Summary: Mrs D complains about the care of her late mother-in-law by a care home and Trust. The Ombudsmen have found fault causing injustice. The Trust and Council have agreed to apologise and make payments to Mrs D.

The complaint

1. Mrs D complains about the quality of care her late mother-in-law, Mrs J, received in Alton House Care Home (funded by the Council) and Portsmouth Hospitals NHS Trust before she passed away in December 2017. In particular, she complains:
1. Mrs J developed a grade 3 pressure ulcer following admission to the Trust on 17 December 2017.
2. The Trust did not provide adequate pressure ulcer care.
3. The transport back to the Home was delayed.
4. The Trust discharged Mrs J when the Home was not ready to receive her, because there was no appropriate pressure relieving mattress in place.
5. The Trust discharged Mrs J without adequate pain relief.
6. The Home manager switched off Mrs J's oxygen, removed her pillows, failed to tell the district nurse about the pressure sore, and did not deal appropriately with Mrs J's end of life care, causing it to be undignified and hectic.
7. The Home did not properly check Mrs J and changed her only once during the night.
8. The Home did not refund £195 to the family, despite there being no contract between the family and the Home.
9. The Council did not properly investigate her complaint and did not take into account evidence from the Trust's investigation.
2. Mrs D says her mother-in-law was caused unnecessary severe pain and distress, resulting in significant distress to the family.

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The Ombudsmen’s role and powers

3. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
4. 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).
5. 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.
6. We have powers to investigate adult social care complaints in both Part 3 and Part 3A of the Local Government Act 1974. Part 3 covers complaints where local councils provide services themselves, or arrange or commission care services from social care providers, even if the council charges the person receiving care for the services. We can by law treat the actions of the care provider as if they were the actions of the council in those cases. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
7. We normally name care homes in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home. (Local Government Act 1974, section 34H(8), as amended)
8. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
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)
10. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Care Quality Commission (CQC), we will share this decision with CQC.

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How I considered this complaint

11. I spoke to Mrs D about her complaint and considered the information she sent, the Council’s and Trust’s responses to my enquiries, and:
• The Care Act 2014
• The Care and Support Guidance
• The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 ("the Regulations")
• Hampshire Safeguarding Adults Board Policy, Guidance and Toolkit
• The Trust's Discharge Planning Policy
• The Nursing and Midwifery Council's code: Professional standards of practice and behaviour for nurses and midwives (“the Code”)
• National Pressure Ulcer Advisory Panel, European Pressure Advisory Panel, Pan-Pacific Pressure Injury Alliance: Prevention and treatment of pressure ulcers 2014
• NHS Improvement: Pressure ulcers revised definitions and measurement 2018
• The National Institute for Health and Care Excellence clinical guidelines: Pressure Ulcers: prevention and management ("the NICE guidelines")
12. I considered clinical advice from a senior nurse with expertise in the care of older people.
13. I sent Mrs D, the Council and the Trust my draft decision and considered the comments I received.

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What I found

Relevant law and guidance

Fundamental Standards of Care

14. The Regulations set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall. The standards include:
• Dignity and respect (Regulation 10): Service users must be treated with dignity and respect and in a caring and compassionate way.
• Safe care and treatment (Regulation 12): Providers must do all that is reasonably practicable to mitigate risks to the service user’s health and safety.
• Safeguarding from abuse (Regulation 13): Service users must be protected from abuse and improper treatment, this includes neglect.
• Premises and equipment (Regulation 15): Providers must make sure that the premises where care and treatment are delivered are clean, suitable for the intended purpose, maintained and where required, appropriately located.
• Good governance (Regulation 17): Providers must maintain securely an accurate, complete and contemporaneous record in respect of each service user.

Safeguarding adults

15. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)
16. The Council’s safeguarding procedures say it should determine whether or not there is a statutory duty to carry out a safeguarding enquiry within 24 hours of a safeguarding referral. If there is, a safeguarding planning meeting should be held within seven days to plan the safeguarding enquiry. Following the enquiry, a report will be written and the Council will decide whether there continues to be risks to the adult or whether the actions taken have resolved the matter.

