Summary: We uphold Mrs K’s complaint about the care and treatment of her father Mr J. We found fault by the Council, the Mental Health Trust and the Practice in relation to some aspects of Mr J’s care. We recommend the organisations apologise and take action to address this. We have not found any fault by the organisations in relation to Mrs J’s care.

The complaint

1. Mrs K complains about the care provided to her elderly mother and father, Mr and Mrs J, by Stockton-on-Tees Council (the Council), North Tees and Hartlepool Foundation Trust (the Hospital Trust), Tees, Esk and Wear Valley Foundation Trust (the Mental Health Trust) and Yarm Medical Practice (the Practice).
2. In relation to Mrs J, Mrs K complains that:
• there was a multi-organisational failure to identify Mrs J’s need for mental health and social care support following a fall in October 2020. Mrs K’s concerns about this were repeatedly ignored,
• Mrs J’s ability to act as a carer for Mr J was not properly assessed and the Council failed to protect her from Mr J’s dementia related aggressive behaviour; and
• the Practice failed to identify signs of Mrs J’s cancer which delayed her diagnosis and impacted on her care.
3. Regarding Mr J, Mrs K complains that:
• there was a multi-organisational failure to identify that Mr J’s behaviour had significantly deteriorated and Mrs K’s concerns were repeatedly ignored,
• there were delays assessing Mr J’s mental capacity and care needs, which then delayed him accessing a suitable residential care placement,
• an error with his prescription further impacted on his increasingly aggressive behaviour; and
• Social care support provided to Mr J while he was living at home was inadequate.
4. Mrs K also complains about an overall lack of joined up approach and communication between health and social care organisations for her mother and father’s care. She also says the Council’s complaint response was dismissive of the risk to the family from Mr J’s behaviour.
5. As a result, Mrs K says Mr and Mrs J did not receive appropriate care and support. Further, the family and neighbours were put at risk. The situation has also had a significant impact on Mrs K’s mental health and wellbeing. Mrs K would like an acknowledgment of the errors and for systemic improvements to be put in place to prevent this happening again.

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The Ombudsmen’s role and powers

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. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
8. 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.
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 discussed the complaint Mr and Mrs J’s daughter, Mrs K. I reviewed information provided by the Council, the Practice and both Trusts including the responses to my enquiry questions, the social worker’s case notes, Mr and Mrs J’s clinical records and the home care agency’s daily notes. I also took advice from one of our clinical advisers, a registered GP. I have taken account of the relevant guidance and legislation. I have carefully considered all the written and oral evidence submitted to us, even if I do not mention specific pieces of evidence within the decision statement.
11. I shared the draft decision with Mrs K, the Council, the Practice and both Trusts and they had an opportunity to comment. I have carefully considered all the comments I received.

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What I found

Key legislation and guidance

Hospital Discharge

12. Department of Health guidance: Ready to go? Planning the discharge and the transfer of patients from hospital and intermediate care (March 2010) (the ‘Ready to go guidance’) is the core guidance around hospital discharge.

Mental Capacity Act 2005 and Code of Practice

13. A ‘person who lacks capacity’ means a person who does not have the ability to make a particular decision or take a particular action for themselves at the time the decision or action needs to be taken. A person may lack capacity to make some decisions for themselves but will have capacity to make other decisions.
14. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
15. The Mental Capacity Act says:
• A person must be assumed to have capacity to make decisions unless it can be proved otherwise,
• Wherever possible, a person should be helped to make their own decisions,
• People have the right to make decisions that others might think are unwise and should not be automatically treated as lacking capacity,
• Any decision made on behalf of someone who lacks capacity must be in their best interests,
16. Any decision made on behalf of someone who lacks capacity should be an option that is least restrictive of their basic rights and freedoms.
17. There are two stages that need to be considered when assessing a person’s mental capacity. Firstly, whether that person has an impairment of the mind or brain. Then, whether that impairment means that person is unable to make a specific decision when they need to do it.
18. A person is considered unable to make a decision if they cannot understand the information relevant to the decision, retain and weigh up that information to make a decision and communicate their decision.

Mental Health Act 1983 – Code of Practice

19. There are five overarching principles, including:
• Least restrictive option and maximising independence – Where it is possible to treat a patient safely and lawfully without detaining them under the Act, a patient should not be detained…. Any restrictions should be the minimum necessary to safely provide the care and treatment required having regard to whether the purpose for the restriction can be achieved in a way that is less restrictive to the person’s rights and freedom of action.
• Empowerment and involvement - Patients should be fully involved in decisions about their care, support and treatment. The views of families, carers and others, if appropriate, should be fully considered when taking decisions. Where decisions are taken which are contradictory to the views expressed, professionals should explain the reasons for this.

National Institute for Health and Care Excellence (NICE) guidance

20. Referral for suspected lung or pleural cancer: Referrals to cancer pathways should be made for people with chest x-ray findings that suggest lung cancer or aged over 40 years with unexplained coughing up blood. An urgent chest x-ray should be offered/considered for people with two or more of the following unexplained symptoms: cough, fatigue, shortness of breath, chest pain, recurrent chest infection, weight loss and appetite loss.

What happened

21. In April 2020, Mr J was diagnosed with dementia.
22. In October 2020, Mrs J had a fall and was admitted to hospital. Mr J agreed to a temporary care package of four visits a day to check on his wellbeing and to encourage him to eat and take his medication.
23. A few days later, Mrs J was discharged. A social worker visited Mr and Mrs J at home. Mrs J declined any support for herself. Mr J also wished to end the temporary care package. However, the social worker decided he was unable to properly make this decision and the care package remained in place. Due to his dementia, Mr J was also regularly monitored by a Community Psychiatric Nurse (the CPN) from the Mental Health Trust.
24. Mrs J felt intermittently unwell and raised concerns with the Practice. In late November 2020, Mrs J was admitted to North Tees Hospital where she was diagnosed with advanced lung cancer.
25. On 14 December 2020, a Multidisciplinary Team meeting took place to discuss Mrs J’s discharge. Mrs J wished to return home. Mrs K was concerned that Mrs J would be unable to cope at home and felt she needed a care home placement. All professionals agreed Mrs J’s needs could be met at home with a care package. She was discharged home later that day.
26. Mr and Mrs J continued to receive four daily visits from care workers. There were ongoing conflicting views between Mrs J, Mrs K and the social worker about whether Mrs J could remain at home.
27. On 17 December 2020, following a rapid deterioration in Mrs J’s health, a visiting district nurse helped to arrange for Mrs J to move to a care home. Mrs J died a few days later.
28. The CPN arranged for Mr J to have extra support over the Christmas period. In January 2021, Mr J’s care package was increased to include additional domestic and shopping calls. Following a confrontation with a neighbour, Mr J also started taking a daily dose of 500 µg Risperidone, an antipsychotic drug which can be used to treat dementia related aggression. Mr J’s behaviour improved.
29. In February 2021, Mrs K raised concerns about Mr J’s financial management. The social worker assessed Mr J and decided that he was unable to manage his own finances. Mrs K supported Mr J with his finances and the Council applied for an appointeeship to be put in place. An appointee is someone who manages financial affairs for a person who is unable to do it themselves.
30. In March 2021, the CPN arranged for 28 days of Risperidone to be delivered to Mr J’s house and wrote to the Practice, asking it to take over prescribing the medication.
31. In April 2021, following concerns from Mrs K, the CPN and a consultant psychiatrist visited Mr J. They decided Mr J’s behaviour did not meet the threshold for a Mental Health Act Assessment.
32. Mr J’s aggressive behaviour began to escalate throughout April and there were further incidents with his neighbours. On 21 April, the CPN discovered that Mr J’s prescription had not been repeated so he had not taken his Risperidone for three weeks. This was quickly rectified. Mr J’s behaviour mostly settled for a while.
33. In June 2021, Mr J’s aggressive behaviour escalated again. His relationship with Mrs K had a significant breakdown due to his belief that she was stealing his money. He also became suspicious of the care workers and accused them of stealing from him. On 10 June, Mr J was detained under Section 2 of the Mental Health Act.
34. In September 2021, Mr J was discharged to a care home. This placement later broke down and he moved to a different care home.
35. Mr J died in October 2022.

Analysis

Mrs J’s care and support

Failure to identify Mrs J’s need for support

36. Mrs K complains that there was a multi-organisational failure to identify Mrs J’s needs following her discharge in October 2020 and to put the necessary support in place. Mrs K also feels that Mrs J’s capacity was repeatedly overestimated.
37. Mrs J, Mrs K and the relevant professionals had conflicting views regarding Mrs J’s care needs. A key consideration here is Mrs J’s ability to make her own decisions. I have outlined the main principles above.
38. Having reviewed the Council, Hospital Trust and Practice records, I can see that Mrs J’s capacity was considered on a number of occasions by several professionals including different GPs, social workers and nurses.
39. The Council’s case notes record the social worker discussing care needs with Mrs J after she was discharged home in October 2020. Mrs J said that she would like Mr J’s care package to remain in place, however she declined a care needs assessment for herself. Following further concerns from Mrs K, the social worker again discussed care needs with Mrs J on two occasions in November 2020. Again, Mrs J declined a needs assessment for herself, saying she did not feel she needed any help. Mrs J was provided with information about how to ask for help if she changed her mind.
40. Following Mrs K’s concerns, the Practice offered Mrs J referral options for social care support. Again, Mrs J declined further support and the Practice were also satisfied that she had capacity to make this decision.
41. The Hospital Trust’s inpatient records noted no apparent mental capacity concerns.
42. Multiple professionals considered that Mrs J was able to make decisions about what support she wished to receive. This is in line with the Mental Capacity Act, which states that a person must be assumed to have capacity unless it can be proved otherwise. The records suggest that Mrs J was keen to maintain her independence. However, Mrs J also chose to accept care, support and referrals where she felt it was necessary. While Mrs K was concerned for her mother’s welfare and strongly felt that it was an unwise decision to decline support, it was a decision that Mrs J was entitled to make. I find no fault by any of the organisations involved in Mrs J’s care on this point.

Mrs J’s discharge home

43. Mrs K complains about the decision to discharge Mrs J home in December 2020, following her cancer diagnosis. Mrs K says that if the district nurse hadn’t fast tracked her mother to a care home, Mrs J would have died at home without adequate support.
44. I have reviewed the Council’s case notes and the Hospital Trust’s records. Mrs J was visited multiple times on the ward by a physiotherapist. Mrs J was found to be moving slowly but independently, with the help of a Zimmer frame. She was able to safely move from her bed to a chair and around the ward by herself, as well as toileting independently. Mrs J was aware of her physical limitations when moving and able to use strategies to address this. Mrs J was clear about her wish to return home to be with her husband and her pets.
45. The ‘Ready to go guidance’ states “there is evidence that too many older people inappropriately enter long-term residential care direct from an acute hospital. Such decisions should not be made in an acute hospital other than in very exceptional circumstances”. The professionals were keen for Mrs J to be allowed to return home and see how it went. It was not apparent at the time that Mrs J would deteriorate so rapidly.
46. A multi-disciplinary team meeting was held to discuss Mrs K’s concerns about her mother’s return home. The meeting was attended by the physiotherapist, the CPN, a ward nurse, a ward doctor, Mrs K and her brother. The physiotherapist had no concerns about Mrs J’s ability to move safely and the nurse confirmed that Mrs J was toileting independently and had no overnight needs. The meeting discussed Mrs K’s concerns. The professionals agreed Mrs J did not meet the criteria for 24-hour care. They found she was clear in her wish to return home and that her needs could be met there. Following consideration of all of the relevant information and risks, it was agreed that Mrs J would be discharged home and the care package monitored. I have seen no evidence to suggest such a rapid deterioration in Mrs J’s health was imminent at the point of discharge. I find no fault in the way this decision was reached.
47. Mrs K feels that her concerns were repeatedly ignored and that there was a lack of joined up working between the organisations. The care records show the Council and the Trust staff were aware of Mrs K’s concerns and discussed these with her in detail. I am satisfied that professionals weighed up the risk factors appropriately and clearly recorded the reasons for their decision to discharge Mrs J home. In summary, I find no fault in the way the discharge was handled, albeit I accept Mrs K disagrees.

Impact of Mr J’s behaviour on Mrs J

48. Mrs K complains that there was a failure to offer Mrs J a carer’s assessment or to properly consider the impact of Mr J’s behaviour on her.
49. In the Council’s complaint response of 22 October 2021, it apologised that Mrs J had not been offered a carer assessment and took this as a learning point. During my investigation, it has come to light that there were three attempts to offer Mrs J a carer’s assessment in April 2020, via two phone calls and a letter. Mrs J did not respond, so the Council closed the referral.
50. As part of Mr J’s needs assessment in October 2020, Mrs J was also offered a carer’s assessment by the social worker. It is recorded in the Council’s case notes that Mrs J chose to decline. As Mrs J was offered a carer’s assessment on several occasions, there is no fault on this point.
51. Mrs K also says that Mr J was not offered a carer’s assessment in relation to Mrs J. The Council has explained that Mr J was not viewed as a carer or expected to provide any formal care, and therefore did not require a carer’s assessment.
52. Mrs K further complains that there was a failure to keep Mrs J safe from Mr J’s aggressive behaviour.
53. Following Mrs K’s concerns, the social worker asked Mrs J whether she was experiencing any aggressive behaviour from Mr J. Mrs J was asked, in private, on several different occasions. The CPN also asked her about this.
54. Mrs J said Mr J could sometimes be short tempered and raise his voice. However, she said he was not physically aggressive towards her and that she felt safe with him. The carers did not report seeing any incidents of aggression from Mr J towards Mrs J. This factor was included in the risk assessments completed by both the social worker and the CPN. I have found that the social worker and the CPN acted on Mrs K’s concerns and appropriately considered the risk based on the information available to them.

Delayed cancer diagnosis

55. Mrs K complains that the Practice failed to diagnose Mrs J’s cancer earlier, which led to a delay in her receiving treatment.
56. I reviewed Mrs J’s clinical records and sought advice from one of our GP clinical advisors. The clinical records show Mrs K had various medical conditions including recurring anaemia and ongoing back pain from a fall in 2019. Throughout 2020, Mrs J experienced episodes of dizziness, tiredness, back pain and occasional black stools. Mrs K was admitted to hospital several times for iron infusions to treat her anaemia. Following infusions, her blood results were satisfactory until October 2020 when her iron levels did not improve.
57. Each time Mrs J raised a concern, the Practice considered her concerns and acted. This included repeated blood tests, hospital admissions for iron infusions and referrals for a magnetic resonating imaging (MRI) scan of her back and a gastrologist to investigate possible digestive bleeding.
58. Mrs J did not exhibit the typical symptoms of lung cancer, such as coughing, shortness of breath, coughing up blood and chest pain, which would have required further investigation under the NICE guidelines (see above). Mrs J was displaying other less specific symptoms such as tiredness, dizziness and weight loss, however these could also be explained by her anaemia.
59. The clinical evidence shows the Practice took appropriate action and made the necessary referrals, based on the symptoms Mrs J was displaying at the time. This was in keeping with good clinical practice.
60. I appreciate Mrs J’s diagnosis must have been a shock for Mrs J and her family, and this would have been a very difficult time for them all. However, I have not seen any evidence to suggest that there were clear missed opportunities to identify the cancer at an earlier stage. Therefore, I have found no fault.

Mr J’s care and support

Failure to act when Mr J’s behaviour deteriorated

61. Mrs K complains there was a multi-organisational failure to identify that Mr J’s behaviour had deteriorated significantly and take appropriate action to keep him and other people safe. Mrs K says her concerns about Mr J’s behaviour were repeatedly ignored.
62. There was a significant difference between the views of Mrs K, Mr J and the professionals. Mrs K feels Mr J should have moved into a care home as early as October 2020 as he was unsafe at home. Mr J was clear in his wish to remain at home and repeatedly refused suggestions of moving into a care home. Up until June 2021, multiple professionals including the social worker, the care workers, the CPN and the psychiatric consultant, agreed that Mr J could be safely managed at home.
63. It is not our role to substitute our judgment for the view of the professionals who were there at the time. Instead, we consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome.
64. Again, the Mental Capacity Act is the key framework for making decisions about people’s lives (see above). Mr J strongly wished to remain at home. Therefore, the professionals needed to consider whether he had the capacity to make this decision for himself. Assessments of someone’s capacity is specific to the decision to be made at a particular time. Capacity can also vary at different times.
65. Even if a person has been deemed unable to make one decision, there are other decisions about their lives they will be able to make. For example, Mr J was found to lack the capacity to decide to remove his care package or to manage his finances. However, this is separate from whether he was able to decide where he wanted to live.
66. As Mr J was refusing to move to a care home, a decision could only be made on his behalf if he was found to lack the capacity to make that decision. Further, any decisions made on his behalf would need to follow the principle of being the least restrictive option available.
67. The social worker and the CPN discussed care homes with Mr J on multiple occasions. Some of these conversations were in response to Mrs K’s concerns, others were part of his general care. He was offered the option of a short-term respite placement, which he also declined. The records show that during the conversations, Mr J could get muddled, repetitive in his speech and sometimes agitated. However, he was also able to show some insight into his limitations, understand potential risks and explain how he could mitigate these and how to call for help. He was compliant with the care visits and taking his medication. He was considered to have capacity to decide where he wanted to live. Mrs K strongly believed this was unwise, however this does not necessarily mean that Mr J did not have capacity to make that decision. The professionals have acted in line with the Mental Capacity Act and I found no fault with how these decisions were reached.
68. Both the Council’s case notes and particularly Mr J’s mental health notes shows that the organisations were aware of all of Mrs K’s concerns, the incidents which happened and the possible risks. The CPN carried out regular and detailed risk assessments, which carefully weighed up each concern and reached a well-reasoned decision.
69. I have looked at all the reported risk incidents. I recognise there were incidents which were naturally very concerning for Mrs K. Each time an incident happened, the CPN and social worker took appropriate action. For example, when Mr J left a gas hob on there were attempts to install a gas safety valve. When this was not possible in his property, it was suggested to install an electric hob or swap the cooker for a microwave instead. I also note that each incident happened as a separate event, over a period of several months, rather than occurring regularly.
70. Mr J’s money management was a source of contention. The Council took steps to appoint an independent person to manage his money, with the aim of reducing the risk to Mrs K. Unfortunately, there were delays with the advocacy service appointing someone due to a backlog. The Council has already acknowledged and apologised to Mrs K for this.
71. Regarding Mr J’s behaviour, it was known that Mr J was sometimes presenting differently to his family than to professionals. I recognise Mr J did display some aggressive behaviour towards his children. This became particularly difficult and distressing for Mrs K when Mr J began to believe she was stealing his money. I acknowledge how stressful and upsetting Mrs K found this.
72. There were also some incidents of aggressive behaviour towards Mr J’s neighbours which resulted in the police being called. One incident involved physical aggression. There were three incidents over four months. One occurred close to Mrs J’s funeral, when Mr J was grieving. Another incident occurred when Mr J had not taken his Risperidone for two weeks.
73. When the social worker and CPN contacted Mr J, he was usually calm and polite to them. The care workers who visited four times a day rarely reported any concerns about his behaviour until June 2021, shortly before he was sectioned. The care agency was comfortable sending a single care worker to the property as the staff did not feel at risk. Mrs J said that she felt safe with him.
74. This does not minimise Mrs K’s experience. However, it does demonstrate that Mr J’s behaviour fluctuated and that there was a fine balance to be found between managing risk and respecting Mr J’s wish to remain at home. The evidence shows professionals took appropriate action to mitigate the risks. This included offering respite, introducing Risperidone and completing regular mental health reviews. Following the Risperidone, Mr J’s behaviour became more settled initially. The CPN and social worker considered the risks could be managed at home at the time. This remained the least restrictive option while it was possible. This was in line with the requirements of the Mental Capacity Act.
75. Mrs K feels that her concerns were ignored. I have reviewed the relevant records and found the professionals working with Mrs K did take her views into account. Mr J’s mental health notes extensively records all risk incidents, how these were considered and what action was taken. The CPN regularly visited Mr J, including out of hours and on weekends. The CPN also arranged extra support for Mr J over the Christmas period after Mrs J died. The CPN also had regular discussions with the consultant psychiatrist. They carried out joint visits to Mr J to decide whether a Mental Health Act Assessment was required. However, prior to June 2021, Mr J did not meet the criteria for an assessment.
76. The CPN reached a different view to Mrs K, but clearly recorded the rationale for each decision and I have not found fault with the way these decisions were reached.
77. Mrs K also complains about a lack of joined up working between organisations. Overall, I have seen evidence in the records of regular communication between the CPN, the social worker, the consultant psychiatrist and the care workers. This included multidisciplinary team meetings and joint visits. An Occupational Therapist was also involved to assess Mr J. The professionals generally shared the same view on the ability to support Mr J at home. The CPN regularly wrote to the Practice to update Mr J’s GP.
78. In June 2021, the CPN and consultant psychiatrist visited Mr J and decided that the threshold for a Mental Health Act Assessment had been met this time. At this point, there had been a clear change in Mr J’s circumstances and needs. Mr J was becoming increasingly more aggressive towards Mrs K and had also started to display some aggression towards the care workers, accusing them of stealing from him. Mr J was at risk of carer breakdown and the Mental Health team felt he could no longer be managed safely in the community. Following an assessment, Mr J was admitted to hospital under Section 2 of the Mental Health Act.

Mr J’s mental capacity

79. Mrs K complains that the organisations collectively failed to recognise that Mr J had lost his capacity and underestimated the risk to family and neighbours. She also says there were delays completing mental capacity assessments, which delayed Mr J moving to a care home.
80. Much of this has already been covered above. Mr J had his capacity considered on several occasions by the social worker, the CPN and a number of different GPs, including some formal assessments. The Council decided that Mr J lacked capacity to make certain decisions, however he was found to have the capacity to decide where to live up until June 2021. A number of different professionals agreed on this point. I am satisfied that the Council and the Mental Health Trust properly considered Mr J’s capacity and the risks arising from his behaviour. These decisions were made in line with the principles of the Mental Capacity Act and the Mental Health Act.
81. In response to my enquiries, the Council accepted that there were some delays in completing formal mental capacity assessments and also appointing an advocate. This is fault. The Covid-19 pandemic contributed to this delay. The Council and Mental Health Trust’s records show that Mr J was subject to constant informal reviews, which considered his capacity and the current risks. I have seen nothing to suggest that the formal reviews would have reached a different decision to the informal reviews, as all relevant information was available at the time. Therefore, I have not found any injustice to Mr J as a result of the delay.
82. I recognise that Mrs K was involved in managing Mr J’s finances for longer than ideal, due to a delay appointing an advocate. The Council has accepted this delay, apologised and taken it as a learning point for its staff. I am satisfied that the Council has taken reasonable steps to put things right.

Mr J’s medication

83. Mrs K says there was an error with Mr J’s dementia medication which meant he missed three weeks of doses. She says this had a negative impact on his behaviour.
84. In January 2021, the CPN started Mr J on 500µg daily Risperidone to help manage his aggressive behaviour. Following this, Mr J’s behaviour settled and improved. On 2 March, the CPN wrote to the Practice. He explained that he had arranged for 28 days of tablets to be delivered to Mr J’s address and asked the GP to take over prescribing for future repeat prescriptions.
85. By mid-April 2022, Mr J’s behaviour deteriorated and there were further incidents of aggressive behaviour. Around 21 April, the CPN discovered that Mr J had run out of Risperidone at the end of March and had missed around 21 days of medication.
86. The Practice failed to take over the repeat prescription. As a result, Mr J ran out of medication. The Practice received the CPN’s letter of 2 March 2022, in which the request for the Practice to take over responsibility for the prescription was highlighted. It is unclear why this request was not processed in time for the start of April.
87. During my enquiries, the Mental Health Trust accepted that the medication error could have potentially been identified sooner, had the medication safe and care provider records been checked during visits. The Mental Health Trust has asked its team to ensure medication is checked at every home visit.
88. Further, the care agency staff also should have noticed that Mr J’s medication had run out and flagged this up. The Council and the care agency noted that the staff were only responsible for administering medication to Mr J. However, both organisations have accepted that the staff could have used their initiative to question why no medication was available. The care agency says it has introduced new technology to improve its processes.
89. There was a collective failure by the Practice, the Mental Health Trust and the care agency to manage Mr J’s Risperidone properly.
90. We cannot know the full impact the missing medication had on Mr J’s behaviour. However, the records suggest that his behaviour had settled with the Risperidone and deteriorated when he was not taking it. We cannot know whether or not the aggressive incidents would have occurred, had Mr J been taking his medication. However, it is likely to have had some negative impact on his behaviour and exacerbated an already difficult situation.

Mr J’s home care

91. Mrs K complains about the care provided to Mr J at home by a care agency, on behalf of the Council, who visited four times a day. She says Mr J’s personal care and meals were not adequately managed. She says Mr J would often say he had eaten when he had not and was regularly missing meals because the care workers took what he said at face value.
92. The Council says Mr J did not require help with his personal care and was often already out of bed and smartly dressed when the carers arrived, and there was evidence that he has already eaten.
93. I have reviewed the daily care records, which records Mr J as usually being dressed in the morning before the care workers arrived. Overall, there are few concerns recorded about his personal hygiene. However, there are a few references to him wearing the same clothes without being washed or occasionally looking dishevelled. It is noted the care workers sometimes prompted Mr J to change his clothes but that he would decline. The carers noted Mr J could become angry if the point was pushed. The records show the carers took over responsibility for his laundry.
94. After Mr J was sectioned, the hospital records show that Mr J was independent with his personal hygiene and notes that he was smartly dressed and took pride in his appearance.
95. While there may have been occasions where Mr J’s personal hygiene could have been better, the records suggest that it was generally adequate and he was keen to remain independent in this area. I have not seen anything to suggest that Mr J was found to lack capacity to make decisions about his own personal hygiene and what to wear. There is evidence that the care workers offered him extra support at times and Mr J declined. The care workers were not able to make Mr J change his clothes and wash if he did not wish to. I have not found fault on this point.
96. I have found fault with Mr J’s meal management. Mr J’s care plan clearly states that he is to be encouraged to eat at all four daily visits, and that he will often say he has eaten when he has not, or that this may have only been a biscuit. He was also known to regularly say that Mrs K was bringing fish and chips for his tea, when this was not the case. Despite his care plan, there are multiple records of care workers simply noting that Mr J said he had already eaten and nothing to suggest that any further action was taken.
97. I accept that there are some notes of bowls being found in the kitchen sink, usually at breakfast time, which suggests that Mr J was preparing himself some meals at times. However, this is not consistently documented and often it is not clear whether the care workers had properly satisfied themselves that Mr J has eaten, or simply accepted his account.
98. There were some days in March and April 2021 where there is no record of any meal being prepared for Mr J at any care visit for a whole day. At one point, no meals were prepared for him for four days in a row.
99. Mrs K noticed that food she had provided was still in the fridge and care workers believed she was bringing Mr J tea far more often that she was. It is evident that Mrs J raised these concerns with the carer workers numerous times. In April 2021, after Mrs K raised concerns, the agency sent a memo to the care workers to say they should prepare a meal for Mr J, regardless of whether he claimed to have eaten. Following this, the meal management improved for around three weeks, with Mr J eating the meals well.
100. Unfortunately, in May 2021, despite the memo, meal preparation declined again. The care agency records returned to visits noting that Mr J had eaten and little to suggest meals were being made every day.
101. I found that the care agency did not always act in line with Mr J’s care plan in relation to meals, which included that Mr J’s account could be unreliable.
102. I am not satisfied that the care workers took sufficient steps to ensure Mr J’s nutritional needs were met. There are periods where the care workers supported Mr J’s meals properly, however this was highly variable. There are a significant number of visits where Mr J was not prepared any food. While Mr J could not be made to eat a meal he did not want, he should have been encouraged to eat at every visit. Further, when meals were prepared for him, Mr J usually accepted them and ate well.
103. There is also inconsistent record keeping by the care agency. Often there is little information in the records to confirm why the care worker was satisfied that Mr J had genuinely already eaten or whether that there was any attempt to encourage him to eat.
104. This amounts to fault. As a result, Mr J’s nutritional needs were not always met. Mrs K was also frustrated and worried by the situation.

Support for Mrs K

105. Mrs K complains that the was a lack of support for her, in her role as a carer for her parents.
106. I have reviewed the Council’s records and can see that Mrs K was offered support on a number of occasions. In November 2020, the social worker’s case notes show that Mrs K was offered a carer’s assessment for herself but declined.
107. In January 2021, the social worker also discussed ways to relieve some of Mrs K’s carer strain, such as reminding the care workers to contact other options first where possible (such as the GP or 111) instead of always calling Mrs K first. The Council also sought to put an appointeeship in place to manage Mr J’s finances, as this was currently managed by Mrs K and becoming a source of contention for Mr J.
108. During the multidisciplinary team meeting in February 2021, Mrs K was referred to dementia advisors. She was also offered a consultation with a psychologist for support to discuss her feelings and carer strain. The Trust acknowledged the psychologist’s referral was not actioned until May. The records also show that both the social worker and the CPN took time to listen to Mrs K’s concerns during regular phone calls.
109. Overall, while some actions were not always taken as promptly as they could have been, I can see that Mrs K was offered several different options for additional carer support.

Complaint handling

110. Mrs K says the Council’s complaint response was dismissive about the risk to family from Mr J’s behaviour.
111. During my enquiries, the Council said it did not intend to be dismissive and it recognises that Mr J presented differently to family.
112. As mentioned above, I have seen evidence that both the Trust and the Council were aware of Mrs K’s concerns and risk to other people, including family, formed part of several risk assessments. I am satisfied that the Council took Mrs K’s concerns seriously and also recognised that Mr J often behaved differently towards professionals.
113. The Council took several learning points from Mrs K’s complaint, including around offering carers assessments and improving timeliness for formal reviews. The Council has confirmed that these have been shared with managers and their staff. I am satisfied that the Council has taken reasonable action to put things right.

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Agreed actions

Council

114. Within one month of my final decision statement, the Council will:

• Apologise to Mrs K for the care agency’s handling of Mr J’s meals

Within three months of my final decision statement, the Council will ensure the care agency has:

• Reviewed its policies and procedures in relation to meeting nutritional needs. This should include ensuring policies are clear about properly supporting people with their meals, adequately monitoring food intake and consistently preparing meals in line with care plans when required.
• Reviewed their policies and procedures in relation to record keeping. This should include ensuring that staff properly record actions taken to meet a person’s care plan, or clearly recording any rationale for not completing an action i.e. not preparing a meal.
• Ensured that this information has been shared with staff
• The Council will write to the Ombudsmen, with supporting evidence, to confirm these steps have been completed.

Council, Practice and Mental Health Trust

115. Within one month the Council, the Practice and the Mental Health Trust will:

• Apologise to Mrs K for errors in relation to Mr J’s medication management.

Within three months the Council will write to the Ombudsmen to confirm that the care agency has:

• Reviewed their policies and procedures to ensure that there is a robust protocol in place for the administration and recording of medication along with a clear route for escalating any concerns.

Within three months the Practice should write to the Ombudsmen to confirm that they have:

• Reviewed their policies and procedures to ensure that there is a robust protocol in place for the administration of repeat prescriptions.

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Final decision

116. I found no fault by the Council, the Hospital Trust, the Mental Health Trust or the Practice in relation to Mrs J’s care and treatment.
117. There were delays by the Council finding an appointee and completing some formal reviews for Mr J. However, I am satisfied that it has taken appropriate steps to address this.
118. The Council, the Practice and the Mental Health Trust failed to managed Mr J’s medication properly. The Council also failed to ensure that Mr J’s nutritional needs were met. I am satisfied the actions the Council, the Mental Health Trust and the Practice have agreed to take represent a reasonable and proportionate remedy for the injustice caused to Mrs K by the fault I have identified. The Mental Health Trust has already taken steps to improve its medication monitoring. I have now completed my investigation on this basis.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman