The Ombudsman's final decision:
Summary: We find the Trust (NLaG) delayed in processing a request for an incontinence assessment but we do not find evidence of injustice. The care home’s records show adequate continence care provision and we note the Trust’s general service improvement in shifting assessment services to its district nurses.
- Mrs Y complains about the actions of North Lincolnshire Council (responsible for the actions of the two care homes involved), North Lincolnshire CCG (responsible for the actions of Rotherham Doncaster and South Humber NHS Trust) and North Lincolnshire and Goole NHS Trust (responsible for the actions of Scunthorpe General Hospital) when caring for her father, Mr X, in the last few months of his life. Mrs Y says:
- Mr X was not seen often enough by dementia specialists;
- the first care home said it would refer Mr C for an incontinence assessment, but this did not take place. And also, that this care home delayed, in seeking medical help for Mr X, as his health worsened;
- Mr X failed to receive adequate care in hospital after being admitted from the first care home;
- Mr X was not discharged properly from the hospital to the second care home;
- the second care home did not care for Mr X properly hence his returning to hospital two days later where he remained until his death.
The Ombudsmen’s role and powers
- 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).
- 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.
- The Ombudsmen cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant responsible body has to make. Therefore, my investigation has focused on the way that the body made its decision. 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)
How I considered this complaint
- I have considered the complaint information provided by Mrs Y. I have made enquiries of the Council and Trusts and considered their responses. I shared my draft decision with all parties and noted any comments.
What I found
S117 free aftercare
- Section 117 of the Mental Health Act imposes a duty on both health and social services to provide free aftercare services to patients who have been detained under s3 of the Mental Health Act on discharge from hospital.
- In this complaint the Council and the CCG through Rotherham Doncaster and South Humber NHS Trust (RDaSH) worked in partnership to meet the s117 duty. The CCG discharged Mr X’s health needs to be met by RDaSH.
- It was the Council’s obligation to meet the social care part of Mr X’s aftercare needs. It did this by commissioning and funding the care home placements for Mr X.
Best interest decision making
- A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests.
- Section 4 of the Act provides a checklist of steps that decision makers must follow to determine what is in a person’s best interests. The decision maker also has to consider if there is a less restrictive choice available that can achieve the same outcome.
Joint consideration of complaints
- Under The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 (the ‘Complaints Regulations’) there is a duty to investigate complaints properly and in a way that will resolve them efficiently. There is also a duty to cooperate when a complaint is made to one organisation and contains material relevant to the other.
- The Complaints Regulations say that the organisations must “co-operate for the purpose of (a) coordinating the handling of the complaint; and (b) ensuring that the complainant receives a coordinated response to the complaint.” This involves a duty on each of them to agree who should take the lead in coordinating the handling of the complaint and communicating with the complainant. They must both provide each other with relevant information, if so, requested by the other, and must attend, or ensure they are represented at any meeting held about the complaint.
Discharge from Hospital
- 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. It contains ten key steps for staff to follow during discharge planning, including:
- start planning for discharge or transfer before or on admission;
- identify whether the patient has simple or complex discharge and transfer planning needs and involve the patient and carer in your decision;
- involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.
- The NHS Serious Incident framework requires staff to identify, investigate, with an onus on learning, to prevent likely serious incidents occurring again. The accompanying guidance suggests not all serious pressure ulcers, such as grade 3 and 4, automatically qualify as a serious incident as it would depend on the facts of the case. It says that while some organisations report all grade 3 and 4 ulcers as ‘Serious Incidents’ this is not always good practice.
- Local Authorities, through the Local Safeguarding Adult Board, are under a duty to investigate certain types of safeguarding incidents. If a serious incident occurs within healthcare, healthcare providers are required to notify the local authority.
- Pressure sores(also called ulcers) are caused by pressure on body parts affecting the blood supply to the skin. People with mobility difficulties and aged over 70 are more at risk. Under the European Pressure Ulcer Advisory Panel classification system pressure sores are graded in severity from 1 to 4. Grade 1 indicates the first signs of pressure damage; including redness, discolouration, swelling or heat but with intact skin. Grade 2 is usually an abrasion or blister and involves a partial thinning of the skin. Grade 3 involves full loss of skin thickness with damage to, or death of, the underlying tissue. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and involve the death of underlying tissue.
- From June 2016, after being diagnosed with Alzheimer’s, Mr X saw a specialist at a mental health unit every month for care and treatment.
- In November, Mr X was detained under the Mental Health Act. He was admitted to a mental health unit for assessment and respite care.
- In January 2017, a decision was made under the statutory ‘best interests’ decision-making process that Mr X should be discharged into a care home (the first care home) for long term care. Mrs Y raises several concerns about the care provided from the lack of input from the mental health unit and also any dementia/incontinence specialists.
- On a visit in May, Mr X’s wife (Mrs Z) said she found him ‘critically ill’. She called Mrs Y to the care home and Mrs Y described him as appearing ‘unconscious’. Due to the concerns raised, the care home called 999 and Mr X was admitted to hospital with pneumonia.
- In hospital, Mrs Y says Mr X was left without food and water for three days. She says the family were expected to sign a ‘Do No Resuscitate’ form without any prior discussion. She says staff failed to tell them that Mr X had been diagnosed with a chest infection and then later a urine infection. She reports the specialist ‘boxing gloves’ Mr X wore (to prevent him pulling out his nasogastric feeding tube) were dirty and smelt of urine.
- Towards the end of June Mr X was discharged from hospital to another care home (the second care home). Mrs X reports errors by the hospital on discharge including the family not being involved in the discharge planning. She also says the hospital sent Mr X sent to the second care home without the ‘thickener’ required for his drinks plus a medication error.
- While Mr X was at the second care home, Mrs Y says staff were unaware of Mr X’s special dietary needs and tried to feed him inappropriate food.
- Less than 48 hours after being discharged from hospital, Mr X was taken back to hospital in a ‘serious condition’. The paramedics who attended the care home raised a safeguarding alert to the Council. In hospital, Mr X was initially treated for dehydration. After four days the family were told he would receive ‘end of life’ care only. Mr X died on 2 July.
Rotherham Doncaster and South Humber NHS Foundation Trust’s complaint response
- RDaSH said Mr X’s mental health deteriorated quickly over a short period of time. It apologised for the post discharge visit not taking place within 7 days as it should have done. It said this was due to staff sickness and the case not being reallocated to anyone else.
- In terms of a medication review, it said one had taken place just before the discharge and Mr X was due to have this reviewed every three months. It noted Mr X was reviewed by a Community Nurse (who specialised in dementia) and accepts this occurred after a ‘significant’ delay. It established that the Community Nurse visited Mr X first in April and then in May. It found his medication was discussed with a psychiatrist but was not changed due to the risk of ‘agitation and distress’ to Mr X. After a second visit in late May, the Community Nurse wrote that the side effects of the medication were to be discussed with a psychiatrist. He also made a referral for physiotherapy due to Mr X’s falls and said he would return on 1 June.
- The Trust responded to Mrs Y on her specific query on the lack of an assessment on the risks of aspiration to Mr X. The Trust said it was for care home staff to raise this as a concern by making a referral to the Speech and Language service. It said Care Home staff had not raised any such concerns.
- As a complaint remedy, it said it would review the ‘capacity’ in the Care Home Liaison Team to reduce waiting times so no other family would experience such a delay. It said a complaint action plan would be produced to monitor this action. It apologised for any distress and anxiety caused and offered a meeting to discuss any outstanding concerns.
North Lincolnshire and Goole NHS Foundation Trust’s response
- NLaG responded by organising a meeting with Mrs Y, her mother, two members of its complaints team and Mr X’s social worker. Mrs Y and her mother raised their concerns in this meeting. The Trust’s complaints manager provided her response and conclusions verbally. The meeting was recorded and a CD of the recording was sent to Mrs Y.
- The Chief Executive of the Trust followed up the meeting by sending a summary letter listing the proposed remedies which, in summary, comprised of learning points for staff, future staff training and apologies. Specifically:
- the Trust would raise with the ward manager the lack of discussion with the family and the attitude of the ward staff;
- the Trust apologised for the way the ‘end of life’ conversation was raised with the family and said it was clearly inappropriate;
- the Ward Manager would discuss the case with the Ward staff;
- the Matron would be asked to carry out ‘spot checks’ on the ward;
- the Chief Nurse had been advised of staff attitudes with respect to end of life care;
- the member of staff responsible for liaison between Mental Health Services and the Trust had been advised of the lack of follow up after discharge;
- the Trust’s End of Life Strategy group would be advised of what happened in terms of the communication with the family to prepare for Mr X’s end of life;
- And, the Trust’s Dementia Clinical Nurse Specialist had been made aware of the complaint and it was hoped it would be used in future ‘lessons learnt’ dementia training.
North Lincolnshire Council’s response to our enquiries
- The Council says its records shows it worked closely with RDASH staff and Mrs Z up to the point of discharge from the RDASH’s mental health unit. It says it arranged for Mrs Z to visit the first care home before the decision was taken to place him there.
- The Council reports the first care home did monitor Mr X’s incontinence issues by keeping ‘bladder diaries’ between March and May. It says these record the required instances of incontinence, quantities of fluids drunk and the care provided.
- In relation to the alleged delay in seeking medical help, the Council says an emergency care practitioner was called in the morning but there was no call back until Mr X had been admitted to hospital. It also says, on the day the ambulance was called, a nurse monitored his temperature and paracetamol was provided.
- With respect to the medication error, the Council says this was the fault of the hospital and not the care home. It says the care home identified the error promptly and contacted the ward to raise this. And the care home had noted the hospital discharge letter did not record the need for drink thickeners. It highlights that the ward arranged for the drink thickener to be sent because the care home contacted it.
- The Council advises that, once the Ombudsmen first requested background information on this complaint, it arranged for its ‘Provider Development Team’ to visit this care home in March 2018. The Council says the team found evidence of the following records on Mr X’s file: daily recording sheets including diary sheets, discharge summary, mental health and behaviour plans, care plan and a feeding and swallowing plan. It reports that it also took action to ensure the complaints meeting findings were shared with the Provider Development Team in 2017. And this was considered in the annual ‘validation’ process planned for the care home in December 2017.
Response from the Provider of both care homes to our enquiries
- In summary, it says its records show it sought support and advice as needed from relevant professionals such as emergency care, GP and district nurses. It says all its records were updated as Mr X’s needs deteriorated.
- It advises it received no complaints from Mr X’s family about the care provided. On the contrary, it highlights that Mrs Z sent staff a ‘thank you’ card after Mr X died.
- Mrs Y has asked me to point out, for context, that the card was sent as a courtesy to the staff that ‘did care to a greater degree’ for Mr X and should not be used by the care home to ‘reflect’ the family’s experience to the Ombudsmen.
- In addition, the Provider says the Council’s safeguarding team took no further action after an initial check of Mr X’s records.
Response from NLaG to our enquiries
- The Trust accepted my comments on the faults in its complaints handling:
- that there is no evidence - contrary to regulation 13 of the complaint’s regulations - that the Trust discussed the ‘manner’ in which the complaint would be handled with the complainant.
- that the Trust’s complaints handling (meeting and summary letter) does not fully adhere to regulation 14 requiring the Trust to explain how the complaint has been considered and how it reached its conclusions.
- The Trust apologises for its faults. It says learning points from this complaint will be raised at a meeting of its complaints officers. It says it has made changes to the complaints process since this complaint was investigated in 2017. It also says it is ‘refreshing’ the complaints policy and is working with patients and staff to highlight areas for a training programme. It says there is more senior oversight with the Clinical Director now meeting with its complaints investigators before the final response is ‘signed off’.
- The Trust agrees to my initial recommendation of a remedy to acknowledge the distress caused to Mrs Y arising from the faults. And, her avoidable time and trouble taken in pursuing her complaint. It agreed to make a ‘token’ payment of £500. It also offered another meeting to Mrs Y to answer her continuing concerns and queries.
- During the investigation, the Ombudsmen uncovered a serious issue that had not been raised in the complaint to date. In the complaint recording, the complaint manager says Mr X had a grade 3 pressure ulcer when he came into hospital in May 2017. She suggests it had been acquired in the care home.
- We made further enquiries of both the Trust and the Council to try to establish if the pressure ulcer was ‘community’ acquired (in the care home) or the hospital.
- The Council responded to dispute that poor care in the care home may have caused the pressure ulcer. It says its daily care home records show no evidence of a pressure ulcer. It says that, on the contrary, Mr X was mobile, receiving regular personal care including barrier creams. It also says it was never officially informed of any pressure ulcer issues when Mr X was discharged in to the second care home nor as a safeguarding incident.
- The Trust confirms its records show a pressure ulcer and says it was identified as a grade 2 (as opposed to a grade 3).
- The Trust says the ulcer was noticed on admission to a ward six hours after the initial A&E admission. It admits there is no record of Mr X’s ‘skin integrity’ when he came into A&E and finds the standard of records in A&E did not meet the usual requirements. It considers that, on the balance of probabilities, ‘the damage was done’ in the 24 hours leading to the A&E admission. It accepts that, while it is ‘possible’ that Mr X acquired the pressure ulcer in hospital, at the time it was recorded as acquired in the care home. It confirms the ulcer was treated during the hospital stay and did not deteriorate any further. It accepts the care home should have been notified on the discharge summary.
a) Mr X was not seen often enough by dementia specialists:
- RDASH has accepted that this did not happen until April despite his discharge in January. This is fault, although, when the Community Nurse did visit, he did not find anything requiring urgent action. His notes show he spoke with the care home manager who had no concerns and Mrs Z was noted as satisfied with the care provided. So, while there was fault by RDASH in not reviewing Mr X between January and March, I do not see evidence of injustice.
b) The first care home said it would refer Mr X to the incontinence service, but this did not take place. Also, this care home delayed in seeking medical help for Mr X as his health worsened:
- The aim of continence services is to improve symptoms of bladder and bowel problems giving sufferers back control and reducing the impact on their quality of life.
- The care home says it carried out its own continence assessments in March and May 2017 and monitored Mr X’s fluid intake and incontinence incidents. It addressed the instances of incontinence by changing Mr X’s clothes when needed. It also says it made a referral to the Trust’s continence service. Unfortunately, the continence service did not respond to the home until October 2017 and said this was due to the lack of administrative support at the service. The Trust (NLAG) has admitted to me there were delays at the time due to a lack of ‘capacity’ and ‘overdemand’. It reports it has taken action to reduce the delays by allocating patients in care/nursing homes to the community nursing teams. Overall, I do not see evidence of fault in the way the care home dealt with Mr X’s incontinence.
- With respect to the alleged delay in seeking medical help on 29 May 2017, the care home notes show a nurse was monitoring Mr X in the morning for being ‘chesty’. The notes also show she administered paracetamol and an emergency care practitioner had been called. The records show that, as Mr X’s oxygen levels dropped, at 13.15 an ambulance was called. I know Mrs X says the family insisted on an ambulance being called - and this may well have been the case - but I do not see evidence of the care home delaying in seeking medical help for Mr X.
c) Mr X failed to receive adequate care in hospital:
- It is evident, as the Trust has already admitted, that ward staff failed to communicate properly with the family until the dementia specialist nurse attended. The complaints manager was clear in the complaint meeting recording that staff failed to address the ‘end of life’ issues with the family properly and failed to note they held full legal authority allowing Mr X’s personal information to be disclosed to them. The complaint manager said this would be addressed via dementia training and the other service improvements proposed in paragraph 30. She also provided an apology for the poor standard of the ‘boxing gloves’ on the ward and failure to inform the family about the insertion of feeding tube and catheterisation.
- However, the complaints manager was clear the care on the ward was subject to clinical decision making by ward staff and this is a separate issue to the communication faults identified. The discharge summary recorded Mr X as having been assessed by medical staff as ready for discharge. So, while I understand Mrs X’s distress arising from the failures of communication by ward staff, it is unlikely I could add anything further to the Trust’s investigation here.
d) Mr X was not discharged properly from the hospital to the second care home.
- The Trust accepts the errors during discharge in terms of the medication error and failure to provide a ‘thickener’ for drinks and apologises. Luckily the second care home picked up these errors.
- A significant related fault is the Trust’s failure to include and seek Mrs Y’s agreement in the discharge process. This is a direct contravention of the guidance issued by the Department of Health (paragraph 13). It is clear Mrs X lost an opportunity to have her questions answered, her views considered and any alternative options considered while advocating for her father who was no longer able to provide informed consent. Mrs Y says if her father had been discharged into a hospice this might have avoided the upheaval of the care home placement failing within 48 hours and her father being returned to hospital. She says the discharge decision came as a surprise to them and her father was moved to the home late at night.
- I consider the Trust’s failure to include Mrs Y in the discharge decision represents fault causing a significant injustice warranting a remedy. I recommend a symbolic payment of £500 to remedy this injustice together with a review by the Trust of carer/family involvement in its discharge planning. The Trust has accepted my recommendations.
e) The second care home did not care for Mr X properly hence his returning to hospital two days later where he remained until he died
- Mrs Y says the home attempted to feed Mr X corned beef hash in contravention of his diet plan. She reports he did not eat it. The second care home denies that Mr X was provided with an inappropriate diet. It says the discharge documents showed that Mr X was to be provided with a texture C diet and ‘custard’ consistency fluids to be taken. I will not investigate as further investigation is unlikely to reconcile these differing accounts.
- With respect to the admission back to hospital, there is no evidence the admission to hospital was a direct consequence of fault by the second care home. The paramedics raised a safeguarding concern and the Council decided not to progress it after reviewing the information provided, including after speaking with Mrs Z. I appreciate Mrs Y strongly disagrees with the Council’s decision not to progress the safeguarding alert, but this was a decision it was entitled to take.
f) Pressure Ulcer
- I cannot reach any finding, on the probable cause for Mr X being admitted to a hospital ward with a stage 2 pressure ulcer, six hours after being admitted to A&E. This is mostly due to the lack of records in A&E. There is no indication of a pressure ulcer while Mr X was in the care home, according to the records I have seen. I note the Council’s subsequent actions, after the complaint meeting, to inspect the care home records of Mr X’s care and its practices in relation to skin integrity.
- I also note the Trust’s regret at the lack of record keeping at A&E and assurance that practices have been overhauled since Mr X’s admission. I should add that given the Trust’s records show the ulcer was grade 2, and not the more serious grade 3 as originally reported, together with its steps taken to review practice, it is not proportionate to continue to investigate this part of the complaint on its own.
Agreed recommendations and Final decision
- While Mr X suffered a three-month delay in seeing a dementia specialist in the care home there is no evidence of a significant injustice.
- The care home did refer Mr X for a continence assessment, and the Trust (NLaG) failed to respond promptly. This is fault. However, there is no evidence of a significant injustice as records show the care home dealt with Mr X’s incontinence satisfactorily.
- There is evidence of fault by the Trust (NLaG) in its communications with the family and in its complaints handling. The Trust reports that is has overhauled it complaints service which now includes oversight from senior officers and staff training. This service improvement together with its agreement to my recommendation to pay Mrs Y £500 within one month of the date of this decision satisfactorily acknowledges the distress caused and her time and trouble taken to complain.
- There was fault by the Trust (NLaG) when it failed to involve Mr X’s family in the hospital discharge process. This represents a significant injustice as Mrs Y lost an opportunity to raise her concerns/queries and have her views considered. I recommended the Trust make a ‘symbolic’ payment of Mrs Y £500 to remedy this lost opportunity within one month of the date of this decision which it has agreed to do. It has also apologised for this fault.
- There is no evidence to suggest the second care home did not care properly for Mr X.
- The Trust (NLaG) has agreed to the Ombudsmen’s recommendations. This remedies the injustice arising from the faults. I have completed the investigation.
Investigator's decision on behalf of the Ombudsman