Discharge from hospital

17. The Trust’s Discharge Planning Policy says when patients are transferred to a care home, the nurse in charge of transfer should complete and send a nursing transfer letter and the care home should be contacted and given a full handover prior to discharge. The Code states that nurses must keep colleagues informed when they are sharing the care of a patient.

Pressure sores

18. Pressure injuries (also called pressure ulcers or sores) are wounds caused by pressure on part of the body interrupting the blood supply to the skin. People with mobility difficulties and who are over 70 are more at risk.
19. 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. Subcutaneous fat may be visible but bone, tendon and muscle are not. Grade 4 indicates severe pressure damage, usually a deep wound that may go down to the bone and involve the death of underlying tissue.
20. A Kennedy Ulcer is a dark sore that rapidly develops during the final stages of a person’s life. These ulcers are unavoidable.
21. A deep tissue injury (DTI) is a pressure related injury to subcutaneous tissue under intact skin. The damage starts on the inside and gradually works its way to the surface of the skin. A DTI may therefore not become apparent for 24-72 hours because in the early stages there is no evidence of any damage to the skin. Initially, these lesions have the appearance of a deep bruise which then evolves into a purple blister, open wound or black necrosis.
22. The NICE guidelines say that adults who are at high risk of developing a pressure sore should be repositioned at least every four hours.

Charging for residential care

23. Where a council arranges care and support to meet a person's needs, it may charge the adult for the cost of the care.
24. The “Care and Support (Charging and Assessment of Resources) Regulations 2014” state that people who have over the upper capital limit are expected to pay for the full cost of their residential care home fees. However, once their capital has reduced to less than the upper capital limit, they only have to pay an assessed contribution towards their fees. The council must assess the means of people who have less than the upper capital limit, to decide how much they can contribute towards the cost of the care home fees.

What happened

25. Mrs D’s mother-in-law, Mrs J, was elderly, had vascular dementia, incontinence, problems with communication and poor mobility. She had been living in Alton House Care Home, funded by the Council. She made a contribution to the cost of her care of £134.47 per week. Mrs J’s end of life care plan was to be at the Home if possible, with her family present.
26. In December 2017, Mrs J was poorly. Mrs D says the Home did not keep in touch with the family about her condition. Mrs J was seen by a GP on 13 December 2017 who prescribed antibiotics for a chest infection and spoke to Mrs D and her husband on the phone. Mrs J’s condition deteriorated, and she was supported in a half-seated position to help her breathing. The Home’s daily care logs say that, on the morning of 17 December 2017, Mrs J was very sleepy and struggling with her breathing. There is no reference in the logs to Mrs J having any pressure sores.
27. The carers called 111 and paramedics attended. They considered Mrs J needed treatment for sepsis. Following discussion with the family, it was agreed Mrs J should be taken to hospital. Mrs D says she felt pressured into this decision as Mrs J had not wanted to go into hospital.
28. Mrs J went to the Trust’s Emergency Department, arriving at 11.45 on 17 December 2017. She was admitted and diagnosed with sepsis due to a chest infection. The family was advised Mrs J was at the end of her life. They asked if she could go back to the Home but were told she was too frail to be moved.
29. At 15.33 a nursing review found a “large red patch 5cm x 5cm of non-blanching red/purple area to buttocks. No open areas. Very fragile skin.” The review noted Mrs J had been regularly repositioned since her arrival to help her breathing, “so [the red area was] potentially already existing from community.” At 18.47 a grade 1 pressure sore on Mrs J’s sacrum was also seen and Mrs J was identified as being at very high risk of pressure ulcer development.
30. The next morning Mrs J was moved to the medical assessment unit. She was deemed fit to travel home via ambulance with oxygen. Transport was booked and arrived six hours later, but the crew was unable to transport Mrs J as they could not carry oxygen. Further transport was arranged for the morning of 19 December 2017.
31. A tissue viability review at 16.34 on 18 December 2017 diagnosed a grade 3 pressure sore, which was suspected to be a DTI. The note says Mrs J was on a softform mattress and advised she be repositioned every two hours. The nurses contacted the Home. The records say “Home not aware of pressure damage, so I have updated”. It is unclear if a pressure relieving mattress was requested. The nurse discussed the matter with Mr D, but he was unsure if Mrs J had a pressure relieving mattress in place at the Home. I have seen no evidence the Trust contacted the district nurses.
32. Mrs J was given pain relief at 09.00 on 19 December 2017. Following a delay with transport Mrs J was collected at 14.05 and returned to the Home. The Trust’s discharge summary form makes no reference to Mrs J’s pressure injuries.
33. The Home’s daily logs say when Mrs J arrived she was screaming in pain. Mrs D says Mrs J had pressure sores and her bowels were completely impacted. Mrs J was supported by pillows and had oxygen via a nasal cannula, which she found uncomfortable. Mrs D says the Home manager removed the pillows and turned the oxygen off "to see what would happen"; an alarm went off, so she had to turn it back on.
34. The district nurses were contacted. When they arrived they removed the oxygen as it was not benefitting Mrs J and put in place a syringe driver for pain relief. The district nurses’ notes say “Carers said there was a 8cm x 8cm grade 3 to bottom. Felt inappropriate to move her to check when settled. Discussed Kennedy ulcers, but can’t tell without checking. Family v upset about hospital care. Patients skin was intact before admission.” The nurses asked the carers to keep Mrs J comfortable and said they would return the next day to document and record the sores.
35. The log for that night say Mrs J was checked regularly, was comfortable and “all visible skin areas [were] intact”. There is no evidence she was repositioned.
36. The district nurse arrived on the morning of 20 December 2017 to give morphine. She found Mrs J was still on a hospital sheet and in a hospital gown. The Home manager said Mrs J had not been changed to prevent discomfort. The nurse said Mrs J needed to be repositioned every three or four hours. The evidence shows Mrs J had been on a softform mattress, but the nurse ordered an alternating airflow mattress that day. She photographed Mrs J’s pressure injuries.
37. That night Mrs J was repositioned every four hours. Mr D stayed with Mrs J all night and went home in the morning when Mrs D arrived.
38. Mrs J deteriorated further on the morning of 21 December 2017. Mrs D says the Home manager “was rushing around shaking Mrs J’s shoulders telling her to hang in there” as Mr D was on his way to the Home. Mrs J sadly passed away at 08.55.
39. A safeguarding report was made to the Trust due to concerns about poor discharge causing unnecessary pain and Mrs J’s skin integrity.

Mrs D’s complaints

40. The Council says it did not receive a formal complaint from Mrs D. Its social care records show that, in January 2018, Mrs D spoke to the Council about her concerns about the quality of care provided by the Home. On 26 January 2018 the social worker advised Mrs D to report her concerns to the CQC and sent her a copy of the Council’s complaints form.
41. Mrs D spoke to the Council about her concerns again on 5 February 2018. This was dealt with as a safeguarding referral and the Council made initial enquiries of the Home and Trust. The social care records say that other reports of poor care at the Home had been made to the CQC in autumn 2017.
42. Mrs D reported her concerns about the Home to the CQC. In June 2018, the CQC wrote to Mrs D in relation to the Home manager switching off Mrs J’s oxygen. It had found conflicting accounts of what happened before the arrival of the district nurses and no independent evidence to confirm which account was accurate. It found there was no evidence of a breach of the Regulations.
43. In March 2018, Mrs D complained to the Trust about the way Mrs J had been treated. She said she had been transferred to five different wards, had not been repositioned, was not given pain relief before she was discharged, and transport back to the Home had been delayed by 28 hours. Mrs D said Mrs J was not treated with dignity.
44. The Trust responded to Mrs D’s complaint in July 2018. It said that Mrs J’s pressure injury was likely to have been a DTI that started in the community. Mrs J should have used a pressure redistribution mattress, her skin should have been kept clean and dry and protected with barrier products, and she should have been repositioned every two hours. The Trust accepted there was no written evidence Mrs J was repositioned this frequently and apologised. It had since introduced a ‘safety checklist’ to the Emergency Department, which included turning of patients.
45. The Trust accepted that Mrs J was discharged without having had adequate morphine, due to the delay in providing transport, and apologised for this.

Care home charges

46. Mrs D emailed the Council in January 2018 about the Home’s refusal to return an overpayment of Mrs J’s contribution. The Home had emailed Mrs D on 16 January 2018 to say they were sending her a cheque for £172.89 to refund nine days of Mrs J’s care after she had passed away. Mrs D says she did not receive this cheque and eleven days contribution should have been refunded.
47. The Home had said the contract allowed it to keep two days of contributions after Mrs J’s death, to pay for redecoration of the room. Mrs D says the family had no contract with the Home. The Council’s finance team advised it was a matter for the Home. In response to my enquiries, the Council said the Home had refunded £38.42 in June 2018 “as a gesture of goodwill”. This equated to two days of Mrs J’s contribution.

Safeguarding investigation

48. In response to my enquiries the Council said it had decided there was no statutory duty to carry out a full safeguarding enquiry. However, the Council also said there had been a thorough investigation in February/March 2018. The Council had visited the Home, examined case records, interviewed staff, and inspected Mrs J’s room. The investigation had found:
• The Home left Mrs D to sit in a chair, rather than go to bed, as she “did not enjoy being lied flat" and would decline to go to bed unless particularly unwell or tired.
• The manager had said she had not attempted to adjust Mrs J’s oxygen.
• Mrs J had not been repositioned on the night of 19 December.
• There was good verbal communication with district nurses, but they did not always provide a written record of their interventions.
• The Home manager denied being “overly animated” on 21 December 2017. The staff denied the manager had “left the room in an angry state”.
• The room Mrs J used from 19 December 2017 had not been deep cleaned or decorated.
49. The Council’s social care records show that on 29 March 2018 it decided the “safeguarding [was] not substantiated”.
50. The Council wrote to Mrs D in July 2018. It said there was no conclusive evidence to prove or disprove the concerns she had raised about the Home. However, the Home now asked district nurses to provide written instructions and would complete body maps when a resident went to hospital. The Home was also more aware of the time taken for a pressure injury to become apparent and would advise hospital staff if a resident had not been mobile.

Mrs D’s complaint to the Ombudsmen

51. Mrs D remained dissatisfied and in December 2018 she complained to the Local Government and Social Care Ombudsman. She repeated her concerns about the quality of care at the Home and said Mrs J had not been allowed to die in dignity and peace. She said:
• The Council’s investigation had not been impartial.
• Concerns had been raised about the Home by other families.
• She was now aware that Mrs J had had pressure sores before she went to hospital.
• The owner of the Home had threatened court action against her if she took the complaint further.
52. We asked the Council to deal with Mrs D’s complaint. It wrote to her on 28 January 2019. The Council said:
• Although the social worker knew the Home manager in a professional capacity, it had no reason to believe the investigation had been biased.
• Concerns about the Home raised by others did not call into question any of the findings of the safeguarding investigation.
• The issue abut Mrs J’s pressure sores had already been investigated under safeguarding and the Council would not re-investigate.
• The Home had contacted the family on 14 and 16 December 2017 about Mrs J’s health.
• Mrs D would need to contact the CQC if she had queries about its findings on the oxygen incident.
• As the Home had threatened legal action against Mrs D, the Council considered it would be reluctant to apologise and the Council had no powers to instruct it to do so.
• It had no information about how the Home had cared for Mrs J prior to her hospital admission. It would request this information if Mrs D wished.
53. Mrs D complained to the Ombudsmen.

My findings

54. I have considered each part of Mrs D’s complaint separately below.

Mrs J developed a grade 3 pressure ulcer following admission to the Trust on 17 December 2017 and the Trust did not provide adequate pressure ulcer care.

55. A grade 3 pressure injury, which was suspected to be a DTI, was diagnosed on 20 December 2017 when Mrs J was in hospital. I have considered whether the pressure injury was caused by poor care in the Home or the Trust and whether it could have been prevented.
56. I have seen no records from the Home indicating whether or not Mrs J had a pressure injury before she left for hospital on 17 December 2017. However, there is no record of a pressure injury on her admission to the Trust’s Emergency Department and the district nurses note of 20 December 2017 says Mrs J’s skin was intact before admission.
57. The nursing review in the afternoon of 17 December 2017 identified a reddened area and a grade 1 injury was noted a few hours later. The Ombudsmen’s nursing adviser’s view is that, based on Mrs J’s overall condition and the fact that she was at the end of her life, it was most likely it was an unavoidable Kennedy ulcer.
58. The nursing adviser has said that, given Mrs J's overall frail condition and her need to be nursed in a half seated position in the Home because of breathing difficulties, the lesion on her buttock/sacrum was likely to have started developing in the Home, but it may not have been visible. It may then have deteriorated on the journey to hospital and in the Emergency Department. The pressure injury could have worsened if Mrs J had not received care in line with the NICE guidelines.
59. Whilst there is evidence that Mrs J’s pressure areas were treated and that she was repositioned in hospital, the Trust has accepted it cannot evidence that Mrs J was repositioned every two hours. As Mrs J’s pressure injury deteriorated, I find there was fault by the Trust in not providing adequate pressure injury care.

The transport back to the Home was delayed.

60. The Trust has accepted Mrs J’s transport was delayed and has already apologised for this.

The Trust discharged Mrs J when the Home was not ready to receive her, because there was no appropriate pressure relieving mattress in place.

61. Whilst a pressure relieving mattress by itself would not prevent development or deterioration in a pressure ulcer, given Mrs J’s high risk of pressure ulcer development the Home should have had a pressure relieving mattress in place. The Trust should have ascertained if this was the case and it is unclear if this was done.
62. If a mattress was not in place the Home should have contacted district nurses to arrange a delivery on 18 December 2017 after the discussion with the Trust. There is no evidence this happened, although there is evidence Mrs J was on a softform mattress at the Home and the district nurses ordered an airflow mattress on 20 December 2017.
63. Given that Mrs J was at the end of her life and the family were keen for her to return home, she should not have needed to remain in hospital whilst the mattress was being obtained. This should however have been discussed with her family. I therefore find there was no fault by the Trust in discharging Mrs J when an airflow mattress was not in place.
64. The Trust should have informed the district nurses of the pressure injury prior to discharge or in a nursing transfer letter. This does not appear to have happened, which is fault. However, district nurses visited Mrs J in the Home on the day of discharge and were therefore able to view the sore.

The Trust discharged Mrs J without adequate pain relief.

65. The Trust has accepted Mrs J did not have adequate pain relief before she was discharged, due to the delay in transport. It has apologised for this.

The Home manager switched off Mrs J’s oxygen, removed her pillows, failed to tell the district nurse about the pressure sore and did not deal appropriately with Mrs J's end of life care, causing it to be undignified and hectic.

66. The safeguarding investigation found the Home denied Mrs D's allegations, and the Home’s daily logs do not describe what happened in detail. This means, whilst I have no reason to question Mrs D’s account of what happened and accept she was distressed by the Home manager’s actions, I cannot say I have evidence of fault. Removing pillows and acting in an “overly animated” way would not be a breach of Regulations and the CQC found no evidence of a breach of the Regulations in relation to switching off the oxygen. I therefore do not find fault by the Council on this part.
67. The evidence is unclear whether the Home staff told the district nurses about Mrs J’s pressure injuries. However, even if there was fault here, the impact was mitigated as the evidence shows the district nurses were aware of the injuries on 19 December 2017.

The Home did not properly check Mrs J and changed her only once during the night.

68. The Home’s records show Mrs J was checked on the night of 19 December 2017, but she was not repositioned or changed. The district nurse found Mrs J to still be in her hospital gown and on the hospital sheet the next morning.
69. The Home says this was because the district nurses did not leave a written instruction to reposition Mrs J. In my view this should not have been necessary. The Home was aware Mrs J had pressure injuries and should have care plans in place to reposition residents with pressure injuries. As Mrs J had a pressure injury and should have been repositioned every 2 or 4 hours, it was fault for the Home not to turn Mrs J.

The Home did not refund £195 to the family, despite there being no contract between the family and the Home.

70. Mrs J’s care at the Home was funded by the Council but she contributed to the cost. The Council says it does not charge a client contribution after someone has passed away, but the Home’s charges are a "local matter for the home". The Home says its contract allows it to retain two days of contribution for the cost of redecorating the room.
71. Mrs J’s financial contribution was to the Council, not the Home. As the Council’s policy is not to charge a contribution after someone has passed away, it was fault by the Council not to refund eleven days of Mrs J’s contribution. This was £19.20 per day (£211.20).

The Council did not properly investigate her complaint and did not take into account evidence from the Trust's investigation.

72. Mrs D did not make a formal complaint to the Council. It says it investigated her concerns under safeguarding.
73. There is evidence a safeguarding enquiry was carried out in February/March 2018. When the social care case was closed in August 2018, the case summary says the family's complaint "was fully and robustly investigated and it was deemed that the actions of Alton House did not contribute to her death and they had completed all actions as requested by community nurses".
74. However, I find there was fault in the safeguarding process. I have seen no evidence a safeguarding planning meeting was held or an enquiry report produced. In addition, the Council says the concerns were unsubstantiated, but its investigation found evidence Mrs J was not repositioned on 19 December 2017, which I have found to be fault.
75. The purpose of a safeguarding enquiry is to decide whether the local authority, or another organisation, should do something to help and protect the adult. As Mrs J had died, it should therefore have considered whether action was needed to prevent risk to others in the Home. However, the investigation did not properly consider how Mrs J’s pressure areas had been cared for and it makes no findings on whether the Home’s practices and need for written instructions from the district nurses caused risk to other residents.
76. The spring 2018 investigation did not take into account the Trust’s findings that the suspected DTI may have been caused in the Home, as these were not issued until July 2018. The Council’s July 2018 letter to Mrs D deals with this. It accepts a DTI may have started to develop in the Home but makes no findings about whether there had been poor care by the Home. I do not find fault by the Council here.
77. After Mrs D approached us, we asked the Council to deal with her complaint. Although the Council wrote to her in January 2019, I do not consider it investigated her complaint properly.
78. It said it could not do so as it would need to ask the Home for information and some matters had already been considered by the safeguarding enquiry. The purpose of the complaint investigation should have been to consider if the safeguarding process had been properly followed and evidence could have been sought from third parties if necessary.
79. The Council also said it would be unable to require the Home to apologise to Mrs D. As the Council commissioned the care, it is responsible for the Home’s actions and for any apology necessary. I therefore find there was fault in the way Mrs D’s January 2019 complaint was handled.
80. In response to my draft decision, Mrs D gave examples of discrepancies in the care home’s records. Whilst I have noted these differences, I have no evidence false records were kept.

Did the fault cause injustice?

81. I have found fault by the Trust as there was inadequate pressure injury care. The Trust has accepted there was delay with transport and inadequate pain relief. These faults caused unnecessary severe pain and distress to Mrs J for longer than the day of discharge. This is a significant injustice.
82. I have also found there was no evidence the Trust told the district nurses about Mrs J’s pressure sores. However, the injustice caused by this was mitigated as the district nurses visited Mrs J at the Home on the day of discharge and were aware of the injuries.
83. The Home’s failure to reposition Mrs J on the night of 19 December 2017 also caused her avoidable pain and distress.
84. As Mrs J has died, we cannot remedy the injustice caused to her. However, I consider Mrs J’s family were caused significant distress by witnessing the pain and discomfort Mrs J was in.
85. There was fault by the Council in not refunding Mrs J’s contributions to the cost of her care after 21 December 2017. This has caused a financial loss to Mrs D who has had to re-pay the DWP.
86. There was fault by the Council in the safeguarding process and in the way it dealt with Mrs D’s complaint, causing Mrs D time and trouble.

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Recommendations

87. Within a month of my final decision, the Trust has agreed to:
1. Apologise to Mr and Mrs D.
2. Pay them £500 to acknowledge the distress caused to them.
88. Within a month of my final decision, the Council has agreed to:
1. Apologise to Mr and Mrs D.
2. Refund the contributions Mrs J made after 21 December 2017 (£211.20).
3. Pay them £200 to acknowledge the distress caused to them.
4. Pay them £100 to acknowledge the time and trouble they were put to due to fault in complaint handling.

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Final decision

89. There was fault by the Trust and Council which caused injustice. The actions the Trust and Council have agreed to take remedy the injustice caused. I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman