raise a safeguarding referral if needed, to be reported back to [the GP] at the next meeting [on 12 September 2019].” The community matron was present at that meeting.
16. On 30 August, the Social Worker spoke to the GP. The GP said Mrs Y was not malnourished, and her weight loss was not significant to cause concern.
17. A week later, the GP visited Mrs Y at home. The GP said Mrs Y seemed comfortable and there was no evidence Mrs Y’s husband mistreated or starved her. The GP did not document that home visit in Mrs Y’s medical records.
18. On 23 September, the Social Worker closed the safeguarding investigation. She was happy there was a plan to monitor Mrs Y’s weight, and the GP did not have concerns about her weight loss.
19. Over the next few months, Mrs Y suffered with recurrent urinary tract infections. Then in February 2020, she suffered a stroke needing a hospital admission for a month. On 16 and 21 March, the hospital recorded Mrs Y’s weight as 44.5kg and 41.5kg respectively.
20. Mrs X asked the GP to carry out a home visit on 9 April. The Surgery tried to return Mrs X’s call but could not get through to her.
21. A few days later, Mrs Y went to hospital and died on 16 April.
22. In response to Mrs X’s complaint, in June 2020, the Council said:
• The Social Worker appropriately spoke to the relevant parties, including Mrs Y in private to discuss her weight and nutrition. Mrs Y had capacity to discuss her weight and packed lunches at the Day Centre.
• The GP and Day Centre Manager did not have concerns about Mrs Y’s weight. The Day Centre Manager noted Mrs Y’s packed lunches (made by Mrs Y’s husband) were poor, but Mrs Y ate it all.
• Mrs Y’s carers did not raise any concerns about her husband’s nutritional support.
23. In response to Mrs X’s complaint, in February 2021, the Surgery said the GP would not have done anything differently for Mrs Y. The GP, community matron service and Social Worker did not have any concerns about Mrs Y’s weight.
24. Mrs X raised further issues to the Surgery. In May 2021, the GP said:
• She felt Mrs Y’s MUST score was inaccurate, so decided to follow up with the community matron service.
• Mrs Y did not have any markers of malnutrition following blood tests.
• She was sorry for not following up Mrs Y’s weight with the community matron service. Also, for not documenting a home visit on 6 September 2019.
• She would take action to ensure similar failings do not happen again.

Relevant law and guidance

25. 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.
26. The Care Act requires that each local authority must make enquiries, or cause others to do so, if it believes an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should establish whether any action needs to be taken to prevent or stop abuse or neglect and if so, by who.
27. The Council follows the Berkshire Safeguarding Adults Policies & Procedures when carrying out safeguarding investigations.
28. The National Institute for Health and Care Excellence (NICE) issued clinical guideline known as Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition in 2012.

Analysis

The Council’s safeguarding investigation

29. I have reviewed the Council’s safeguarding and the Social Worker’s records.
30. I consider the Social Worker carried out the safeguarding investigation in line with the local procedure. I will explain why.
31. After agreeing to carry out the safeguarding enquiry, the Social Worker spoke to Mrs Y to get her views and desired outcomes. The Social Worker spoke to Mrs Y with her husband present and in private. I consider the Social Worker appropriately discussed the safeguarding concerns with Mrs Y in private. That allowed the Social Worker to decide that Mrs Y was not acting under duress. The Social Worker provided a safe environment for Mrs Y to communicate any concerns about her husband’s nutritional support for her. The Social Worker noted Mrs Y would like for her husband to continue to provide daily meals, and for the Social Worker to discuss her weight loss with her GP. I consider the Social Worker worked well with Mrs Y to understand her views and her desired outcomes. That was in line with the local safeguarding procedure.
32. Mrs Y suffered with dementia, which suggested she might lack capacity to make decisions about the safeguarding concerns. The Social Worker recognised that and decided she did not need to carry out a mental capacity assessment. The Council told me that was because the Social Worker felt Mrs Y could understand what was going on. The Social Worker made a professional judgement that Mrs Y had capacity to understand the questions being asked about her weight and husband. I have not found fault with how the Social Worker made that decision.
33. The Social Worker carried out a risk management plan. She noted that Mrs Y was a low risk of neglect based on her discussions with Mrs Y and the GP. That was good practice.
34. A key principle of the local procedures is that safeguarding investigations are proportionate to the decision to be made. I consider the Social Worker’s investigation appropriately struck that balance. The Council’s safeguarding documents showed the Social Worker understood that involving the GP would be important to better understand Mrs Y’s weight. The GP would be crucial in ensuring that Mrs Y was safe and well. Therefore, I do not consider the Social Worker missed an opportunity to include other professionals outside the GP and the Day Centre Manager.
35. When the Social Worker decided to close the safeguarding investigation, she confirmed the Protection Plan for Mrs Y. That said: “[Mrs Y] has been seen by the District Nurses and [the GP] is not concerned about [Mrs Y’s] weight at the moment and the plan is for District Nurses to visit [Mrs Y] again to monitor her weight”. Before making that decision, I am persuaded the Social Worker discussed the safeguarding concerns with the correct professionals involved with Mrs Y.
36. The Council did not review Mrs Y’s safeguarding plan after closing the enquiry in September 2019. It told me it does not routinely review all safeguarding plans. Mrs Y’s protection plan would keep her safe. The Council was satisfied the GP would monitor Mrs Y and raise any concerns in future.
37. I consider the Council’s explanation why it did not review Mrs Y’s protection plan is robust. It does not need to, and I do not consider the Council acted with fault in not reviewing the plan before closing the safeguarding investigation.
38. After the Social Worker close the safeguarding investigation, the Council completed a care and support review of Mrs Y’s needs. The Council recognised Mrs Y’s needs had changed and assessed her to decide if it could provide any further support outside of the GP’s agreed actions. I consider that was good practice.
39. I will now consider how the GP monitored Mrs Y’s weight loss.

The GP’s support for Mrs Y’s weight loss

40. I have reviewed the Surgery’s medical records for Mrs Y including the referrals to the community matron service.
41. The GP decided to monitor Mrs Y’s weights rather than provide nutritional support. That was despite Mrs Y being a high risk of malnutrition. However, I do not consider the GP’s approach was fault. The GP has provided a robust explanation why they wanted to keep Mrs Y’s weight under review before providing nutritional support. Because it had been five years since her last recorded weight. Also, a recent blood test had not shown markers of malnutrition.
42. I consider the GP appropriately asked the community matron service to monitor Mrs Y’s weight during the Surgery meeting on 22 August. However, I have not seen any evidence the GP followed up with the community matron service after then. A good opportunity to chase that would have been the next Surgery meeting in September. That was fault. During my investigation, the GP told me they do not have access to the community matron records, so cannot say what happened with Mrs Y’s weight.
43. There is no doubt Mrs Y lost 2kg between August 2019 and March 2020.
44. The NICE clinical guidance (1.3.1) states: “Nutrition support should be considered in people who are malnourished, as defined by any of the following:
• a BMI [body mass index] of less than 18.5kg/m2
• unintentional weight loss greater than 10% within the last 3-6 months
• a BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within the last 3-6 months
45. I am not persuaded that during the six months after August 2019, Mrs Y lost enough weight (not even 5%) for the GP to consider nutritional support. Also, the GP told me Mrs Y’s BMI was over 20kg/m2 in August. By March 2020 that had decreased to 15.06kg/m2. That is a sign Mrs Y may have needed nutritional support. However, it would have been for the GP to consider, rather than to provide nutritional support.
46. Overall, I cannot say the GP would have provided nutritional support to Mrs Y, if not for the fault I have identified. That leaves Mrs X with a sense of uncertainty if events would have been different for Mrs Y. However, I am not persuaded I have seen evidence to conclude the GP’s (or the Council’s) actions caused Mrs Y’s death or impacted on her human rights.
47. In May 2021, the GP recognised and apologised for the fault above. She said she ensures the minutes from previous meetings are always covered. A specific member of staff now takes responsibility for carrying out specific agenda items. The Surgery’s administration team also chases any outstanding items. That is good practice.
48. During my investigation, I also found the GP did not record that she visited Mrs Y at home on 7 September. I consider that poor record keeping was also fault, but it did not cause Mrs Y or Mrs X any injustice. In May 2021, the GP recognised and apologised for that fault. The GP agreed to carry out an audit of their last 20 home visits to ensure her record keeping was accurate.
49. Overall, I am persuaded the Surgery has remedied the potential injustice to others from the faults I had identified. Therefore, I will not take any further action with this part of the complaint.

The missed home visit in 2020

50. Mrs X also says the GP missed the opportunity to visit her mother at home on 9 April 2020.
51. I have reviewed the Surgery’s records. The GP from 2019 was not involved with Mrs Y in April 2020. Instead, the Surgery’s records show that another GP was asked to call Mrs X back. That GP noted: “Failed encounter @ 12:22 Rang few times Line busy. (was asked to ring daughter) [sic]”. This was most likely in response to Mrs X’s request for a home visit to her mother.
52. I consider the GP in April 2020 appropriately called Mrs X back but could not get through to her. I am not persuaded that GP acted with fault.

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Final decision

53. The Council carried out its safeguarding investigation into Mrs Y’s weight loss in line with the local procedures. However, the GP did not appropriately monitor Mrs Y’s weight. That fault caused Mrs X uncertainty. The GP recognised that fault and has appropriately remedied the injustice to Mrs X and potentially others.

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Investigator's decision on behalf of the Ombudsman