Summary: Ms X complained about diabetes management and care provided to the late Mr Y, when he went into respite care, during his admissions to hospital, and then a nursing home. We found fault by the Trust in its record keeping and monitoring of Mr Y. The Trust acknowledged this in its response to Ms X’s complaint and put service improvements in place. The Trust agreed to provide a further remedy to Ms X to recognise the distress and uncertainty caused. We also found fault by Priory Adult Care in its management of Mr Y’s diabetes. Priory Adult Care agreed to provide a remedy to Ms X. We did not find fault by the Council, Trust and ICB in changes to Mr Y’s care plan for his respite placement, or in the Care Home’s management of Mr Y’s diabetes.

The complaint

1. Ms X complains on behalf of the late Mr Y, that Calderdale & Huddersfield NHS Foundation Trust (the Trust), Calderdale Metropolitan Borough Council (the Council), NHS West Yorkshire ICB (the ICB), Valorum Care Group, and Priory Adult Care failed to provide adequate care for Mr Y’s diabetes and dementia.
2. Ms X specifically complained that:

• the Council, Trust and ICB failed to plan and provide adequate care for Mr Y during a respite placement at the Care Home;
• Valorum Care Group failed to manage Mr Y’s diabetes during his respite placement at the Care Home;
• The Trust failed to manage Mr Y’s diabetes during admissions to hospital, and did not provide adequate nutrition, wrongly administered sedation to Mr Y, and put a DNACPR in place without discussing it with Ms X; and
• Priory Adult Care did not properly manage Mr Y’s diabetes while he was at the Nursing Home, delayed calling an ambulance, wrongly administered sedation to Mr Y and did not allow visits from family.

3. Ms X complains that poor care meant Mr Y experienced avoidable mental, emotional and physical harm, contributed to Mr Y’s deterioration and death, and caused her great distress and anxiety.
4. In bringing her complaint to the Ombudsmen, Ms X seeks acknowledgements that things went wrong and explanations. She also seeks service improvements and financial remedy.

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The Ombudsmen’s role and powers

5. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
6. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
7. 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.
8. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

9. I have considered information from Ms X, provided over the telephone and in writing; information from the Trust, the Council, the ICB, Valorum Care Group, and Priory Adult Care; independent clinical advice from a registered nurse; and the relevant law and guidance.
10. Ms X and the organisations had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

The law and guidance relevant to this complaint

Fundamental Standards of Care

11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
12. The National Institute for Health and Clinical Excellence (NICE) guideline, Type 1 diabetes in adults: diagnosis and management covers care and treatment for adults with Type 1 diabetes.
13. The Nursing and Midwifery Council (NMC) Code sets out the professional standards of practice and behaviour for nurses, midwives and nursing associates.

Background to Ms X’s complaint

14. Mr Y had diagnoses of Type 1 diabetes and dementia. He had been living at home, with a package of care funded jointly by the Council and ICB. Mr Y then went to a residential care home (the Care Home, managed by Valorum Care Group), for respite care. The placement was also funded jointly by the Council and ICB.
15. On the second day of respite care, Care Home staff were unable to support Mr Y to administer insulin. The Care Home contacted the out of hours district nursing service (managed by the Trust) for support. The district nurse team reviewed Mr Y, and he was admitted to hospital with hyperglycaemia.
16. Mr Y was treated in hospital and discharged to a nursing home (the Nursing Home, managed by the Priory Adult Care) under the discharge to assess pathway. Arrangement for the placement at the Nursing Home involved the Trust district nursing team, the Council and ICB, and was discussed with Ms X. Mr Y had subsequent hospital admissions with raised blood glucose and ketones, and was discharged to the Nursing Home. Mr Y then had a further hospital admission after a fall. Sadly, Mr Y died in hospital.
17. Ms X complained to the organisations listed above about the care provided to Mr Y. Each of the organisations responded separately to her complaint. The Trust asked another NHS hospital trust to carry out an independent review of Mr Y’s hospital care.
18. Ms X was dissatisfied with the responses she had received from the organisations, and complained to the Ombudsmen.

Analysis

19. As Ms X has raised several issues within her complaint, I have considered these under separate headings, below.

A) The Trust, Council and ICB’s care plan for Mr Y while he was at the Care Home

20. Ms X complained the Trust, Council and ICB failed to plan and provide adequate care for Mr Y during a respite placement at the Care Home. Specifically, she said she had been told the Trust’s district nursing team would administer Mr Y’s insulin while he was at the Care Home, but the care plan was changed to say he could administer it himself when this was not the case.
21. Mr Y had a clinical diabetes management plan that had been prepared before he began the respite care placement. Ms X had also prepared a care plan which was provided to the care home. The clinical management plan says it was designed to help Ms X, carers and district nursing services with the day to day management of Mr Y’s diabetes. The plan sets out a fixed dose regime, complemented by meals with consistent carbohydrate quantities in an attempt to avoid significant blood glucose variation. The clinical management plan remained in place during Mr Y’s time at the Care Home, and a copy was provided to the Care Home along with the support plan for Mr Y.
22. The respite placement for Mr Y was planned by a multi-disciplinary team (MDT) involving the Council, the Trust’s district nursing service and the Care Home.
23. The Council said it could not locate its care and support plan for Mr Y for his respite placement. As noted above there was a clinical diabetes management plan in place for Mr Y at the placement. There are also available supporting records of communications between the Council, Trust, Care Home and Ms X, prior to Mr Y beginning his respite placement. These records include details of care planning for Mr Y’s respite placement.
24. The records indicate that as well as the clinical diabetes management plan, information from Ms X about how Mr Y’s diabetes was managed was also provided to the Care Home. In its response to Ms X’s complaint, the Care Home said it had taken into account the information she had provided.
25. The records say that before Mr Y’s respite placement began, the Care Home had discussed the respite placement with Ms X. The records say that “district nursing team will be supporting with insulin”. The Trust discussed Mr Y’s care plan with the Care Home and the Council, providing the Care Home with Mr Y’s clinical diabetes management plan and information from Ms X. The note of the discussion with the Care Home provides further detail about the planned support from the district nursing service. It said Care Home staff could dial and supervise Mr Y self-administering insulin but would not be able to administer insulin. It said that the district nurse team would support the Care Home with Mr Y’s insulin where necessary.
26. We do not have a copy of the Council’s care and support plan for Mr Y’s time at the respite placement, and therefore cannot say whether any changes were made to that plan. However, the supporting documents indicate the arrangements were that Care Home staff would supervise and support Mr Y to self-administer his insulin.
27. I recognise Ms X said her understanding was that district nurses would give insulin, but as noted above, the supporting documents refer to the district nurses providing support to Care Home staff in giving insulin where necessary, rather than the district nurses would administer insulin. The Care Home response also said it was informed at the initial assessment of Mr Y’s needs that he was able to self-administer insulin and staff had to dial the correct amount. The Care Home said there was no evidence that the care plan was changed.
28. The notes do not clarify what was explained to Ms X in terms of how the insulin would be given before the start of the respite placement. I recognise it must have been distressing for Ms X if insulin was not given in the way she expected. However, as noted above there is no indication in the documents available that the plan was for district nurses to administer insulin while Mr Y was at the Care Home. Based on the available information, my view is there was no fault in terms of changes to the care plan by the Trust, Council or ICB.

B) Management of Mr Y’s diabetes by Valorum Care Group during Mr Y’s respite placement

29. Mr Y began the respite placement at the Care Home, as arranged. The diabetes care plan in place at the time clearly set out what should happen if Mr Y experienced an acute hypoglycaemic or hyperglycaemic episode. Ms X complained the Care Home did not follow Mr Y’s diabetes care plan.
30. Regarding monitoring Mr Y’s diabetes and giving his insulin, the records show the Care Home monitored Mr Y’s blood sugar levels. In its response to Ms X’s complaint, Valorum Care Group acknowledged there was one occasion when the Care Home staff did not record the time insulin was given on the first day. The CQC guidance on how to meet the fundamental standards, Regulation 17: Good governance, says providers must securely maintain accurate, complete and detailed records in respect of each person using the service. Valorum Care Group said it would share feedback from this part of Ms X’s complaint with staff to improve record keeping and ensure the time medication is given is accurately recorded. As Valorum Care Group has acknowledged this shortcoming in record keeping and taken steps to prevent recurrence, I have not recommended any further action on this point.
31. The records show the Care Home contacted the Trust’s district nursing team when there were difficulties with administering insulin at 7.00pm on the second day. The district nurse team visited the Care Home and checked Mr Y’s blood sugar, which was within normal range at 8.4mmols.
32. Mr Y’s diabetes care plan did not include guidance on what to do should care staff be unable to give Mr Y his insulin or check his blood glucose, although the record of discussions between the Care Home and the Trust said district nurses would support where necessary. The Care Home contacted the district nurse team for support as the notes indicate was agreed. The district nurses advised care staff to allow Mr Y some time to settle, to be able to try and check his blood glucose, which they were later able to do.
33. There was a further district nursing visit that evening, at 9.20pm, and a telephone review at 11:25pm. These were in response to care staff again contacting the district nurses.
34. Initially Mr Y’s blood glucose was within normal range of 8.4mmols. The district nursing advice to continue to check through the night was in line with the diabetes care plan. However, as insulin could not be given, Mr Y’s blood glucose elevated to 23.2mmols with ketones of 0.3mmols. The care plan advice for blood ketones of less than 0.6mmols is “check in 2 hours until blood glucose reduces”. This is what the district nurse team advised care staff to do. Therefore, the district nurse team gave appropriate advice to the care home staff based on the care plan.
35. As Mr Y’s blood glucose was rising, the Care Home called 111 for advice, and then requested a GP call out. The records indicate that Care Home staff followed the advice given. At 8.30am the next day, the Care Home checked Mr Y’s ketone levels and as they were 1.7mmols, called an ambulance in line with the diabetes care plan.
36. As noted above, while we do not have a copy of the Council’s care and support plan for Mr Y while at the Care Home, the records indicate the arrangement was for the district nurses to support with administering insulin. It is documented the Care Home requested support from the district nursing team and followed the advice given, and called an ambulance in line with the diabetes care plan when Mr Y’s ketones were over 1.6mmols. Therefore, I found the Care Home managed Mr Y’s diabetes in line with his diabetes care plan and followed the advice given by the district nursing team.

C) Admissions to hospital

37. As noted above, following his initial period of respite care, Mr Y was admitted to hospital for issues related to diabetes, and then a subsequent admission after a fall at the Nursing Home.
38. Ms X complained the Trust failed to manage Mr Y’s diabetes, did not provide adequate nutrition, wrongly administered sedation to Mr Y, and put a DNACPR in place without discussing it with Ms X.
39. During his first admission to hospital, Mr Y was assessed by the Trust’s diabetes specialist team and a care plan was provided to support him after discharge. The NICE guideline on Type 1 diabetes referred to above, says individual diabetes care plans should include diabetes education including dietary advice, insulin therapy, self-monitoring, avoiding hypoglycaemia, cardiovascular risk factor monitoring and management, complications monitoring and management, and communicating with the diabetes professional team. While Mr Y’s plan does not provide details for each of these criteria, it includes the relevant interventions based on blood glucose and blood ketone readings.
40. The discharge plan following Mr Y’s first admission to hospital included the diabetes care plan and additional information about supporting Mr Y with any behaviour changes. The records also indicate that after Mr Y had been discharged, the Trust’s diabetes team met with the district nurse team and the Nursing Home, and provided further advice to the Nursing Home about managing Mr Y’s diabetes and actions to take following blood glucose and blood ketone measurements. The discharge summary also shows the diabetes care plan was reviewed by the hospital diabetes team and was shared with the Nursing Home with explanations of the care plan. The care plan included clear interventions to be followed based on blood glucose and blood ketone readings.
41. In response to Ms X’s complaint about how Mr Y’s diabetes was monitored and managed, the Trust acknowledged it had not completed food and fluid charts, accepted Mr Y was not weighed on admission, and said his weight should have been regularly recorded. The Trust also acknowledged Mr Y should have been referred to a dietician during his first hospital admission, so that further advice could have been sought about his reduced food intake alongside the diabetic team. This was fault by the Trust.
42. Ms X complained that failing to monitor Mr Y’s food and fluids during this period meant the Trust failed to adjust his insulin, and meant his diabetes was not properly managed during this period. Ms X said this caused Mr Y’s condition to deteriorate.
43. The Trust response accepted that failure to complete food charts meant it was difficult to monitor Mr Y’s food and fluid intake during this period, and to adjust his insulin in line with this as set out in his care plan. We recognise failing to document food intake may have had an impact on the care provided to Mr Y. Clear documentation supports other members of the multidisciplinary team in making their own assessments and taking the right steps to advance care, based on what has already been provided. Therefore, a lack of records of food and fluid intake may have caused miscommunication between staff and delays in treatment for Mr Y.
44. We are unable to say, even on balance of probabilities, whether this had an adverse impact on Mr Y’s condition. Because food intake is not recorded during this period, we cannot say whether or not Mr Y’s insulin was adjusted accordingly. This led to uncertainty for Ms X about what happened and what impact this may have had for Mr Y, and I recognise the distress this caused to Ms X.
45. In its response to Ms X’s complaint, the Trust said it would provide education to staff around the importance of completing dietary and fluid intake charts for patients with dietary or complex healthcare needs. The Trust also said it would include the issue of referral to a dietician in junior doctor training sessions. Therefore the Trust has taken reasonable steps to improve its services in this area following Ms X’s complaint, and has appropriately apologised to Ms X. I recommended the Trust provide a further remedy to recognise the impact on Ms X, set out below.
46. Ms X also complained the Trust put in place a DNACPR without discussing it with her. In its response to Ms X’s complaint, the Trust referred to the guidance from the Resuscitation Council UK regarding decisions about DNACPR. The Trust said the guidance recommends the next of kin should be consulted even though formal consent is not required. The Trust apologised for not explaining this properly to Ms X when it contacted her, and acknowledged the distress this caused her. I recognise the lack of explanation would have been distressing for Ms X. The Trust’s response recognised this and offered an appropriate apology to Ms X on this point.
47. Ms X also complained the Trust wrongly administered sedatives to Mr Y, and that this had an impact on his ability to eat and drink, which in turn affected his diabetes management. The records available indicate Mr Y was given lorazepam to support his behaviours. The Trust said Mr Y was initially given lorazepam while in the emergency department, so that blood tests could be done and Mr Y’s blood glucose could be monitored. The Trust’s response to Ms X’s complaint referred to further details from the records about lorazepam given during Mr Y’s first admission to hospital. It said the prescription was increased but acknowledged it was not clear from the records why this happened. The Trust acknowledged this fell below the expected standards for record keeping and said this would be raised with the medical team.
48. It is documented that Ms X was concerned about the level of sedation and reduced carbohydrate intake, and the geriatric consultant met with Ms X to discuss her concerns. Following this discussion, the dose of lorazepam was reduced to 0.5mg when required only. The Trust also acknowledged that given the prescription of lorazepam, a referral should have been made to the mental health liaison team for Mr Y. It said the consultant sought verbal advice from the team but this was not noted in the records. The Trust apologised for this.
49. Therefore, while the Trust acknowledged the reasons for increasing the prescription of lorazepam were not recorded, it took steps to address this by raising the issue with the medical team to improve services. The Trust also acknowledged Ms X’s concerns at the time when the consultant discussed the issue with her, and the dose was then reduced in view of her concerns. Therefore the Trust has provided a reasonable response to Ms X on the issue of her concerns about sedatives, and I have not made any further recommendations on this point.

