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Leeds Teaching Hospital NHS Foundation Trust (19 001 798b)

Category : Health > Hospital acute services

Decision : Not upheld

Decision date : 03 Sep 2020

The Ombudsman's final decision:

Summary: Ms Q complains about the care her father received. The Ombudsmen have found no fault by the Council. While there was fault by the Trust and the Care Home, those organisations have taken appropriate steps to remedy the injustice Ms Q and Mr R suffered.

The complaint

  1. The complainant, who I shall call Ms Q, complains about the actions of Leeds City Council (the Council), Leeds Teaching Hospital University NHS Foundation Trust (the Trust) and Paisley Lodge Care Home (the Care Home), a Council-funded care home regarding the care of her elderly father, Mr R.
  2. Specifically, she complains that:
    • the Care Home has not properly investigated its failure to maintain appropriate levels of cleanliness and hygiene in relation to her father’s accommodation, personal care and catheter management. It also did not take sufficient remedial action to improve its property and procedures;
    • the Trust failed to properly investigate her father’s fall on a hospital ward and has not taken sufficient action to prevent these errors occurring again;
    • the Trust resuscitated her father despite a Do Not Attempt Resuscitation order being in place;
    • there were repeated excessive delays by the Council and Trust in relation to her father’s discharge planning, assessment and placement in a new care home. This led to her father being wrongly discharged back to the Care Home and later remaining in hospital longer than necessary. Communication between professionals and Ms Q was also poor;
    • the joint organisational handling of her complaint has not resolved her concerns;
    • a social worker should not have made comments about the frequency she visited her father; and
    • the Council mishandled the sale of her father’s property to fund his care fees.
  3. As a result, Ms Q says that her father suffered unnecessary pain, distress and humiliation. Ms Q has also found the situation distressing and believes the fall contributed to her father’s death.
  4. Ms Q is seeking service improvements to prevent this situation happening again.

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What I have investigated

  1. I have investigated Ms Q’s complaints in the first five bullet points in paragraph two. The final section of this statement contains my reasons for not investigating the rest of the complaint.

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The Ombudsmen’s role and powers

  1. 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)
  2. 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).
  3. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe it is unlikely they would find fault (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)
  4. The Ombudsmen will not generally investigate a complaint unless they are satisfied the matter has been brought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint. (Local Government Act 1974 section 26(5), as amended and Health Service Commissioners Act 1993, section 9(5))
  5. 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

  1. I have considered information provided by Ms Q, the Council, the Trust and the Care Home. I have also spoken with Ms Q on the telephone. Ms Q and those organisations had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What happened

  1. Mr R had been a resident at the Care Home for several years. He had dementia and, in 2018, underwent frequent treatment for recurrent urinary tract infections (UTIs). As a result, he had an indwelling (long term) catheter put in place.
  2. In July 2018, Mr R was briefly admitted to hospital with a UTI. At this time, Ms Q started to raise concerns about the care Mr R’s was receiving at the Care Home and asked for him to be moved to another care home. Ms Q raised a safeguarding alert with the Council, however this was closed after initial enquiries found no concerns. Mr R was discharged to the Care Home.
  3. Shortly after, Mr R was re-admitted to hospital again, to replace his catheter which he had pulled out. It was decided that Mr R should not return to the Care Home. The Council tried to relocate Mr R to Ms Q’s preferred care home, however this care home was not accepting new admissions at the time. As a result, Mr R was discharged back to the Care Home as a temporary measure while a new placement was found.
  4. A few weeks later, in late September 2018, Mr R was admitted to hospital with another UTI. The Council continued making enquiries to place Mr R in another care home. Ms Q maintained her strong preference for a particular care home which was located near to her home. Ms Q has health issues which make travelling difficult and was keen for her father to move closer to her so she could visit him more regularly. The Council tried to accommodate Ms Q’s request. However, there were multiple problems and ultimately, Ms Q’s preferred care home decided there was no suitable vacancy for Mr R. The Council began to explore other options.
  5. In mid-November 2018, Mr R had a fall on the ward in the early hours of the morning. The fall was unwitnessed.
  6. Mr R was transferred to a different hospital (but still part of the Trust) for fracture treatment where, following discussion with doctors, Ms Q agreed to a Do Not Attempt Resuscitation (DNAR) order.
  7. In early December 2018, Mr R had a heart attack while he was away from the ward, having transferred to a different department for a scan. He was resuscitated by staff. Mr R died two days later.


The Trust’s investigation into Mr R’s fall

  1. The Trust’s ‘Clinical slips, trips and falls procedure’ (2017) states:
    • “Falls that result in serious harm - Serious harm is a fall that results in a fracture, serious head injury or death. All falls resulting in death are reported as potential Serious Incidents. A robust Root Cause Analysis (RCA) investigation is undertaken of each fall with fracture, serious head injury or death within 5 days of notification of the incident.”
    • “Action plans will be developed and implemented by Clinical Support Units (CSU’s). Responsibility for improvement remains with the CSU, as does monitoring sustained improvement through performance management.”
    • “RCAs will be reviewed at the Trust’s review panel meeting which CSUs will be expected to attend to determine whether the fall is a serious incident. A summary of key findings, themes and lessons to be learned will be produced and circulated every quarter.”
  2. As noted above, all serious falls within the Trust require a Root Cause Analysis (RCA) investigation. The outcome of the Trust’s investigation into Mr R’s fall found that the root cause was an inadequate level of supervision at the time of the fall. It noted that Mr R should not have been lodged on the Oncology ward and that he could have been discharged prior to the date of the incident.
  3. I recognise that Ms Q has some outstanding concerns regarding conflicting accounts about how and where Mr R fell. This has undermined her confidence in the Trust’s investigation. Given that the fall was unwitnessed and no additional information is available, it is unlikely that further investigation by the Ombudsmen would resolve this issue any further.
  4. I also acknowledge Ms Q’s view that the fall directly contributed to Mr R’s death. The fall was undoubtedly distressing for Mr R, and Ms Q, and would have caused unnecessary pain and injury. However, the Trust has provided a copy of the coroner’s report which shows that Mr R had a number of medical conditions at the time, with heart problems and aspiration pneumonia being recorded as the primary causes of death. Aspiration pneumonia is the inflammation of the lungs caused by breathing in material to them. While the fracture from the fall is listed as a secondary cause of death, multiple other secondary causes were also included. This indicates that there were multiple causes leading to Mr R’s death, and I cannot say that Mr R’s death could have been avoided had he not fallen.
  5. The Trust found that Mr R’s fall was avoidable and has apologised to Ms Q. Therefore, I have not re-investigated the circumstances of the fall as the Trust has already accepted fault.
  6. Instead, I have focused on whether the Trust’s investigation into Mr R’s fall was completed properly and if appropriate improvements have been put in place.
  7. The Trust provided a detailed explanation regarding the actions it has taken to reduce the risk of falls. The Trust said it is committed to reducing falls and has re-launched its Quality and Improvement work to reduce falls. The Oncology ward, on which Mr R fell, is an active member of this work. The Oncology department has a yearly collaborative event to review falls and explore where practices can be improved. The Trust advised that the Oncology ward has a daily morning ‘safety huddle’ to discuss any patients at risk of falls and any falls which have occurred over the last 24 hours.
  8. The Trust explained that it has permanently increased staffing levels.
  9. The Trust now shows a video to all patients, explaining how they can reduce risk of falling. The Trust is aiming for an overall 20% reduction on falls and has provided statistical evidence to show it is carefully monitoring fall data and is on track for an overall reduction. The Trust is also currently reviewing the fall prevention sensors in place with a view to increase the numbers available for use.
  10. It is clear from the Trust’s response to Ms Q’s complaint that it took Mr R’s fall very seriously. It is not possible to avoid all falls, however steps can be taken to reduce the risk. The subsequent actions by the Trust demonstrate that it has put a substantial number of improvements in place to address the risk of falls. I am satisfied that the Trust has investigated Mr R’s fall in line with the relevant guidance and has already put appropriate systemic improvements in place.

The Council’s safeguarding enquiry

  1. Section 42 of the Care Act 2014 says that 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.
  2. On 30 July 2018, during one of Mr R’s hospital admissions, Ms Q raised concerns about the Care Home with the Council. The Council closed the safeguarding enquiry the next day, following initial enquiries. Ms Q is unhappy that no one from the Council visited the Care Home before closing the enquiry.
  3. The safeguarding co-ordinator was satisfied that the hospital and district nurses had no concerns about Mr R’s catheter care or hydration and noted that there is a risk of infection with catheters.
  4. During my enquiries, the Trust confirmed that it had no concerns about Mr R’s catheter management and there is no record of the district nurse raising concerns on his catheter management plan. Information available to the public from the NHS confirms that infections, such as UTIs, are a common risk associated with indwelling catheters.
  5. There is no requirement for the safeguarding team to visit a Care Home and it is open to the Council to decide the extent of its enquiries. Given that initial enquiries with professionals who were independent to the Care Home had raised no concern about Mr R’s catheter care, I have found no fault with the Council’s decision to close their enquiry at this stage.

Delayed discharge and communication

  1. Ms Q complains that the Council and the Trust delayed Mr R’s discharges. Ms Q believes that unnecessary repeats of social care assessments contributed to the delays. She also says communication between professionals was poor and, on two occasions, led to Mr R being inappropriately discharged back to the Care Home.
  2. Mr R had several hospital admissions over a short period of time. Hospital social workers are required to assess or review a person’s needs before each discharge. The Council has explained that it was not necessary to carry out a full needs assessment each time and Mr R only required a review of his needs during his hospital admissions after August 2018. Having reviewed the Council’s records, I have seen no evidence of delay, with all reviews being completed within a week of admission.
  3. On 3 August 2018, Mr R was discharged back to the Care Home. The Trust’s records showed it had completed blood tests, a confusion screen, a compute tomography (CT) scan of Mr R’s brain and a swab of the catheter site before it discharged Mr R. The Trust has showed it had no concerns about each of those areas before it discharged Mr R. Therefore, based on the Trust’s records, I am satisfied Mr R was medically fit to be discharged on 3 August 2018.
  4. Ms Q says the discharge on 3 August 2018 was a mistake, due to a communication error between social services and the hospital. The Council says the hospital social worker was advised on 2 August that Mr R was not medically fit for discharge and was then discharged the next day without advising social services. The Trust’s records show that a staff nurse spoke with Ms Q on 3 August to advise her of discharge, who said she had raised concerns about Mr R returning to the Care Home. The staff nurse advised Ms Q to raise her concerns with the district nurse who would be visiting the next day and notified the community social work team of Ms Q’s concerns.
  5. The records indicate some miscommunication between the Council and the Trust during the discharge. However, social services had closed their safeguarding enquiry on 31 July 2018 having found no concerns. Further, while Ms Q was trying to arrange a placement for Mr R at her preferred care home, this had not been fully confirmed. Given that social services had not upheld Ms Q’s safeguarding concerns at the time and there was no confirmed alternate placement for Mr R, it seems likely Mr R would have been discharged back to the Care Home regardless of the miscommunication. However, Ms Q would have found the situation frustrating.
  6. Mr R was admitted to hospital again between 8 to 24 August 2018. The Council has confirmed that the social worker had made referrals to alternate care homes within a week of Mr R’s admission to seek a new placement. Unfortunately, Ms Q’s preferred care home was no longer accepting new placements and there were no other vacancies in the area. Therefore the Council decided to discharge Mr R back to the Care Home temporarily while a new placement was located, as the safeguarding concerns had not been upheld and it felt Mr R’s needs could be safely met there. While it was frustrating for Ms Q to see Mr R discharged back to the Care Home, he was unable to remain in hospital indefinitely, particularly as hospital admissions come with their own risks of infection. Given that there were no other confirmed placements for Mr R, I have not found fault with the decision to discharge Mr R back to the Care Home temporarily.
  7. The Trust’s investigation found that, at the time of his fall, Mr R’s discharge had generally been delayed. The Trust has acknowledged its part in the delay, when Mr R was found to be unsuitable for rehabilitation and was discharged from the physiotherapist, there was a six day delay before Mr R was referred to the hospital social worker. This is fault, although it would not have significantly delayed Mr R’s discharge given the subsequent difficulties finding him a new care home placement.
  8. While a lengthy delay followed, as the community social worker attempted to locate a suitable new placement for Mr R, I have not found fault with the Council’s actions. The Council’s records show that the community social worker completed all required assessments promptly, was proactive with chasing up potential new placements and regularly updated the hospital social worker and Ms Q.
  9. Ms Q has complained about communication from social workers regarding the new placement. The records show that the community social worker repeatedly tried to contact Ms Q by telephone. It is recorded that there are several occasions where phone calls were unsuccessful and there was no option to leave a message, however the social worker regularly called Ms Q again.
  10. It is clear from the social worker’s records that she was making a significant effort to place Mr R in Ms Q’s preferred care home. She also checked multiple other options, although few beds were available given Ms Q’s relatively narrow travelling area, due to her mobility problems.
  11. Ms Q’s preferred care home repeatedly delayed completing assessments, missed several scheduled assessment visits to Mr R and provided the social worker with conflicting and changeable information about availability of placements. These delays were outside of the social worker’s control and she frequently chased up potential placements, often on a daily basis. I have not found that the actions of the community social worker delayed Mr R’s discharge during his last hospital admission.

The Care Home’s investigation into cleanliness and hygiene

  1. During its response to Ms Q’s complaint and when replying to my enquiries, the Care Home has accepted that the cleanliness of Mr R’s accommodation fell below the expected standard. The Care Home has explained that Mr R would not always allow staff into his room to clean, however there were also missed opportunities to clean his room during his hospital admissions. Mr R’s room was also due to be redecorated, however this does not account for some of the problems such as the poor standard of hygiene in the bathroom.
  2. The Care Home has also accepted fault in relation to the standard of Mr R’s personal care, although notes that Mr R frequently resisted staff attempts to assist him. The Care Home has provided information which supports that Mr R was regularly refusing support with his personal care. The Care Home explains that it involved Mr R’s GP, hospital urology department and the local mental health team in an attempt to resolve matters. These are appropriate actions.
  3. The Care Home has apologised to Ms Q for the distress caused. It confirmed that redecoration of the bedrooms is being carried out. The Care Home has also provided a copy of an Infection Control Audit completed in May 2019. The outcome was an overall ‘low risk’ score. At the time of the audit, there was only one resident suffering a urine infection and no areas of concern were found surrounding catheter management or bedroom standards and staff training in infection control was over 90%. Some areas of required repair were flagged in bathrooms, however the bathrooms were found to be visually clean.
  4. The Care Home has accepted Ms Q had raised complaints with staff about cleanliness and catheter care and these were not always escalated properly to management as should have happened. The Care Home has implemented new reporting procedures to ensure concerns are put through the right channels and reach management. The Care Home says it has also taken action against staff who had not delivered the expected standard of care.
  5. The Care Home has outlined other improvements that have since been implemented, such as moving from paper based to electronic records, allowing for personal care to be monitored more closely and prompt reviews where required.
  6. There were areas where the Care Home’s cleanliness fell below the expected standard. The Care Home has accepted this and apologised to Ms Q. Therefore, I have focused on whether the Care Home has taken sufficient steps to improve. From the evidence provided by the Care Home, I am satisfied that reasonable actions have been taken to address the issues and that there is nothing to indicate ongoing problems in regard to cleanliness and infection control.

Urinary tract management

  1. Ms Q raised concerns that Mr R’s catheter was regularly attached to a night bag during the day time, which requires the user to carry it around by a handle when moving. Ms Q says this was inappropriate as Mr R had dementia and would not remember to carry the night bag with him and would end up pulling it out. Ms Q said Mr R should have used a day bag which would be attached to his leg.
  2. The Care Home’s catheter care policy does not explicitly prevent the use of night bags during the day, however the indication is that night bags are commonly used overnight while legs bags are used during the day, primarily for dignity reasons.
  3. Unfortunately, the Care Home did not record which type of catheter bag it used daily. On the balance of probabilities, I am persuaded by Ms Q’s account that Mr R sometimes used a night bag during the day. That was fault, and Mr R would have suffered a loss of dignity. The Care Home has accepted it would have been undignified for a resident to use a night bag during the day. Staff should encourage residents to return to their room and replace the night bag with a leg bag. The Care Home also said it has provided training to staff around dignity and the use of visible catheter bags in communal areas.
  4. During the joint complaint meeting, the Care Home stated that it hadn’t always got Mr R’s catheter care right, although it also noted that it had involved Mr R’s GP and made referrals to the urology department to help manage the recurrent UTIs.
  5. The Trust has confirmed that it had no concerns about how Mr R’s catheter was being managed and that the District Nurse who was monitoring his catheter care had not raised any concerns either. The Trust has commented that the risk of catheters being pulled out is high with dementia patients. As discussed above, UTIs are a common risk in patients with indwelling catheters. As such, it is not possible to say that the Care Home’s actions were the sole cause for the high number of UTIs that Mr R suffered.

The Do Not Attempt Resuscitation (DNAR) order

  1. During my enquiries, the Trust has confirmed that Mr R’s DNAR order was not properly handled when he transferred to the CT department for scans. In addition to a written DNAR, it is expected that departments will also confirm resuscitation status when ordering radiology tests. Mr R’s written notes should have travelled with him, with the DNAR form clearly displayed on the front. However, his notes did not go with him. This is clear fault.
  2. As Mr R’s resuscitation status was not readily accessible when he moved to the CT department, he was resuscitated following a cardiac arrest when he should not have been. While I do not criticise the staff for needing to make a fast decision to resuscitate a patient with an unclear resuscitation status, this would have been avoided if the written notes had correctly travelled with Mr R.
  3. Ms Q has explained that the decision to agree to the DNAR order was difficult for her to reach, however she had done so on the advice of doctors, believing it was in Mr R’s best interests and wanting to help him avoid unnecessary pain. Therefore, for Mr R to be resuscitated following this decision, was deeply distressing for Ms Q.
  4. I do not consider the Trust’s fault caused any injustice to Mr R. He was unresponsive when the doctors were trying to resuscitate him, so would not have experienced any physical or psychological impact.
  5. Through its enquiry response, the Trust has offered its apologies that Mr R’s notes did not travel with him. The Trust also explained that it has fully implemented a move to electronic patient records, which has improved how patient resuscitation status is shared. This significant change to the Trust’s record system means that a patient’s medical information can be accessed by all departments without physical written notes needing to travel with the patient and therefore will help reduce the risk of this error occurring again.

Joint complaint handling

  1. Overall, I am satisfied that Ms Q’s complaint was handled reasonably. The Trust co-ordinated a joint complaint response which allowed Ms Q’s concerns to be considered as a whole. A lengthy meeting took place, during which the organisations involved openly accepted where errors had been made, apologised and shared systemic improvements put in place.
  2. There are two areas where the Trust’s complaint handling could have been better. Firstly, the Trust took away a few points for clarification, however I cannot see that these were properly followed up and fed back to Ms Q. However, some points, such as whether the community social worker chased up Ms Q’s preferred care home, have been answered through the course of this investigation.
  3. Secondly, the Trust provided an inadequate written response following the meeting. While an audio recording was provided to Ms Q, this format is not easily accessible to complainants, or indeed the Ombudsmen, and should also be accompanied by a written response confirming the key points from the meeting. The Trust has recognised that its written letters were ‘too lean’ and has undertaken work with the Patient Experience Team to improve their letters. This is an appropriate response.


  1. There were several failings, by multiple organisations, in Mr R’s care. These have caused injustice to Mr R and Ms Q. However, the organisations have openly accepted these failings. Therefore, my investigation has focused on whether adequate steps have been taken to address these errors and if there is any outstanding injustice.
  2. Ms Q has stated that she is not seeking apologies or any other personal remedy. She simply wishes to know that improvements have been made to prevent such errors occurring again.
  3. The Trust and the Care Home has provided evidence that multiple systemic improvements have been put in place. Further, the Care Quality Commission recently inspected the Care Home in January 2020. The report rates the Care Home as ‘Good’ in all areas. The Care Home is noted to be clean and well maintained, with ongoing refurbishments continuing across multiple areas including bedrooms. There were no concerns about infection control and it was noted that staff had been appropriately trained. The report also found that complaints were being appropriately recorded, investigated and responded to under the Care Home’s complaint procedure. This inspection report supports my view that the Care Home has made sufficient changes and demonstrates improvement in areas Ms Q has complained about.
  4. I am satisfied that appropriate actions and improvements have been taken to address the accepted fault and I do not consider any further recommendations by the Ombudsmen are required. I hope Ms Q can take some reassurance from this.

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Final decision

  1. I have completed my investigation and uphold Ms Q’s complaint. There was fault by the organisations which caused injustice to Mr R and Ms Q. Although Ms Q does not agree with my decision, I am satisfied the organisations have already taken action to remedy the injustice.

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Parts of the complaint that I did not investigate

  1. I have not investigated how Mr R’s fall occurred, as the Trust has already accepted that his fall was avoidable. Instead my investigation has focused on the Trust’s actions to put things right.
  2. Ms Q complained that a social worker commented on the frequency she visited her father. The social worker denied making those comments. In the absence of any independent evidence, I consider an investigation by the Ombudsmen is unlikely to establish fault by the Council.
  3. Also, I have not investigated the Council’s handling of the sale of Mr R’s property to fund his care fees. Ms Q has not yet raised that complaint with the Council. She should complain first to the Council using their formal complaint procedures. Ms Q can approach the Local Government and Social Care Ombudsman to consider her complaint if she is dissatisfied with the Council’s response.

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Investigator's decision on behalf of the Ombudsman

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