Heaton Medical Centre (21 012 428b)

Category : Health > General Practice

Decision : Upheld

Decision date : 31 Oct 2022

The Ombudsman's final decision:

Summary: We found fault by the Practice and a care home acting on behalf of the Council with regards to how they managed Mrs H’s medication. We also found the care home failed to maintain appropriate hygiene standards at times. Although this fault did not have a significant impact on Mrs H’s care, it caused her son, Mr G, considerable confusion and distress. The Council and Practice will apologise to Mr G and take action to ensure similar problems do not occur in future.

The complaint

  1. The complainant, who I will call Mr G, is complaining about the care and treatment provided to his mother, Mrs H, by a care home acting on behalf of Bolton Metropolitan Council (the Council) and Heaton Medical Centre (the Practice) between April and August 2021. Mr G is also complaining about the Council’s subsequent safeguarding investigation.
  2. Mr G complains that:
  • the care home failed to maintain Mrs H’s personal hygiene and dressed her in soiled clothes, including garments that were not her own;
  • the care home failed to maintain appropriate COVID-19 precautions;
  • the care home and Practice failed to ensure Mrs H received her prescribed medication. This included Alendronic Acid and nutritional supplement drinks;
  • the care home and Practice failed to properly investigate and treat swelling to Mrs H’s leg. This swelling subsequently turned out to be a symptom of Deep Vein Thrombosis (DVT);
  • the Practice failed to arrange a DEXA bone density scan for Mrs H; and
  • the Council failed to carry out a thorough safeguarding investigation in response to concerns about Mrs H’s care and treatment.
  1. Mr G says the failings in his mother’s care caused her health to deteriorate and led to hospital admissions. In addition, Mr G says he found these events extremely distressing.

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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), as amended).
  2. 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.
  3. 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. In making my final decision, I considered information provided by Mr G and discussed the complaint with him. I also considered information and records provided by the Council and Practice, including the clinical and care records. I took account of relevant legislation and guidance. Furthermore, I considered comments from all parties on my draft decision statement.

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What I found

Relevant legislation and guidance

COVID-19 pandemic

  1. In response to the continued COVID-19 pandemic and the need to keep hospital beds free, the Government introduced updated guidance around hospital discharges in August 2020. This was entitled Hospital Discharge Service: Policy and Operating Model (the discharge guidance).
  2. The discharge guidance set out that patients must be discharged from hospital as soon as it was clinically safe. It introduced a “discharge to assess” model consisting of four care pathways.
  3. The discharge guidance set out the Government would fund, via the NHS, the cost of post-discharge recovery and support services (such as rehabilitation and reablement) for up to six weeks. This was to enable care to continue until a person’s longer-term care needs had been assessed, at which point the person’s care would move to normal funding arrangements.

Alendronic Acid

  1. Alendronic Acid is a medication that is intended to help a person’s bones stay as strong as possible. This medication can help people who have, or are at risk of developing, osteoporosis. This is a health condition which weakens the bones and makes them more fragile and likely to break.
  2. The British National Formulary (the BNF) provides information and guidance for medical practitioners on prescribing, dispensing and administering medication.
  3. The BNF says Alendronic Acid is not suitable for patients with impaired kidney function. This is because toxicity and side-effects can be increased if a person’s kidneys are unable to remove toxins form the blood efficiently.
  4. One measure of kidney function is the estimated glomerular filtration rate (eGFR). The BNF says Alendronic Acid should not be prescribed for a person with an eGFR lower than 35ml/min.

Bone density scan

  1. A bone density scan uses low-dose X-rays to see how dense a person’s bones are. During a bone density scan, a special type of X-ray called dual energy X-ray absorptiometry is passed through the body. This is often shortened to DEXA.
  2. A person may need to have a DEXA scan if they are over 50 and are at risk of developing osteoporosis.
  3. Some breast cancer treatments can lower bone density and increase the risk of osteoporosis. This includes the medication Letrozole (a drug that reduces the level of the hormone oestrogen).

Safeguarding

  1. Section 42 of the Care Act 2014, says a local authority must make enquiries if it has reason to think a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themself. An enquiry is the action taken by a council in response to a concern about abuse or neglect. These are often known as ‘Section 42 enquiries’.
  2. An enquiry could range from a conversation with the person who is the subject of the concern to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

  1. Mrs H had a diagnosis of dementia and required assistance and support with some activities, such as personal care. She was living at home with daily support from carers and her family. In addition, Mrs H was receiving treatment for breast cancer and was taking the medication Letrozole (a drug used to treat hormone-dependent breast cancer).
  2. In April 2021, Mrs H was found to be struggling to cope at home. The Council arranged a 6-week respite placement for her in the care home. This was initially funded by the Council.
  3. Mrs H’s care was discussed at a multidisciplinary team meeting on 19 May. Care home staff reported that Mrs H had swollen ankles. A GP from the Practice advised staff to assist Mrs H to move around and seek further advice if her ankles became sore, red or hot to touch.
  4. As care home staff remained concerned that the swelling was still present, the Practice arranged for its paramedic to examine Mrs H on 26 May. The paramedic noted Mrs H’s ankle was “[r]ed in colour smooth and shiny…Painful to touch.” The paramedic diagnosed cellulitis (a skin infection) and a GP prescribed antibiotics to treat this.
  5. The Council convened a meeting to discuss how Mrs H was settling in the care home. The meeting was also attended by Mr G. Those present agreed Mrs H’s care needs could be best met in the care home and the placement became permanent on 28 May.
  6. On 1 June, the care home contacted the Practice as Mrs H had a sore throat and chesty cough. She tested negative for COVID-19. A GP prescribed a further course of antibiotics to treat any potential chest infection.
  7. On 9 June, care home staff raised further concerns about Mrs H’s ankle at the weekly multidisciplinary team meeting. They reported that the ankle remained swollen and red despite treatment with antibiotics.
  8. A GP reviewed the photographs of Mrs H’s ankle on 14 June. He concluded there was no evidence of cellulitis and diagnosed slight oedema (fluid build-up).
  9. A GP visited Mrs H on 2 July as Mr G remained concerned about Mrs H’s ankle. The GP arranged an appointment for Mrs H with the local DVT clinic. The GP also prescribed an anticoagulant medication as an interim measure.
  10. Mrs H attended the DVT clinic on 5 July. An ultrasound scan revealed she had a DVT in her left leg.
  11. On 15 July, Mr G complained to the care home about various aspects of Mrs H’s care. He said he had found Mrs H wearing the same stained clothes for a fortnight. In addition, Mr G said he found some of Mrs H’s underclothes were soiled and that care home staff were not encouraging her with her personal hygiene.
  12. The care home manager responded to this complaint on 23 July. He apologised about Mrs H’s soiled clothes and said he would address this with the deputy manager and care staff. The care home manager said Mrs H sometimes refused assistance with toileting and personal care but that staff would continue to offer assistance.
  13. On 9 August, Mr G accompanied Mrs H to a hospital appointment. He subsequently raised concerns with the care home and Practice regarding Mrs H’s breathlessness and reduced mobility. This led the Practice to arrange for Mrs H to be admitted to hospital the following day. Mrs H underwent treatment (including a blood transfusion) for severe anaemia. The clinical team also treated Mrs H for pneumonia. Mrs H remained in hospital until 20 August, when she was discharged back to the care home.
  14. The care home manager contacted the Council’s safeguarding team on 20 August. He explained that Mrs H’s Alendronic Acid medication had been missed from her medication list in error when she was admitted to the care home in April. As a result, he reported that Mrs H had not received this medication.
  15. On 23 August, Mr G visited Mrs H. She was noted to be tired and lethargic. Mr G was concerned about her condition. A subsequent test found her oxygen saturation levels were low. The care home arranged for Mrs H to be admitted to hospital following consultation with an out-of-hours GP. The clinical team treated her with supplemental oxygen.
  16. In the meantime, Mr G also contacted the Council’s safeguarding team. He reported various concerns about the care provided to Mrs H by the care home. These included concerns around medication management and the treatment of her swollen ankles.
  17. A duty social worker discussed Mrs H’s care with Mr G and the care home manager on 23 August. She concluded further enquiries would be necessary.
  18. In late September, Mrs H was admitted to hospital having tested positive for COVID-19. At that point, Mrs H was considered to be near the end of her life. She was discharged to a different care home under the Fast Track Continuing Healthcare (CHC) Framework.
  19. On 11 October, the Council convened a safeguarding strategy meeting. The meeting concluded concerns that Mrs H had been a victim of neglect were unsubstantiated.
  20. On 21 October, Mr G complained again to the care home. He said not all of Mrs H’s clothes and possessions had been returned. Mr G said the family had instead received many items of clothing that did not belong to Mrs H as well as dirty clothes.
  21. The care home manager responded to Mr G on 22 November. He explained that he had been unable to locate Mrs H’s missing clothing and offered to pay for these items. In addition, the care home manager explained that he had taken disciplinary action against a member of staff who had failed to launder Mrs H’s clothes before returning them.

My findings

Hygiene concerns

  1. Mr G complained that the care home failed to maintain Mrs H’s personal hygiene and dressed her in soiled clothes. He said this increased the risk of COVID-19 transmission. Mr G said the care home staff dressed Mrs H in garments that were not her own. Furthermore, Mr G said that the care home returned soiled clothes to the family when Mrs H was admitted to hospital.
  2. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the care standards expected of residential care providers. These regulations are accompanied by guidance produced by the Care Quality Commission (the CQC). Regulation 12 relates to safe care and treatment. The CQC guidance emphasises the role of cleanliness in preventing and controlling the spread of infections. This was particularly important during the COVID-19 pandemic.
  3. The care home’s complaint responses of 23 July and 22 November acknowledge staff failed to launder Mrs H’s clothes, despite having on-site laundry facilities. Furthermore, the care home accepted that Mrs H had been dressed in clothing that belonged to other residents. The care provided by the care home in this area was not in keeping with Regulation 12, therefore. This was fault and increased the risk of infection in the care home. This was upsetting for Mr G.
  4. Mr G also complained about the care home’s failure to support Mrs H with her personal hygiene. He described an occasion on which he visited Mrs H and staff failed to prompt her to wash her hands. Mr G also provided photographs that show Mrs H had dirty hands when he accompanied her to a hospital visit in July 2021.
  5. In response to Mr G’s complaint, the care home said staff did attempt to support Mrs H with toileting and personal care but that she often refused this assistance.
  6. When Mrs H was admitted to the care home, staff completed a personal needs care plan for her. This noted that Mrs H required assistance with bathing and toileting but could sometimes become agitated when receiving personal care. This is reflected in the daily care notes, which show Mrs H sometimes became angry when staff attempted to help her.
  7. It is understandable Mr G was concerned to find Mrs H with dirty hands. Nevertheless, the records suggest care staff did attempt to support Mrs H with her personal hygiene during her time in the care home, albeit she was often reluctant to accept this support. While I accept there may have been occasions on which Mrs H did not wash her hands, I found no evidence to suggest a pattern of omission or neglect in this area of Mrs H’s care. I found no fault on this point.

Medication – Alendronic Acid

  1. Mr G complained that the Practice and care home failed to ensure Mrs H received her Alendronic Acid medication. Mr G said Mrs H had been receiving this medication as regularly prior to her admission to the care home.
  2. The complaints correspondence and case records reveal some confusion on this point. The evidence shows the Alendronic Acid was erroneously missed off the Medication Administration Record (MAR) sheet when Mrs H was first admitted to the care home. This was identified by the Practice, who entered the medication as a repeat prescription on 26 April 2021. However, the Practice told me that neither the care home nor family requested it and so the medication was never issued.
  3. The clinical records show a Practice pharmacist completed a medication review for Mrs H on 12 August. The pharmacist noted that Alendronic Acid would be contraindicated for a patient with eGFR below 35ml/min. As Mrs H had an eGFR of 19ml/min, the pharmacist removed the medication from the list of repeat medications.
  4. The pharmacist also noted that a care worker at the care home told her the medication had been stopped by a Practice GP following Mrs H’s admission in April. It is unclear from the clinical records when this happened.
  5. Mr G subsequently raised concerns that both the Alendronic Acid and nutritional supplements were missing from Mrs H’s MAR sheet. On 19 August, a GP from the Practice wrote to Mr G to explain that Mrs H’s Alendronic Acid medication had been stopped as it was contraindicated for someone with her poor kidney function.
  6. The following day, the care home manager made a safeguarding referral to the Council as a result of the Alendronic Acid having been missed from the MAR sheet. The referral explained that Mrs H had not received the medication since her admission in April 2021.
  7. The matter was discussed at a safeguarding meeting in October 2021. The deputy care home manager recalled that a Practice GP had decided to discontinue the medication at a multidisciplinary team meeting shortly after her admission.
  8. The safeguarding team discussed this with the GP on 13 October. The GP recalled that, in April 2021, he advised the care home to stop administering the medication. This was due to Mrs H’s poor kidney function. However, the GP acknowledged he had made no record of this decision.
  9. In summary, the evidence shows the Alendronic Acid was erroneously excluded from the MAR sheet when Mrs H was first admitted to the care home. The medication was then added to the MAR sheet by the Practice. However, it was never issued. The medication was ultimately removed following the pharmacist review in August 2021.
  10. I found fault by the Council with regards to the care home’s failure to include the Alendronic Acid on the MAR sheet when Mrs H was first admitted.
  11. I have considered whether this had a significant adverse effect on Mrs H’s care. I am satisfied it did not. This is because the Alendronic Acid was clearly contraindicated for a person with Mrs H’s poor kidney function. This means it was likely in Mrs H’s best interests not to receive the medication between April and August 2021.
  12. Furthermore, a Practice GP decided to discontinue the medication in April 2021 in any case. The GP did not record his decision. However, I am satisfied, on balance of probabilities, that the GP did make this decision. This is because both the GP and deputy care home manager recalled the GP’s instruction to stop the Alendronic Acid medication.
  13. The General Medical Council (the GMC - the regulatory body for doctors) makes clear that a doctor should “[r]ecord your work clearly, accurately and legibly”. The failure of the GP to record this prescribing decision was contrary to the GMC’s good medical practice guidance. This was fault.
  14. The failure to record the decision caused Mr G understandable confusion and distress. I understand the Practice now keeps notes of multidisciplinary team meetings. This should ensure that prescribing decisions are properly recorded in future. I have made an additional recommendation to the Practice in the ‘recommendations’ section of this decision statement.

Medication – Nutritional supplements

  1. Mr G complained that the Practice discontinued Mrs H’s nutritional supplement drinks without consulting a dietician. Mr G says that, despite claiming Mrs H did not need these supplements, the Practice later prescribed a similar supplement. Mr G said the Practice should not have discontinued Mrs H’s supplements without consulting with her permanent GP.
  2. This National Institute for Health and Care Excellence (NICE) produces guidelines for the prescription of nutritional supplements. This is called Nutrition support for adults: oral nutrition support, enteral tube feeding and parenteral nutrition [CG32].
  3. The guidelines set out that nutritional support should be considered for people who are malnourished. The guidelines define a person as malnourished if they:
  • have a Body Mass Index (BMI) of less than 18.5kg/m2;
  • have experienced unintentional weight loss greater than 10% within the last three to six months; or
  • have a BMI of less than 20kg/m2 and unintentional weight loss greater than 5% within the last three to six months.
  1. In the event that a person is considered to be malnourished, clinicians can prescribe oral nutritional supplements (such as Ensure drinks) to help the person maintain a healthy weight. However, Section 1.6.9 of the NICE guidelines emphasise that “[o]ral nutrition support should be stopped when the patient is established on adequate oral intake from normal food.”
  2. At the time of her admission to the care home, Mrs H was taking nutritional supplements daily. However, I understand the Practice discontinued the supplements as Mrs H had a recorded BMI over 25kg/m2. This was slightly above the healthy weight range.
  3. In July 2021, Mr G queried whether Mrs H was still receiving the supplement drinks. This was discussed at the weekly multidisciplinary team meeting on 21 July. The GP noted Mrs H had a BMI of 26.1kg/m2 and was described by care home staff as “a very good eater”. The GP concluded it would not be appropriate to prescribe oral nutritional supplements. He wrote to Mr G to explain this.
  4. I have reviewed the care home records. As Mrs H was not considered at risk of malnutrition, the care home was not required to maintain detailed fluid and nutrition charts. Nevertheless, the daily care records make regular reference to Mrs H’s nutritional intake and appetite. These records show Mrs H generally had a very good appetite. There is no indication from the records to suggest Mrs H was refusing meals or otherwise at risk of malnutrition. Furthermore, Mrs H’s weight and BMI remained consistent throughout her time in the care home.
  5. With this in mind, I am satisfied the decision to discontinue the oral nutritional supplements was in keeping with NICE guidelines and constituted good clinical practice. I find no fault by the Practice on that point.
  6. In response to my enquiries, the Practice acknowledged that a GP did prescribe an alternative oral nutritional supplement for Mrs H on 22 September. The Practice said Mrs H’s presentation had not changed and that there was no clinical indication for nutritional supplements. However, the Practice said the GP felt pressured to prescribe them by Mrs H’s family.
  7. The General Medical Council (GMC) is the regulatory body for doctors in England. The GMC produces guidance entitled Good Medical Practice. This sets out expectations for doctors in terms of their professional practice. Section 16a of the guidance says that a doctor must “prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs.”
  8. The Practice has acknowledged there was no clinical basis on which to prescribe a nutritional supplement in September 2021. For this reason, this prescription was contrary to the requirements of the GMC guidance. This was fault.
  9. However, I am satisfied that, in prescribing this supplement, the GP was attempting to be responsive to Mr G’s concerns about Mrs H’s nutritional care. It is important to be clear that this did not cause Mrs H any harm, nor place her at risk of harm. Taking everything into account, I do not consider this prescribing decision resulted in an injustice to Mrs H or Mr G.

Deep Vein Thrombosis

  1. Mr G said the Practice and care home failed to treat swelling to Mrs H’s leg that subsequently turned out to be a symptom of a DVT. Mr G says the care home should have escalated matters to the Practice sooner than it did. He also says the Practice should have sent a GP to examine Mrs H more promptly.
  2. The clinical records show the paramedic who reviewed Mrs H on 26 May completed an appropriately thorough assessment of her ankle. In addition to a physical examination, the paramedic took Mrs H’s observations (which were within the normal range) and completed a Wells Score test. This is a simple test that allocates a patient points for a variety of symptoms and risk factors. These are then totalled to make a final score that is used to calculate the clinical probability of a DVT diagnosis. The paramedic concluded that a diagnosis of cellulitis was more likely. This was ultimately a matter of clinical judgement for the paramedic.
  3. NICE produces guidelines for the treatment of cellulitis entitled Cellulitis and erysipelas: antimicrobial prescribing [NG141]. These guidelines recommend treatment with antibiotics in the first instance. The clinical records show a GP prescribed appropriate antibiotics that day. I am satisfied the treatment provided by the Practice at that consultation was in keeping with good clinical practice and I found no fault on that point.
  4. The clinical records show care home staff sought further input from the Practice on 9 June when Mrs H’s symptoms did not improve following treatment with antibiotics.
  5. When the GP reviewed photographs of Mrs H’s ankle on 14 June, he was satisfied there was no evidence of cellulitis. Rather, he concluded the slight swelling around Mrs H’s ankle was likely due to oedema. The GP noted there was “no evidence of any acute abnormality of the left ankle”. The care home records for this period suggest Mrs H was settled and was eating and drinking well.
  6. Mr G remained concerned that Mrs H’s ankle was still swollen. Staff discussed this with a GP at the multidisciplinary team meeting. There is no detailed note of this meeting. However, the GP records note that Mr G wanted an appointment with a GP to discuss Mrs H’s ankle. Again, the care home records document that Mrs H remained settled during this period and did not appear acutely unwell.
  7. A GP visited Mrs H at the care home on 2 July. The GP recorded her view that Mrs H was suffering from oedema in both legs. Nevertheless, she completed a further Wells Score test and discussed the result with the local DVT clinic. The GP also prescribed an anticoagulant medication as an interim measure.
  8. The DVT clinic arranged for Mrs H to have an ultrasound scan as an outpatient on 5 July. This revealed Mrs H had a DVT in her left leg. The clinic commenced Mrs H on an alternative anticoagulant medication.
  9. The Practice remained in correspondence with the DVT clinic as GPs were concerned the new medication may not be suitable for Mrs H due to her low eGFR level. The clinic advised that Mrs H should remain on the new medication unless her eGFR level fell below 15ml/min.
  10. The evidence I have seen shows the care home sought appropriate clinical input from the Practice regarding the swelling to Mrs H’s ankles. This led to in-person reviews by both a paramedic and GP. I find no fault by the Council on this point.
  11. NICE produces guidance for the diagnosis and management of DVT entitled Venous thromboembolic diseases: diagnosis, management and thrombophilia testing [NG158]. This recommends an ultrasound scan for any patient with a Wells Score of 2 points or more. The GP who reviewed Mrs H on 2 July scored Mrs H at 3 points. The decision to arrange an ultrasound was appropriate, therefore. Furthermore, the Practice’s decision to prescribe interim anticoagulant medication was in keeping with the NICE guidelines. I found no fault by the Practice with regards to the clinical care it provided in this area.

DEXA scan

  1. Mr G said the Practice assured him it would arrange a DEXA scan for Mrs H but that this did not happen.
  2. In its response to my enquiries, the Practice explained that Mrs H was under the care of the breast unit at the local hospital. The Practice said the breast unit arranges DEXA scans where necessary for patients receiving treatment with Letrozole.
  3. I made enquiries with the local hospital Trust regarding this. The Trust explained that the scans are carried out by a private company and that the results are then shared directly with the patient’s GP. The Trust confirmed it referred Mrs H for a scan in June 2021. However, the Trust has now identified that the private company failed to act on this referral.
  4. The Trust has now resent the referral for urgent action by the private company. In addition, the Trust will review all other DEXA scan referrals to ensure these have been acted upon appropriately.
  5. In summary, my investigation has found Mrs H did not receive the planned DEXA scan. However, I am satisfied this was not due to an omission by the Practice. I found no fault by the Practice on this point, therefore.

Safeguarding enquiries

  1. Mr G complained that the Council failed to carry out a thorough safeguarding investigation in response to concerns about Mrs H’s care and treatment. Furthermore, he said the Council did not involve him properly in the safeguarding process.
  2. The Council’s records show a duty social worker spoke to the care home manager on 20 August to discuss the confusion surrounding the decision to discontinue Mrs H’s Alendronic Acid medication.
  3. The social worker also spoke to Mr G on 23 August. Mr G explained that he would like the Council to investigate his concerns about Mrs H’s care. Mr G agreed to put his concerns in writing. He did so in a series of emails on 24 and 25 August. The Council’s records show the social worker acknowledged receipt of these emails on 25 August.
  4. The Council allocated Mrs H’s case to a safeguarding officer on 20 September. The safeguarding officer spoke to Mr G the following day. She noted Mr G’s concerns related primarily to missed medication and delayed treatment for Mrs H’s DVT.
  5. The safeguarding officer spoke to the care home manager on 23 September. The care home manager advised that Mrs H had tested positive for COVID-19 but appeared to be asymptomatic. The safeguarding officer then spoke to Mr G to inform him of this. She noted that she intended to arrange an online safeguarding strategy meeting and would provide Mr G with details in due course.
  6. However, when the safeguarding officer spoke to the care home manager again on 29 September, she found Mrs H had been admitted to hospital as her oxygen saturation levels had dropped.
  7. When the safeguarding officer spoke to Mr G on 7 October, Mrs H remained very unwell in hospital. Mr G said he blamed the care home for the COVID-19 outbreak and wanted action taken. The notes of this conversation suggest it was a difficult call. The safeguarding officer noted that “I asked [Mr G] what level of involvement he presently wished to have in the safeguarding process taking into consideration that his priorities were his mother. [Mr G] agreed for me to arrange the meeting with [the care home] next week and for the information to be [fed back] via email.”
  8. The safeguarding strategy meeting proceeded on 11 October. This was attended by the care home manager and his deputy, as well as Council officers and a pharmacist from the Practice. The safeguarding officer also sought additional information from a Practice GP regarding Mrs H’s Alendronic Acid medication. The meeting concluded that:
  • the Alendronic Acid medication was initially omitted from the list of Mrs H’s medications by the care home in error;
  • a Practice GP subsequently decided in April 2021 to discontinue this medication. However, he failed to record this decision;
  • there was evidence in the care records to show care home staff regularly sought GP input with regards to Mrs H’s health care needs;
  • there had been some confusion between the care home and Practice as to whether Mrs H would require a hospital admission. Improved recording of decision might have prevented this confusion from developing; and
  • the Practice withdrew Mrs H’s nutritional supplement drinks as she had a healthy BMI.
  1. The meeting concluded that the safeguarding allegations were unsubstantiated. The meeting agreed the findings of the safeguarding enquiry would be shared with the CQC and the Council’s Quality Assurance and Improvement Team.
  2. On 12 October, the safeguarding officer contacted Mr G to discuss the outcome of the safeguarding enquiries. The record of this conversation show Mr G strongly disagreed with the outcome.
  3. I understand Mr G remains dissatisfied with the outcome of the Council’s safeguarding enquiries. It is important to be clear that it is not the role of the Ombudsmen to substitute their judgement for that of the professionals involved in the safeguarding process. Rather, my investigation has focused on whether the Council undertook these enquiries appropriately and in accordance with the Care Act 2014.
  4. Mr G did not attend the safeguarding meeting on 11 October. The reasons for this are a matter of dispute. In his submissions to the Ombudsmen, Mr G said he was never advised a meeting was to take place. Indeed, Mr G said he was told this would not be possible as the care home was in lockdown due to the COVID-19 outbreak. In contrast, the case records suggest the safeguarding officer discussed the matter with Mr G on 7 October and that he was content for the meeting to proceed in his absence as he was spending much of his time at the hospital in which Mrs H was then an inpatient. In the absence of any further corroborating evidence, I am unable to reach a robust conclusion as to which account is correct.
  5. However, I note the safeguarding officer spoke to Mr G on several occasions to discuss his concerns. Furthermore, Mr G submitted his concerns in writing via a series of emails. These were saved to the safeguarding file and accessible to Council officers. While Mr G did not attend the safeguarding meeting, the Council’s records suggest those present discussed his concerns.
  6. In my view, there is evidence to show Council officers did consult Mr G as part of the safeguarding process. I found no fault by the Council on this point.
  7. The case records show the Council gathered appropriate information from Mr G, the care home and the Practice as part of its safeguarding enquiries. In my view, these represented proportionate enquiries and allowed the Council to reach a view on whether Mrs H was at risk of, or had experienced, abuse or neglect. The Council ultimately found these concerns to be unsubstantiated. I find no fault by the Council on this point.
  8. The safeguarding enquiries did identify some problems regarding the communication between the care home and Practice, particularly around how decisions were recorded. In its complaint response, the Council confirmed that the Practice now records any prescribing decisions made at the weekly multidisciplinary meetings. In my view, this will go some way to ensuring similar problems do not occur for other service users.
  9. Taking everything into account, I am satisfied the Council undertook appropriate safeguarding enquiries in this case. This was in keeping with its duties under the Care Act 2014. I found no fault by the Council in this respect.

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Recommendations

Council

  1. Within one month of my final decision statement, the Council will write to Mr G to apologise for:
  • the care home’s failure to include Alendronic Acid on Mrs H’s medication list when she was admitted in April 2021; and
  • the care home’s failure to launder Mrs H’s clothes in accordance with basic hygiene standards.
  1. The Council will pay Mr G £100 in recognition of the distress caused to him by this fault.
  2. Within two months of my final decision statement, the Council will write to the Ombudsmen to explain what action it will take to ensure the care home has:
  • a robust process in place for managing the medication of residents to ensure all medications are properly recorded and administered. This should include a process of audit and monitoring to promptly identify any omissions; and
  • a clear policy and protocol for maintaining hygiene standards in the care home to prevent the spread of infection. This should include guidance for staff on laundering dirty clothes and ensuring residents are supported to maintain personal hygiene.

Practice

  1. Within one month of my final decision statement, the Practice will write to Mr G to apologise for:
  • its failure to properly record the decision to discontinue Mrs H’s Alendronic Acid medication in April 2021.
  1. The Practice will pay Mr G £100 in recognition of the distress and confusion caused to him by this fault.
  2. Within two months of my final decision statement, the Practice will write to the Ombudsmen to explain what action it will take to ensure the care home has:
  • a robust protocol in place for maintaining a clear and accurate record of any prescribing decisions and the reasons for them, in accordance with the GMC’s Good Medical Practice guidance. The Practice should also explain how it will audit and monitor its records on an ongoing basis to ensure they are maintained to an appropriate standard.

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Final decision

  1. I find fault by the Council and Practice for the reasons I have explained above.
  2. The actions the Council and Practice have agreed to undertake represent a reasonable and proportionate remedy for the fault I identified.
  3. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman

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