D) Care provided at the Nursing Home

50. Ms X complained Priory Adult Care did not properly manage Mr Y’s diabetes while he was at the Nursing Home, delayed calling an ambulance, wrongly administered sedation to Mr Y and did not allow visits from family.
51. Regarding management of Mr Y’s diabetes, as noted above, Mr Y’s clinical diabetes management plan gives clear advice on the interventions to take in an acute hypoglycaemic and hyperglycaemic episode.
52. The records show Mr Y’s blood glucose readings were elevated the evening before he was admitted to hospital, when his blood sugar was 17.3mmols. It is noted that Mr Y was settled and appeared to be asleep.
53. Mr Y’s diabetes care plan says that if there were two blood sugar readings above 14.0mmols, without any symptoms (such as thirst, lethargy, passing urine more frequently than usual, nausea or vomiting), blood ketones should be checked. As noted above, the reading that evening was above 14.0mmols. However, the care plan does not stipulate how long staff should wait before checking blood sugars for a second time. The documentation says Mr Y was settled and appeared to be asleep, but does not provide any information as to whether Mr Y had any symptoms or not.
54. The records say the Nursing Home checked Mr Y’s blood sugars again the following morning at 8.45am. At that time, Mr Y’s blood sugar reading was 31.3, and his ketones were 7.4. The care plan makes it clear that given these readings, hospital admission was necessary.
55. The Nursing Home gave Mr Y a corrective dose of insulin and checked blood sugars again at 10.25am. At this time, the blood sugar reading was again raised at 27.0mmols and ketones were still at 7.4. It seems that at this point, the decision was made to take Mr Y to hospital.
56. The records indicate the Nursing Home contacted the diabetes nurse, but do not specify what time this was. However, in line with his diabetes care plan, Mr Y met the criteria for hospital admission as his ketones were 7.4.
57. The NMC Code referred to above says (section 13.1-13.2) nurses should “accurately identify, observe and assess signs of normal or worsening physical and mental health in the person receiving care” and “make a timely referral to another practitioner when any action, care or treatment is required”.
58. The record of the blood sugar reading that evening does not confirm whether Mr Y had any symptoms or that the blood sugar check needed to be repeated. We are not able to say what Mr Y’s ketones would have been had they had been checked at that stage.
59. We found fault by the Nursing Home in not referring Mr Y to hospital at the time of the high ketones reading at 8.45am the next day. However, we are unable to say whether this had an impact on Mr Y’s condition. I recognise this caused uncertainty to Ms X about whether things may have been different, and that this led to distress for Ms X.
60. The records for Mr Y’s second hospital admission from the Nursing Home on again indicate the reason as high ketones of 4.0. This appears in line with Mr Y’s diabetes care plan which as noted above indicates hospital admission for ketones over 1.5. Priory Adult Care’s response to Ms X’s complaint reflects the records on this point, as it states the decision to admit Mr Y to hospital was because the Nursing Home was unable to control his ketones, and sought medical advice. The available records do not indicate the timing of the blood ketones reading or when medical advice was taken following this. The lack of available records on this point means I am unable to comment on whether there was any delay in calling an ambulance at that time.
61. While I would usually recommend service improvements in view of the fault identified, as the Nursing Home is no longer owned by Priory Adult Care, I have not recommended that Priory Adult Care make service improvements. I have recommended an apology and a payment to Ms X in recognition of the uncertainty caused.
62. Regarding Ms X’s complaint that the Nursing Home wrongly gave Mr Y sedatives, the hospital discharge summary states “lorazepam tablet 500 microgram twice a day as required”. This information was also in the Nursing Home records. In its response to Ms X’s complaint, the Nursing Home said that its nursing staff were not prescribers, and that it gave the medication to Mr Y in line with the prescription. We do not have a copy of the Nursing Home medication administration record that shows when lorazepam was given. The complaint response sets out details from Mr Y’s records about the amount of sedatives given and said this was in line with the prescription. However, the Nursing Home acknowledged it should have raised Ms X’s concerns about sedatives with the prescriber at the time. This meant Ms X did not have the opportunity to have these concerns addressed.
63. Regarding Ms X’s complaint about visiting arrangements, a multidisciplinary team (MDT) meeting was held to discuss Mr Y’s care plan for his time at the Nursing Home. The meeting involved the ICB, Council social work team, the Nursing Home and Ms X. One of the issues discussed at the meeting was supporting family visits. The notes of the meeting say the importance of Ms X and their child being able to visit Mr Y was discussed and that Nursing Home staff would support Ms X with visiting and had noted a list of the times they were able to visit.
64. Ms X complained that they were allowed only a half an hour supervised visit each time. Ms X said she did not consider this was enough to support their needs as a family. Ms X also complained she should have been able to visit Mr Y’s room.
65. In response to Ms X’s complaint, Priory Adult Care said it was following government guidelines and its own policy in place at the time. It said that when Mr Y’s health deteriorated, the Nursing Home requested a risk assessment to enable visits in Mr Y’s own room. However, the risk assessment was still pending when Mr Y sadly died.
66. The Guidance on Care Home visiting says there were no nationally set restrictions for visiting care homes at the time. It says providers were expected to facilitate visits where possible, and to do so in a risk-managed way.
67. At the time Mr Y was at the Nursing Home, Priory Adult Care had in place the visiting policy: Family and friend visits to older people’s care homes (England) during the COVID-19 pandemic. This states to prevent infections in care homes, visiting should be very carefully risk assessed. It states there was no stipulated length of time for visits, but a time frame may need to be agreed in advance to ensure all residents are able to have equal access to visitors. In terms of the form visits could take, the policy states this included window visits, visits in the garden, or visits in a designated room within the home. It said a resident’s bedroom could be used if the home did not have a designated visiting room. As the Nursing Home did have a designated visiting room, this was used in line with the Priory Adult Care policy. As noted above, Priory Adult Care said it had started the process of a risk assessment to enable visits in Mr Y’s room, but this was not completed before Mr Y sadly died.
68. The policy also says staff will remain in the vicinity during the visit while maintaining enough distance to allow for private conversation and family time.
69. I recognise it must have been distressing for Ms X not to have been able to visit Mr Y in his own room, and the impact of this on the family. However, based on the information available, I have not seen any fault by Priory Adult Care on this point, as its actions on visiting appear to have been in line with its policy in place at the time.

Summary

70. I recognise that this was a very difficult and distressing time for Ms X. I found fault by the Trust and Priory Adult Care as set out in sections C) and D) above. I found this caused distress and uncertainty to Ms X.

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Action

71. Within one month of the final decision on this complaint, the Trust has agreed to:

• Make a symbolic payment to Ms X of £250 in recognition of the distress and uncertainty caused to Ms X by the faults acknowledged by the Trust, including lack of food and fluid intake charts, failure to refer to a dietician, and failure to weigh Mr Y on admission or at regular intervals.

72. Within one month of the final decision, Priory Adult Care has agreed to:

• Apologise to Ms X for the distress and uncertainty caused to her by the failings identified; and
• Make a payment to Ms X of £250, in recognition of the distress and uncertainty caused.

73. The Trust and Priory Adult Care should provide us with evidence they have complied with the above actions.

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Decision

74. I found fault by the Trust and Priory Adult Care causing injustice. The Trust and Priory Adult Care have agreed to take actions to address this. I did not find fault by the Council, Trust and ICB in changes to Mr Y’s care plan for his respite placement, or in the Care Home’s management of Mr Y’s diabetes. I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman