Summary: Ms X complained that the London Borough of Wandsworth and Central London Community Healthcare NHS Trust failed to arrange or provide adequate care for her mother, at home, in the summer of 2022. We will not investigate Ms X’s complaint. This is because it is unlikely an investigation would be able to make findings or recommend outcomes Ms X would find satisfactory.

The complaint

1. Ms Y returned home from hospital, following a lengthy admission, in early June 2022. The London Borough of Wandsworth (the Council) commissioned Supreme Care Services Limited (the Care Provider) to visit Ms Y at home and meet her assessed needs. Staff from Central London Community Healthcare NHS Trust (the Trust) also visited Ms Y at home to change dressings, change a pain medication patch and attend to Ms Y’s catheter.
2. Ms Y’s daughter, Ms X, complains that the Council, including the Care Provider it commissioned, and the Trust failed to arrange or provide adequate care for Ms Y during the three‑and-a-half weeks she remained at home. Specifically, Ms X complains:
1. the Council failed to ensure there an adequate amount of care and support was in place for Ms Y at home after she left hospital;
2. the Council kept changing Ms Y’s support at home;
3. the Council failed to tell her that Ms Y’s social worker had left her role or provide alternative contact information;
4. the Care Provider’s staff who visited Ms Y were unprofessional and argued in front of Ms Y;
5. care staff failed to complete all of their allocated duties properly, including washing up and waste disposal;
6. care staff failed to provide appropriate and correct care for Ms Y’s wounds. Including that they did not: use an aseptic technique; apply creams correctly; roll Ms Y properly; or, clean Ms Y properly;
7. the Care Provider failed to communicate or work effectively with district nurses from the Community Trust;
8. the Community Trust inappropriately delayed coming to see Ms Y after she returned home from hospital;
9. failed to communicate or work effectively with staff from the Care Provider;
10. failed to do enough to ensure Ms Y’s pressure sores were being appropriately cared for; and,
11. failed to do enough to help when there were problems getting held of enough wound dressings and continence products.
3. Ms Y died shortly after returning to hospital in July 2022. Ms X complains that Ms Y’s death was avoidable. Ms X complains that the combined failings of the Council, Care Provider and the Trust contributed to Ms Y’s death.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the bodies, or
• we cannot achieve the outcome someone wants

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

6. I considered evidence Ms X provided to the Health Service Ombudsman as well papers we received from the Council and the Trust, and relevant law, policy and guidance.
7. Ms X had an opportunity to comment on my draft decision. I considered the comments she made before making a final decision.

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What I found

8. The following account is a very brief overview and is not intended to be a detailed chronology. However, it is drawn from a comprehensive review of the period via numerous letters from and to Ms X during the complaints processes she followed with the Council and the Trust and other organisations.
9. Ms Y lived at home. She had chronic obstructive pulmonary disease (COPD), a lung condition that makes it difficult to breathe. Ms Y could stand on her own and change her position in a chair, and she could walk to the bathroom herself with a walking aid.
10. In January 2022 Ms Y fell at home at was taken to hospital. Medics noted that Ms Y appeared to have a worsening of COPD due to an infection. They also found she had broken her knee. Ms Y remained in hospital until June 2022. A discharge meeting identified that Ms Y would need support from community nurses to manage a pressure wound, manage her catheter and provide continence products. The Council said it would arrange for care staff to make double-handed (i.e. two care workers attending at the same time) visits to Ms Y four times a day.
11. The hospital discharged Ms Y and she returned home in early June 2022. In a referral to the Trust it included instructions about catheter care, continence care and recent recommendations from its Tissue Viability Service.
12. Ms Y left hospital on 7 June 2022. The hospital provided a limited supply of continence products and dressings and sent prescriptions to Ms Y’s GP practice.
13. Care staff visited Ms Y for the first time the next day. Ms X said they found that the pressure sores had not been cleaned or dressed the previous day in hospital and that Ms Y had been lying in her own excrement for 24 hours. Two community nurses visited Ms Y in the afternoon. They assessed Ms Y and created a care plan for nurses to visit three times a week to change her dressings, and visit once a week to change a pain relief patch and for catheter care. Ms X said that during this visit a nurse told care staff, “very firmly”, what they should and should not be doing to care for Ms Y.
14. On 10 June one of Ms Y’s daughters called Ms Y’s social worker and said the Care Provider’s visits were not long enough to complete all the required tasks. The social worker said they would speak to a manager about the situation. On the same day a tissue viability nurse assessed Ms Y at home and recommended the use of a different type of dressing which they considered would be more appropriate. It ordered a supply of these dressings via Ms Y’s GP practice.
15. On 11 June Ms X called a duty social worker and complained that the morning’s care visit had been shambolic and rushed. She reiterated the request for longer visits. Ms X also called the community nurses and asked a nurse to come urgently to change Ms Y’s dressing and catheter, as Ms Y had been incontinent and the dressing was soiled. A nurse called back and said there was no capacity for a visit. They asked Ms X to change Ms Y’s dressing and said they would arrange for someone to visit the next day. A nurse visited the next day and asked Ms X to help them while they changed Ms Y’s dressing. Ms X told the nurse she did not think the care staff were doing an adequate job and the nurse told her to follow this up with the Council.
16. On 13 June a nurse chased up a supply of the new dressings they had requested on 10 June. Another nurse spoke to Ms Y's social worker about Ms X’s concerns about the adequacy of Ms Y’s care. The social worker said a request for additional support was waiting to be signed off.
17. On 14 June the new dressings had still not arrived. A nurse spoke to the pharmacy about it which said it was waiting for delivery of the dressings. A nurse also provided some dressings from the Trust’s stock. Ms X also spoke to a nurse and noted that Ms Y’s care staff were not always present when the nurses visited. The nurse amended Ms Y’s care plan to say that double-handed visits were required.
18. A paramedic from Ms Y’s GP practice visited Ms Y the next day and assessed her.
19. On 16 June a nurse attempted to assess Ms Y with a view to deciding what type of incontinence product she should have. They were unable to complete their assessment as their measuring tape was not long enough to accurately measure Ms Y’s waist. A nurse returned the following day to complete the measurement and passed it on to the relevant team. Another member of staff said they should trial three different products and requested samples online. They advised Ms X to buy these products while they waited for the samples to arrive if they needed any. Also on 17 June, a supply of dressings (as suggested by the tissue viability nurse on 10 June) arrived. In addition, Ms X left a message with the community nurses to complain about the failure to provide adequate supplies. A nurse called Ms X back. The Trust said they called to discuss the supplies Ms X wanted and to explain what had been ordered and what would need to be bought privately. Ms X said the nurse was aggressive and “berated” her for complaining.
20. On 21 June Ms Y’s allocated social worker left the department.
21. On 23 June Ms X spoke to a community nurse and said they had not received any of the sample incontinence products a nurse had ordered on 17 June. The nurse agreed to escalate the matter. On the same day nurses contacted Ms Y’s GP practice and asked them to review her as she had swollen hands. A GP spoke to Ms Y that day and agreed to arrange blood tests and a review in two weeks.
22. On 24 June a member of the family told a nurse that the samples of incontinence products had still not arrived. They noted that Ms X had bought some incontinence products for Ms Y which were suitable. The nurse sent a request to the NHS supply chain for an order of this product, marked “urgent”.
23. A new social worker was allocated to Ms Y on 26 June. They visited her the next day and noted Ms X’s concerns that the care staff were unprofessional and argued with each other. Ms Y said she had a good rapport with the care staff and felt satisfied with them. She noted that they argued sometimes and said this was because they were rushed. Ms Y asked for the visits to be longer.
24. Also on 27 June, community nurses felt the swelling to Ms Y’s hands and arms had worsened. They contacted the GP practice again. The practice said they would refer Ms Y to a lymphoedema service (lymphoedema is a long-term condition that causes swelling in the body’s tissues).
25. On 28 June a tissue viability nurse from the Trust visited Ms Y. They said they would refer Ms Y to Accelerate, a community lymphoedema service, about the condition of Ms Y’s arms. Also that day, a nurse contacted the NHS supply chain which advised that a supply of incontinence products would be delivered to Ms Y on 1 July.
26. On 28 June Ms X called 111 due to concerns about Ms Y’s health. 111 contacted Ms Y’s GP practice and advised them to offer Ms Y an appointment within three days. Ms X called 111 back and they contacted the practice again and said the practice should offer a same-day appointment. A GP called Ms X the next day and arranged for the practice paramedic to visit Ms Y the following day.
27. The practice paramedic visited Ms Y on 30 June. They considered Ms Y’s vital observations to be satisfactory and felt there were no acute issues which needed immediate treatment.
28. On 1 July a nurse from the Trust visited to change Ms Y’s dressing. They had concerns about Ms Y’s health. Ms X was already in touch with the practice to ask for an urgent appointment. A GP then arranged for an ambulance to take Ms Y to hospital. Ms Y died in hospital around 12 hours later.

Complaints processes

29. From October 2022 Ms X pursued complaints with the Council, the Care Provider and the Trust. She did not get a response from the Care Provider. The Council and the Trust both responded to the complaint and sent final responses in October 2023 and November 2023 respectively.
30. During the complaints process the Trust acknowledged a number of failings in actions. The Trust:

• acknowledged that, if one of its tissue viability nurses had attended Ms Y’s discharge meeting, it may have resulted in an earlier order of the most appropriate dressing for Ms Y;
• said it failed to properly explain to Ms Y’s family the set timescales for initial, post-discharge visits in the community;
• acknowledged that it failed to follow the discharge instructions for double-handed visits and did not put these in place until a week after Ms Y returned home;
• said it also failed to complete a manual handling risk assessment when it first assessed Ms Y, and staff made untested assumptions about the ability and willingness to help when its nurses attended to Ms Y. The Trust noted that these failings fed into the failure to initially arrange double-handed visits;
• said it should have given Ms X an option of a referral to another service for support when she called for assistance several days after Ms Y returned home;
• acknowledged it was unable to complete a continence assessment of Ms Y on its first attempt as the tape measure staff brought was inadequate;
• said its staff missed opportunities to look into and chase the delivery of necessary continence products for Ms Y. It said that if its staff had taken these opportunities the supplies may have reached Ms Y sooner and this may have helped to bridge the bridge the gap between the end of the hospital supplies and the start of the community supplies;
• acknowledged that its staff should have provided Ms Y with additional supplies of dressings while they waited for her prescription to be fulfilled;
• apologised if a member of staff’s communication came across as rude or berating during a call in the middle of the month;
• accepted that there should have been much better communication between its staff and the Care Provider in order to effectively coordinate Ms Y’s care. The Trust also acknowledged that its staff should have considered the need for a multi-disciplinary meeting to support better coordination of care; and,
• acknowledged that, as well as notifying Ms Y’s GP practice, its staff should have completed a comprehensive assessment of Ms Y when they noted worsening lymphoedema symptoms toward the end of June.

31. The Council also acknowledged some failings. The Council:

• acknowledged that the timings of the Care Provider visits meant that the recommendation not to have a gap of more than three hours between calls was not met;
• noted Ms X’s reports of several confrontations between care staff at Ms Y’s home. The Council noted one piece of corroborating evidence – a note by Ms Y’s allocated worker. The Council agreed that arguments in front of service users were unacceptable;
• upheld Ms X’s complaint about care staff failing to dispose of waste safely and hygienically; and,
• acknowledged that no one told Ms X of Ms Y’s social worker’s planned departure from the department.

Analysis

32. The Trust has already been acknowledged that Ms Y’s care in the community was not as well coordinated as it should have been, and that they were other failings. As such, there is no dispute that there was fault in this case.
33. The impact of these failings, and any wider, previously unacknowledged, failings would be very difficult to determine. An investigation may be able to find that Ms X and her family were caused avoidable time and trouble in having to chase up the delivery of supplies and buy products privately in the interim.
34. Ms X is clear in her view that failings by the Council, Care Provider and the Trust are part of a wider, direct, causal link to Ms Y’s avoidable death. However, from our independent perspective, there would be no reliable way of measuring or estimating what the impact of any particular delay or inadequate care visit was. We would need to take account of Ms Y’s underlying health conditions and the involvement of various health professionals throughout this period. Further, we could not ignore that, even with good care, people’s health can worsen and they can develop new conditions and infections. Overall, there would be too many unknowns and too many variables to be able to say, even on the balance of probabilities, that any fault by the Council and the Trust caused or contributed to Ms Y’s avoidable death. It is likely that the most an investigation would be able to say is that, because of the acknowledged failings in Ms Y’s care, Ms X has been left with some uncertainty about whether Ms Y’s health would have deteriorated at the end of June.
35. A finding of this sort would usually result in a recommendation for an apology, which both the Council and the Trust have already provided, and potentially a low financial payment. This would be in stark contrast to Ms X’s wish to receive the highest amount of financial remedy the Ombudsmen could offer.
36. Overall, given the gap between Ms X’s desired outcomes and the Ombudsman’s likely recommendations, I do not think there is a realistic prospect that an investigation of this complaint would produce an outcome that Mr X would consider satisfactory. For this reason, the Ombudsman should not investigate this complaint.

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Decision

37. I have closed this complaint because it is unlikely an investigation would be able to produce the outcome Ms X is seeking.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman