Summary: We found fault by Broadoak Manor Care Home (acting on behalf of St Helen’s Metropolitan Borough Council) in the care it provided to Mrs X. This caused her husband, Mr X, distress and uncertainty. The Council will apologise and take action to prevent similar problems occurring in future.

The complaint

1. Mr X is complaining about the care and treatment provided to his wife, Mrs X, by Broadoak Manor Care Home (the Care Home - acting on behalf of St Helens Metropolitan Borough Council) and Marshalls Cross Medical Centre (the Practice - part of Mersey and West Lancashire Teaching Hospitals NHS Trust) in September and October 2023.
2. Mr X complains that the Care Home failed to act with appropriate urgency when his daughter reported Mrs X had lost sight in her right eye. Mr X says it took several days for his wife to been by a clinician, at which point she was admitted to hospital. In addition, Mr X says he has been given contradictory and untrue responses to his complaint.
3. Mr X says that, by the time Mrs X was admitted to hospital, she had lost her sight completely. Mr X says the family will now never know whether Mrs X’s sight could have been saved with prompt treatment.

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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 investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we 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).
6. 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.
7. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)
8. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the relevant available evidence and decide what was more likely to have happened.

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How I considered this complaint

9. I considered evidence provided by Mr X, the Council and the Trust, as well as relevant law, policy and guidance.
10. All parties had an opportunity to comment on my draft decision. I considered all comments before making a final decision.
11. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Relevant law and guidance

12. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Regulations) set out expectations for care providers across a number of care and administrative domains.
13. Regulation 17 relates to good governance. The Care Quality Commission’s guidance for care providers on how to comply with the Regulations requires them to “securely maintain accurate, complete and detailed records in respect of each person using the service”.

Background

14. In 2023, Mrs X was resident in the Care Home. She had an eye condition for which she took eye drops regularly.
15. On 29 September, Mrs X’s daughter reported to Care Home staff that Mrs X had lost vision in her right eye. There is no record of this conversation in the Care Home’s notes.
16. The Care Home says its clinical lead (a registered nurse) reviewed Mrs X and recommended referring her to an optician. Neither the review nor the recommendations were recorded.
17. Mr X says the family enquired on 30 September and 1 October whether the Care Home had sought clinical input. Again, these contacts were not recorded.
18. On 2 October, the Care Home says a member of staff called the Practice. It says the member of staff was advised the case was non-urgent and that the Care Home should send an email requesting a consultation. There is no record of this call in notes of the Care Home or the Practice.
19. The Care Home sent an email at 7.12pm that day. This detailed that Mrs X was experiencing vision problems that had started on 29 September.
20. The Care Home says a member of staff followed up the email with a call at 9.15am the following day. I could not find a note of that call in the records of either the Care Home or the Practice.
21. At 9,41am a Practice nurse contacted the Care Home to complete a triage. The nurse noted that Care Home staff were “very concerned” and “feel she needs a visit today.” The nurse arranged for a visit from the local Acute Visiting Scheme (AVS).
22. An AVS GP visited Mrs X at 11.00am. The GP noted “sudden loss of vision” and recommended the Care Home call 999. Care Home staff were advised by the ambulance service that there may be an eight-hour wait. As a result, Mrs X’s daughter transported her to hospital.
23. The clinical notes for that attendance record a suspected diagnosis of “macular degeneration” (a group of age-related eye conditions that can cause vision problems).
24. Mrs X was discharged later that day. She had a follow-up appointment booked with the ophthalmology department on 4 October.
25. Mrs X attended the appointment as planned. The reviewing ophthalmologist admitted for further urgent investigation for Papilloedema (swelling of the optic nerve). However, by this point Mrs X had lost her sight completely.

My findings and analysis

26. In the interests of brevity, I will not detail the complaint responses here. Nevertheless, there were certainly points of contradiction in the complaint responses Mr X received from the Care Home and Practice.
27. This situation was exacerbated by the poor standard of the records maintained by the Care Home. These were not in keeping with the Regulations. This is fault.
28. This meant some of the actions or events referred to in the Care Home’s response are not supported by the available documentation. As a result, there are points on which I cannot be certain. However, I have made balance of probabilities decisions where possible below.
29. As I have explained above, there is no record of the conversation in which Mrs X’s daughter raised her concerns about Mrs X’s eyesight. However, I consider it likely, on balance of probabilities, that this conversation happened as Mr X described. This is because the Care Home’s email to the Practice of 2 October detailed that symptoms had started on that date. I also note the Care Home appears to have accepted this.
30. The next point of contention relates to the review of 29 September. The Care Home says this was completed by its clinical lead and recommended referral to an optician. However, there was no record of this review. Nor did the Care Home’s first response refer to it.
31. Having looked at the evidence, I consider it likely, on balance of probabilities, that some form of review took place. That being so, it is unclear why the Care Home did not make a referral to an optician (or optometrist) at this stage as recommended.
32. Mr X said he and his daughter asked for updates on both 30 September and 1 October. These interactions were similarly unrecorded. Nevertheless, I have no reason to doubt they occurred as described, given Mrs X’s family was obviously concerned. These contacts should have served as further prompts to staff. However, the evidence shows the Care Home took no further action during this period.
33. The Care Home said a member of staff called the Practice on 2 October and was advised the case was “non-urgent”. No record of such a call is held in the records of either organisation. There is evidence to show Care Home staff were aware by 2 October of the seriousness of her symptoms. This is shown in the email sent by the Care Home later that day. This recorded that Mrs X had “lost a lot of her vision, completely from her right eye and blurred left eye”. In my view, it is unlikely the Practice would have advised the Care Home the case was non-urgent if it had been advised of these symptoms. For this reason, I consider it likely, on balance of probabilities, that this call did not take place.
34. There is evidence to show the Care Home sent an email to the Practice on 2 October. However, this was not sent until 7.12pm. This meant the Practice did not process it until the following day. It is unclear why the Care Home did not send the email earlier, given the seriousness of Mrs X’s symptoms.
35. The final point of contention was the call the Care Home said staff made to the Practice at 9.15am on 3 October. Despite this precise information, I could not find evidence of the call in either organisation’s records. In the subsequent Practice triage call at 9.41am, the member of Care Home staff referred to the email, but not to an earlier call.
36. Based on the evidence, I consider it likely on balance of probabilities this call did not take place.
37. There could be various explanations for the inconsistencies in the Care Home’s complaint responses. This could include staff misremembering details, or misunderstanding entries in the records. In any case, these are problems that would have been avoided with an appropriate standard of record keeping.
38. On the morning of 3 October, the Practice promptly arranged a visit from an AVS clinician. This led to Mrs X’s swift admission to hospital. I find no fault by the Practice in terms of the care it provided to Mrs X.
39. The evidence I have seen shows the Care Home was made aware of Mrs X’s symptoms on 29 September. Despite this, it did not seek clinical input until, effectively, 3 October. This was a delay of four days. I can find no proper explanation for this delay. This was fault.
40. I cannot now say whether earlier clinical input would have affected the outcome of Mrs X’s care. As a result, Mr X has been left with distress and uncertainty about what might have happened.

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Action

41. I found fault by the Care Home as explained above. However, I have directed my recommendations to the Council as the Care Home was acting on its behalf.
42. Within one month of my final decision, the Council will apologise to Mr X for the distress and uncertainty caused to him by the Care Home’s:

• failure to maintain accurate, complete and detailed records in keeping with the requirements of the Regulations; and
• failure to seek timely clinical input for Mrs X when she developed acute vision problems.

43. Within three months of my final decision statement, the Council will explain what action it will take to ensure the Care Home:

• has a clear records management policy in place to ensure the maintenance of accurate, complete and detailed records, as well as a robust programme of audit; and
• has clear protocols setting out the action staff should take if a resident becomes acutely unwell. This should include guidance on the importance of recognising sudden changes in a resident’s presentation, as well as the importance of seeking clinical input where appropriate.

44. The Council will provide us with evidence it has complied with the above actions.

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Decision

45. I found fault causing injustice. The Council will complete the agreed actions to remedy this injustice.
46. 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