The Ombudsman's final decision:
Summary: We found fault by Hill Care 3 Ltd as it failed to maintain accurate and complete nutritional records for Mr B, an elderly man at risk of malnutrition. We also found fault by the Trust as staff failed to inform Mr B’s family that his dentures were broken. Hill Care 3 Ltd and the Trust will apologise for this fault. We found no fault by the Council in terms of the care it provided to Mr B.
- The complainant, who I will call Mrs B, is complaining about the care and treatment provided to her husband, Mr B, between February and May 2020 by Northumbria Healthcare NHS Foundation Trust (the Trust), Northumberland County Council (the Council) and The Oaks Care Home (the care home – operated by Hill Care 3 Ltd). Mrs B makes the following complaints.
- The Council and Trust discharged Mr B to the care home against his wishes and without her knowledge. Mrs B says Mr B was discharged without his dentures and personal possessions.
- The care home failed to provide Mr B with appropriate care during his placement. Mrs B says Mr B’s condition deteriorated as a result and that he lost weight.
- The Council, Trust and care home said Mr B had dementia and refused to allow him to return home.
- Mrs B says Mr B’s condition deteriorated because of his stay in the care home and that he subsequently contracted COVID-19. Mrs B says this would not have happened had he been allowed to return home.
- Mrs B would like the organisations she is complaining about to acknowledge their failings and apologise. She would also like them to take action to prevent similar problems occurring for other people in future.
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.
- 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
- In making my final decision, I considered information provided by Mrs B and discussed the complaint with her. I also considered information and documentation provided by the Council, Trust and care home. This included copies of the clinical and care records. In addition, I took account of relevant legislation and guidance. Furthermore, I considered comments from all parties on my draft decision statement.
What I found
Relevant guidance and legislation
- 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; and
- involve patients and carers so that they can make informed decisions and choices that deliver a personalised care pathway and maximise their independence.
- The Care Quality Commission (CQC) publishes a series of fundamental standards for care providers below which care must never fall.
- Regulation 14 relates to nutritional and hydration needs. This requires care providers to assess the nutritional and hydration needs of people in their care and provide food and fluids to meet those needs.
- Regulation 17 relates to good governance. This requires care providers to maintain accurate, complete and detailed records in respect of each person in their care.
- Mr B was admitted to the Northumbria Specialist Emergency Care Hospital on 25 February 2020. Mrs B was concerned that he had become increasingly confused and agitated and had experienced two recent falls.
- The clinical team established that Mr B had a history of Chronic Obstructive Pulmonary Disease (COPD – a lung disease causing breathing difficulties) and had been taking antibiotics for a suspected urinary tract infection.
- The Trust’s psychiatric liaison team reviewed Mr B. They identified no acute mental health problems. However, the team noted that Mr B remained confused and was sometimes disorientated.
- On 28 February, Mr B was transferred to North Tyneside General Hospital for treatment.
- Mr B was generally calm and settled during the day. However, he became increasingly aggressive and agitated during the night. Staff noted that Mr B was verbally abusive to them and attempted to strike them regularly. The clinical team diagnosed delirium. The cause of this was unclear but clinicians felt Mr B may also be showing signs of dementia.
- The hospital staff catheterised Mr B on 4 March as his ongoing urinary infection meant he was not passing urine.
- A consultant discussed Mr B’s care with Mrs B on 17 March. He explained that the clinical team were treating Mr B with medication to control his delirium and make him more stable. The consultant explained that Mr B may need an interim care home placement to recover before he could return safely home.
- A clinician spoke to Mrs B by telephone on 24 March. The consultant explained that Mr B remained very unsettled and aggressive at night and was at increased risk of falls. The consultant explained that the clinical team was treating Mr B with sedative and antipsychotic medication.
- On 25 March, ward staff contacted the Council to explain that Mr B was ready for discharge. Staff explained that Mr B would need a respite bed at a specialist dementia care home due to his ongoing delirium and aggressive behaviour.
- A social worker from the Council’s duty team contacted Mrs B later that day to discuss discharge arrangements. He noted that Mrs B was keen for Mr B to return home and felt a care home admission would not be good for him.
- The social worker spoke to Mr and Mrs B’s son, Mr C on 26 March. He noted that Mr C had spoken to Mrs B and reassured her that it would be in Mr B’s best interests to move to a care home on a temporary basis. The social worker subsequently contacted the care home, which advised it would be able to take Mr B that day.
- Mr B continued to behave aggressively towards staff and was confused and disorientated. During an incident on 26 March, Mr B’s dentures were dropped on the floor and a piece broke off. A nurse cleaned and fitted Mr B’s dentures at his request and placed the broken piece in his washbag.
- Mr B was discharged to the care home later that day on an initial three-week placement, with planned follow-up by the local mental health team.
- The Council allocated Mr B a social worker. The social worker contacted Mrs B on 30 March to introduce herself.
- On 13 April, Mr B was admitted to hospital for treatment and reinsertion of the catheter.
- Hospital staff raised a safeguarding referral with the Council due to concerns raised by the ambulance crew that transported Mr B to hospital. The crew reported that it had taken care home staff several hours to notice that Mr B had pulled his catheter out. The crew were also concerned that care home staff were unable to give a medical background for Mr B and provided only limited observations. Furthermore, the crew reported that staff were not wearing proper personal protective equipment (PPE).
- Hospital staff noted Mr B was confused and agitated. He was also noted to be wheezy and had swollen legs. The clinical team arranged a chest X-ray and COVID-19 swab test. The COVID test was negative, and the X-ray did not reveal any significant abnormalities. The clinical team treated Mr B with antibiotics.
- On 14 April, Mr B’s social worker contacted the care home regarding the safeguarding referral. The care home reported that it was still waiting to receive Mr B’s full medical history from his GP. The care home said Mr B’s catheter had been blocked and that he had removed it. It explained that staff observed Mr B before re-catheterising him and called for an ambulance when he was still not passing urine.
- The Council agreed a safety plan with the care home. This involved:
- further training for staff;
- a review of how documents are made available in the event of an emergency; and
- ongoing monitoring by Mr B’s social worker.
- On 17 April, clinical staff completed a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) form for Mr B. This recorded that any attempt at cardiopulmonary resuscitation would be unsuccessful due to Mr B’s frailty.
- Mr B was discharged back to the care home on 17 April. He was placed in isolation as part of the care home’s COVID-19 protocols. The care home carried out 15-minute observations due to Mr B’s increased risk of falls. Mr B also had a falls sensor mat to alert staff if he fell.
- Mr B suffered several falls during his time in the care home. On each occasion he was checked by staff and found not to have sustained any significant injuries.
- Mr B’s social worker spoke to Mrs B on 22 April. The social worker noted that “[Mrs B] agreed that [Mr B’s] return home should be delayed until the virus has resolved as she has health concerns herself. Agreed.”
- On 29 April, the GP practice used by the care home advised staff to test all residents for COVID-19 due to a rise in cases in the area. The care home contacted Mrs B on 7 May to request her permission for this, which she gave.
- Mr B returned a positive COVID-19 test on 11 May.
- Mr B was admitted to hospital again on 14 May with worsening shortness of breath. The clinical team concluded that Mr B’s COVID-19 infection was exacerbating his existing breathing difficulties. Mr B remained confused and agitated. Mr B was initially refusing to take medication and had little appetite.
- On 18 May, a clinician contacted Mrs B and her son to explain that Mr B was very frail and unwell. The clinician advised that Mr B was currently stable but could still deteriorate due to the COVID-19 infection. The clinician also said that, even if Mr B recovered from the infection, it was very unlikely he would be able to return home as his care needs had increased.
- Hospital staff spoke to Mrs B and her son about the possibility of discharging Mr B back to the care home. However, the family was keen for Mr B to remain in hospital.
- Mr B’s condition deteriorated and he died on 20 May.
Discharge from hospital
- Mrs B complained that the Council and Trust discharged Mr B to the care home against his wishes and without her knowledge.
- The clinical records show Trust doctors discussed Mr B’s care with Mrs B on 17 and 24 March, while he was still an inpatient. On both occasions, the doctors made clear that Mr B remained very confused and aggressive, particularly at night, and that it would not be safe for him to return home until his condition had stabilised. Both doctors explained that a short-term care home placement may be necessary.
- A duty social worker spoke to Mrs B again on 25 March. The notes of this discussion make clear that Mrs B was unhappy with the proposed discharge to a care home. The social worker agreed to discuss the discharge plans with Mr B’s son, who was his Lasting Power of Attorney for health and welfare.
- The social worker spoke to Mr B’s son the following day. Mr B’s son told the social worker he had discussed the discharge plan with Mrs B and “is agreeable to respite care for [Mr B].”
- In summary, the case records show Trust and Council staff did discuss the proposed placement with Mrs B and her son before discharging Mr B to the care home. The notes of the conversation on 26 March show Mr B’s son recognised the need for the placement and consented to this on Mr B’s behalf. I find no fault by the Trust or Council on this point.
- Mrs B said Mr B was discharged without his dentures. She also said Mr B did not have his spectacles, clothing and wash bag with him.
- The clinical records show that Mr B’s dentures were broken during an incident on 26 March. At Mr B’s request, staff reaffixed the dentures and placed the broken piece in his washbag. I found no evidence to suggest staff informed Mrs B or the care home of this. This is fault.
- I found no evidence in the records of the Trust, Council or care home to suggest Mr B’s other possessions were missing when he was discharged to the care home. In the absence of any further corroborating evidence, I am unable to reach a sound conclusion on this point.
Care in care home
- Mrs B complained that the care home failed to provide Mr B with appropriate nutritional care during his placement and that he lost weight as a result.
- The care records show Mr B was weighed on admission to the care home. His weight was recorded as 71.9kg and he had a Body Mass Index (BMI) score of 22. This was within the healthy range. The care home completed a Malnutrition Universal Screening Tool (MUST) for Mr B. This is a tool used to establish a person’s risk of malnutrition. Mr B was not considered to be at risk of malnutrition at that stage.
- The last recorded weight for Mr B was taken on 13 May, shortly before his final hospital admission. This was recorded as 68.8kg, with a BMI of 21. Again, this was within the healthy range. However, Mr B had lost some weight.
- I note care home staff completed a further MUST for Mr B at this stage. This determined that he remained at low risk of malnutrition. This was incorrect. As Mr B had lost slightly over 5% of his weight, he should have been classified as at medium risk of malnutrition. This was fault by the care home.
- I am satisfied this did not have a significant impact on Mr B’s care. This is because there is evidence to show care home staff were carefully monitoring Mr B’s food and fluid intake during this period. Furthermore, Mr B was readmitted to hospital shortly after this.
- I note the care home has recognised the MUST calculation was incorrect and has implemented further training for staff. In my view, this is a reasonable and proportionate remedy for this aspect of the complaint.
- It should be noted that the care home was unable to provide all the nutritional records relating to Mr B’s time in the care home. This is because some have been misplaced. This is evidence of poor record keeping by the care home and is contrary to the requirements of the CQC fundamental standards. This was fault.
- The limited records I have seen relate to the period following Mr B’s discharge from hospital on 17 April. These records show Mr B generally had a good appetite. He ate most of the food prepared for him, though he occasionally declined meals.
- Nevertheless, the evidence shows Mr B did lose some weight during his time in the care home. The limited records available mean I am unable to say whether this was a result of poor nutritional care. This will cause understandable uncertainty and distress for Mrs B.
- Mrs B said Mr B was left alone in his room without stimulation, such as a television, radio or newspaper.
- Mr B’s time in the care home corresponded with the emerging COVID-19 pandemic. This meant Mr B was required to self-isolate in his room for 14 days following his discharge from hospital on 26 March. He was then required to undergo a further period of isolation following his discharge on 17 April. Unfortunately, this meant Mr B did have to spend a significant amount of time in his room.
- Mrs B is correct to say that Mr B did not have a television in his room. I have reviewed the Council’s contract with the care home and it was not required to provide one.
- However, I note Mr B’s pre-admission assessment recorded that he enjoyed watching television and reading the newspaper. This should have prompted the care home to discuss the matter with Mrs B. This would have given her an opportunity to provide television or arrange for newspapers to be delivered. This did not happen. The care home has acknowledged this and apologised for it. In my view, this is a reasonable and proportionate response on this point.
- The care home only provided me with the social activity record for a limited period at the beginning of May 2020. Again, this is evidence of poor record keeping. Nevertheless, the available records show Mr B had a radio in his room and staff noted that he liked listening to music. The records show Mr B also enjoyed talking with staff and, where possible, spending time in the lounge.
- On balance, I am satisfied there is evidence to show Mr B was provided with appropriate stimulation during his time in the care home. I found no fault on this point.
- Mrs B complained that Mr B was left without a call bell in his room.
- When Mr B was admitted to the care home in March 2020, he was noted to be confused and disorientated to time and place. At that stage, Mr B was being treated for delirium with possible underlying dementia.
- The care home completed a risk assessment for Mr B in early April. This concluded that his confusion was such that he would be unable to use a call bell. As a result, a sensor mat was placed in Mr B’s room. This was to alert staff if Mr B left his bed. In addition, staff were reminded to listen out for Mr B calling. Staff also carried out regular checks on Mr B (initially every hour, then later every 15 minutes).
- The case records suggest Mr B was too confused to use a call bell. Based on the care records, I am satisfied the care home put in place appropriate alternative measures to reduce the risk to Mr B. I found no fault on this point.
- Mrs B said Mr B was required mobilise regularly due to a back problem. She queried whether care home staff encouraged Mr B to mobilise.
- As I have explained in paragraph 56 above, Mr B was subject to two periods of self-isolation during his time in the care home. This meant Mr B was largely confined to his room during these periods. This limited his opportunities to mobilise to an extent.
- Nevertheless, the records show Mr B liked to mobilise using a walking frame and with assistance from staff. The evidence suggests staff supported Mr B to move around within his room and, when he was not isolating, down the corridor to the lounge area.
- I consider there is evidence to show staff did support Mr B to mobilise within the limitations imposed by his periods of self-isolation. I found no fault on this point.
Planning for future care
- Mrs B said the Council, Trust and care home claimed Mr B had dementia and refused to allow him to return home.
- At the time of his discharge to the care home, Mr B had a working diagnosis of dementia. He was taking Rivastigmine medication (a medication to treat dementia).
- Prior to his discharge, the Trust arranged for a follow up assessment by the local mental health team. Unfortunately, the national lockdown meant a face-to-face assessment could not take place.
- Care home staff instead arranged a telephone review with a Community Psychiatric Nurse (CPN). As Mr B remained confused and delirious, the CPN arranged for a consultant psychiatrist to prescribe an increased dose of antipsychotic medication (Quetiapine).
- The professionals involved in Mr B’s care remained concerned that he was at high risk of falling. This was because Mr B was still unsettled at night and prone to getting out of bed and moving around unsupported.
- Mr B’s social worker spoke to Mrs B on 22 April. She noted that Mrs B agreed Mr B’s return home should be delayed until the pandemic had ended as she had health concerns herself. As a result, the social worker extended Mr B’s temporary placement.
- The professionals supporting Mr B recognised his wish to return home to live with Mrs B. The case records show they hoped this would be possible once Mr B’s condition had stabilised. However, Mr B subsequently contacted COVID-19 and was readmitted to hospital before his condition improved.
- I appreciate this was a very distressing situation for Mrs B. Nevertheless, I consider there is evidence to show that the professionals involved in Mr B’s care acted appropriately in extending his placement at the care home to allow his condition to stabilise. I found no fault in this matter.
- Within one month of my final decision statement:
- the Trust will apologise to Mrs B for failing to inform her that Mr B’s dentures were broken during an incident on 26 March 2020;
- Hill Care 3 Ltd will apologise to Mrs B for the uncertainty caused to her by the care home’s failure to maintain complete nutritional records for Mr B; and
- Hill Care 3 Ltd will write to the Ombudsmen to explain what action it will take to ensure the care home maintains accurate, complete and detailed records in accordance with the CQC fundamental standards. Hill Care 3 Ltd will also explain how it will audit the care home’s records on an ongoing basis to ensure this standard is maintained.
- I found fault by the Trust as staff failed to inform Mrs B that Mr B’s dentures were broken.
- I found fault by Hill Care 3 Ltd with regards to its poor record keeping. This means it is not possible to say whether Mr B’s weight loss was a result of poor nutritional care. This caused Mrs B avoidable distress and uncertainty.
- I am satisfied the actions the Trust and Hill Care 3 Ltd have agreed to complete represent a reasonable and proportionate remedy for the injustice caused to Mrs B by the fault I identified.
- I found no fault by the Council in terms of the care it provided to Mr B.
- I have now completed my investigation on this basis.
Investigator's decision on behalf of the Ombudsman