Summary: Mr A complained about his brother, Mr B’s care and treatment by a care home funded by a council, a GP and a hospital. Mr A said poor care led to his brother’s death. We found fault with the hospital’s complaint handling, leading to frustration for Mr A. The hospital took appropriate action to address this injustice. We have not found fault with the other parts of the complaint or with the other organisations.

The complaint

1. Mr A is unhappy with the care of his brother, Mr B, by Kettering General Hospital NHS Trust (the Hospital), Uppingham Surgery (the GP) and a care home (the Home) funded by Hertfordshire County Council (the Council).
2. Specifically, Mr A complains:

the GP:

• did not take enough action when Mr B became unwell.

The Home:

• did not take sufficient action in alerting emergency services earlier when Mr B became unwell;
• did not provide the Hospital with up-to-date information on Mr B’s condition;
• did not have carer workers stay with Mr B in hospital; and
• did not tell the family of the seriousness of Mr B’s condition.

The Hospital:

• commissioned an independent investigation which was not sufficiently robust and so came to flawed conclusions and recommendations; and
• handled the complaint badly.

3. Mr A said the impact of the circumstances on this case are that his brother died unnecessarily which has caused him distress.
4. As an outcome of this complaint Mr A would like:

• assurances that care will be improved to prevent this situation happening to other patients; and
• Financial payment for the impact of the loss of his brother and for the time and trouble taken to make the various complaints.

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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. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended). The Health Service Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’ in the delivery of health services (Health Service Commissioners Act 1993, section 3(1)).
7. 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).
8. 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.
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. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 

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How I considered this complaint

11. As part of my investigation, I considered evidence from the Hospital, the GP and Home including care records and complaint correspondence. I also considered evidence from Mr A provided in writing and in a telephone call.
12. I also considered the relevant legislation and guidance and took expert clinical advice.
13. I gave Mr A and the organisations the opportunity to comment on my draft decision. I considered comments from Mr A on my draft decision before I made my final decision.

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What I found

Background

14. Mr B had a rare condition which featured symptoms such as excessive eating and delayed development. In 2021 he lived in the Home. He became unwell and went first to the GP, who sent him back to the Home. Then, later that day, the Home sent Mr B to the Hospital as he was still unwell. A doctor in the Hospital examined him and he was discharged.
15. Mr B was admitted to the Hospital again the following day after carers suspected vomiting of blood. Doctors decided to keep Mr B in hospital for observation.
16. Mr B’s condition deteriorated, and in the early hours of the following morning, he vomited blood, suffered a cardiac arrest and died later that day.
17. The Hospital commissioned an independent company to carry out an investigation. Mr A also complained to the GP and Home before approaching the Ombudsman.

The GP

18. Mr A complained that the GP should have recommended Mr B be taken to hospital when the Home first raised concerns about his health.
19. The GP said the Home called to say Mr B was lethargic with no appetite, so it arranged for him to be seen in surgery by an advanced nurse practitioner.
20. Advanced nurse practitioners are educated in expert clinical practice. They have the freedom and authority to act, making their own decisions in the assessment, diagnosis and treatment of patients.
21. The Advanced Nurse Practitioner said Mr B reported no problems with his bowels or eating, he had no signs of pain, and his blood pressure, temperature and oxygen level were all normal.
22. A care worker had seen a small amount of vomit on his pillow that morning and he had not eaten his breakfast which they said was not like him. However, he had since eaten before he arrived at the surgery.
23. The Advanced Nurse Practitioner made a diagnosis of gastroenteritis or a stress related reaction to a recent vaccine jab.
24. The Advanced Nurse Practitioner told the carer to continue monitoring his condition and if there were any further episodes of nausea or vomiting to contact the Practice.

Analysis

25. Mr B’s observations were all in the normal range and his abdomen was not painful. His examination was in line with the National Institute for Health and Clinical Excellence (NICE) guidelines for suspected gastroenteritis.
26. The Advanced Nurse Practitioner made a diagnosis of viral gastroenteritis, and this would not have a need for hospital admission unless the patient showed signs of sepsis or severe dehydration. Neither was in evidence in Mr B’s situation.
27. The indications here were to send Mr B home with safety advice to seek medical attention if the symptoms got worse.
28. People with Mr B’ condition could ingest more food without vomiting but are at no greater risk of a gastrointestinal bleed from vomiting.
29. Taking this into account there was no fault on the part of the GP or the Advanced Nurse Practitioner’s actions.

The Home

30. Mr A said that his brother was very ill with a gastrointestinal bleed and the Home should have alerted the emergency services earlier so that this could have been treated earlier. In addition, Mr A said the Home did not provide enough information to the emergency services and did not stay with his brother in hospital.
31. The Home said it was a non nursing environment wholly reliant on community health services to maintain health. It said staff accessed health services in a timely and proportionate manner to identify any ill health in Mr B.
32. In addition, it said staff reacted promptly to any advice received from medical professionals.
33. The Home said when it was clear Mr B’s health and behaviour was unusual, staff acted quickly to call emergency services on more than one occasion.
34. In conclusion, the Home said it could not have taken any further action that would have resulted in earlier diagnosis and treatment.
35. The Home said it carried out a review which raised a number of learning points, all of which were helpful, but it did not identify failing in care that would have prevented Mr B’s death.

Analysis

36. The Care Quality Commission’s Fundamentals of Care state that residents should not be put at risk of harm and that providers should assess risk to health and safety.
37. The Home did this when raising Mr B’s health issues to the GP on the day he felt unwell. The fact the Advanced Nursing Practitioner acted reasonably when not classing this as an emergency situation, indicates that the Home acted appropriately in not calling emergency services earlier that day.
38. The following day staff called an ambulance when further black liquid was visible on Mr B’s bedding. Staff said they informed the Hospital of this, but there is no note of it in the hospital records. We cannot say, even on the balance of probabilities, whether care workers did not inform the Hospital about this. They informed the GP the previous day, and the vomiting was one of the main reasons why the carers called an ambulance to take Mr B to hospital. Yet it is not mentioned in the hospital admission records. For this reason, we cannot find fault with the Home.
39. Mr A complained that although a staff member was in hospital with Mr B, they then left hospital that evening. Mr A said this meant that no one was advocating for his brother so he could get proper treatment.
40. The Home said the staff member wanted to stay with Mr B but was told by the hospital that they could not stay. The staff member also considered that Mr B was getting the treatment he needed so left the hospital.
41. Mr B died the following day.
42. If the staff member was told they could not stay with Mr B, and he seemed settled, I do not find it was fault to not stay with him. However, the investigation into the Hospital highlighted that it was fault for the Hospital to send the staff away.
43. The Home provided up to date information to the family. It did not downplay the seriousness of the situation. This is because it was not seen by the Home or the Hospital as a life-threatening situation at that time.

The Hospital

44. Mr A said that the Hospital’s complaint handling was poor, and he also felt that the independent investigation it commissioned was not truly independent. He said the company commissioned by the Hospital, in most cases, sided with the NHS over complainants. In addition, he said the Trust was paying the company to complete the report and so it could not be truly independent.
45. As Mr A has already had his complaint investigated by another independent organisation after the Hospital, we will only investigate the treatment of his brother by the Hospital if we find that the independent investigation was potentially flawed.

Analysis

46. When deciding if the investigation was carried out to the required standard, we look at whether it looked at the right evidence, took any expert advice it needed and whether its conclusions are suitably robust.
47. The investigation took into account Mr B’s hospital records as well as taking statements from staff involved in his care.
48. The investigation also commissioned a report from an expert in the rare condition which Mr B had.
49. It weighed this evidence of the records, expert advice and witness statements and found that there were failings in Mr B’s care. However, it found that these failings did not lead to his death.
50. The investigation made several recommendations to the Hospital to improve its care in the future.
51. In relation to independence, I have not seen evidence that the investigation was not sufficiently independent. It is usual practice for a Hospital Trust to pay a company to carry out an independent report and so I have not found fault with this aspect of Mr A’s complaint.
52. Furthermore, I have not found fault with how the investigation was conducted. It took into account the right evidence and sought expert advice as well as speaking to the people involved in Mr B’s care. This meant that the investigation and its conclusions were sufficiently robust.
53. Regarding complaint handling, Mr A said there were several communication issues and delays by the Hospital in responding to his complaint.
54. The independent investigation highlighted several of these issues and recommended an unambiguous apology to the family for how they were treated.
55. It is apparent from the correspondence that the Hospital failed in communicating in an effective and timely manner with Mr A throughout the course of the complaint, which was understandably distressing for him. The Trust’s remedy of an apology was appropriate in the circumstances.

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Final decision

56. I found fault with the Hospital in relation to complaint handling which led to understandable distress for Mr A. The Hospital took appropriate action in apologising to Mr A. I did not find fault with the Hospital, Home, Council and GP in relation to the other aspects of Mr A’s complaint.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman