Cranhill Nursing Home (18 002 879a)

Category : Health > Other

Decision : Upheld

Decision date : 15 Aug 2019

The Ombudsman's final decision:

Summary: Mrs L complains Cranhill Nursing Home failed to care properly for her late husband Mr L. She also complains there was fault in the Council’s safeguarding investigation into Mr L’s care and the events leading up to his death. The Ombudsmen have partly upheld Mrs L’s complaints and made recommendations. The Ombudsmen have not found a link between poor care and Mr L’s death.

The complaint

  1. The complainant, whom I shall call Mrs L, complains about the personal and nursing care her late husband, Mr L, received at Cranhill Nursing Home (the Home), a respite placement funded by the Council and NHS. Specifically, Mrs L says that:
    • the Home failed to care correctly for Mr L’s continence needs, leading to a worsening in his health; and
    • the Home’s nurses failed to respond to Mr L’s symptoms in the days before and on 30 March 2018, or to call an ambulance promptly. Mr L was admitted to hospital with sepsis on 30 March 2018 and died the day after. Mrs L believes this might have been avoided had the nurses acted differently.
  2. Mrs L also complains about the Council’s safeguarding enquiry. Mrs L says the Council failed to look more widely at the care Mr L received before 30 March 2018. She considers the enquiry was biased and not supported by the evidence. Mrs L says this has caused her distress.
  3. Mrs L would like the Council and Home to acknowledge there were failings and give her a financial remedy.

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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. 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.
  4. When investigating complaints, if there is a conflict of evidence, the Ombudsmen may 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. 
  5. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
  6. 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 the following as part of my investigation.
    • Evidence Mrs L has provided by telephone.
    • The Council’s and the Home’s written responses to our enquiries.
    • Documentary records, including; Mr L’s daily care records and care plans from the Home, ambulance records, hospital medical records, the Council’s safeguarding records.
    • Advice from two independent and experienced clinical advisers: a senior nurse and a colorectal surgeon.
  2. Mrs L, the Council and the Home have had an opportunity to comment on a draft version of this decision.
  3. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

Background summary

  1. The Council arranged respite care for Mr L at the Home in February 2018. The care was paid for by the Council and NHS Funded Nursing Care (FNC). Mr L had complex health problems including liver cancer and needed help to move around, either from carers or by using equipment. He needed some help with personal care. Although continent most of the time, he could experience incontinence due to his health conditions and medication and would need personal care at the time. At the end of March 2018, Mr L became unwell and was taken from the Home to hospital by ambulance. He died in hospital the next day.
  2. Mrs L complained to the Council in May 2018. The Council dealt with the concerns she raised under its safeguarding procedures first. The Council held two safeguarding meetings in June 2018. It closed the safeguarding enquiry on 28 June 2018 as it decided the concern of neglect and acts of omission by the Home was not substantiated.
  3. Mrs L was not satisfied with this and remained concerned about Mr L’s care at the Home. The Council therefore considered her complaints about the care and the safeguarding enquiry. The Council replied to Mrs L’s complaint in July 2018. In summary, it said the safeguarding enquiry concluded:
    • the Home did not wait an hour to call an ambulance;
    • there was an impression of a delay because of poor recording by care home staff, but staff actually called an ambulance within five minutes of noticing a worsening of Mr L’s health;
    • continence care was a problem on only one occasion and the Home had adequately addressed concerns about this directly with Mr L; and
    • the rapid worsening of Mr L’s health happened because of his complex health condition and could have happened at any time. There was no indication it happened because of where he was living at the time.
  4. The Home replied to the part of Mrs L’s complaint that related to personal care in June 2018. It also agreed to put in place improvements as a result of the safeguarding enquiry.

Continence needs care

  1. There are standards for safety and quality care homes need to meet, which I will call the Regulations (The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). The Care Quality Commission (the CQC) has written guidance to help care homes meet these standards. This is known as the Fundamental Standards (Guidance for providers on meeting the regulations, March 2015). As part of these, care homes need to make sure:
    • they provide people with suitable care, personalised to their needs. This includes taking account of the person's preferences, and ensuring care and treatment is only provided with their consent (Regulation 9); and
    • they always treat people with dignity and respect. This involves ensuring the person has privacy, supporting their independence and respecting their wishes (Regulation 10).
  2. The Home’s care plan for Mr L said that he had variable mobility. It also said he was often incontinent because of a bladder/bowel fistula (an open connection between the bladder and intestine, which can allow faecal matter to pass into the urine). The care plan says Mr L needed:
    • help with transfer including to wheelchair;
    • help with sometimes urgent continence needs while maintaining as much independence as possible;
    • prompting and help with washing and dressing; and
    • a call bell always within reach.
  3. The Home’s complaint response to Mrs L says that Mr L complained direct to the Home about being left in a wet bed on one occasion in March 2018. The Home said that in response to the complaint, it:
    • interviewed the care assistants who were on shift at the time;
    • spoke to Mr L who said he found it difficult when those two carers were on duty; and
    • arranged for a nurse to supervise those carers when they were attending Mr L.
  4. The Home says Mr L did not raise further concerns about continence care at the time.
  5. The information I have seen indicates that:
    • Mr L had cause to complain about continence care at one point on his stay at the Home;
    • continence care did not continue to be a problem leading up to Mr L’s admission to hospital; and
    • Mr L did not continue to have concerns about continence care after raising the matter with the Home himself.
  6. I consider that:
    • the Home has already taken appropriate action to resolve this part of the complaint; and
    • further investigation is unlikely to find a link between poor continence care and Mr L’s last illness.

Events of 28-30 March 2018

Summary of key events

  1. According to the Home’s records of Mr L’s daily care for 28 March 2018, a carer noted “a sore on his stomach”, applied cream and told the nurse.
  2. The nurse who was on duty on 28 March has stated that she saw the mark observed by the carer on 28 March. The nurse says this was not a bruise or a swelling but a small red dry mark, about 1 cm in diameter.
  3. There are no further notes about bruising or marks in the abdominal area until 30 March. On 30 March:
    • a carer noted at 12:00 that Mr L had “a big bruise left side lower abdominal”, had difficulty standing using an aid, and that he went out for a cigarette;
    • a nurse noted that she observed an “old bruise left side of his lower abdomen” at 13:40;
    • information gathered as part of the safeguarding enquiry indicates Mr and Mrs L had a telephone conversation at about 16:30; and
    • the nurse made an entry timed 17:10 that said the ‘bruise’ was “getting bigger and spreading to groin region”, Mr L “appeared very breathless lethargic and in pain”. The same note includes Mr L’s blood pressure and pulse and says the nurse called an ambulance, the ambulance arrived, paramedics stated Mr L had an internal bleed and took him to hospital.
  4. As part of the safeguarding investigation, the nurse who cared for Mr L on 30 March provided more detailed information about what happened. Although this is not recorded in Mr L’s care notes, she said that she saw the ‘bruise’ between 13:40 and the time she called an ambulance and that it remained largely unchanged. She also said that she wrote the notes in the care records some time after the events, after her shift had ended at 8pm that day. She said that she called the ambulance without delay after seeing the enlarged ‘bruise’ and swelling and checking Mr L’s vital signs. Ambulance records refer to a bruise and swelling reported by the Home, but the paramedics described this as a haematoma (a swelling containing blood).
  5. The telephone bills showing the times of the Home’s telephone calls to Mrs L and the ambulance service’s records corroborate the nurse’s account, that she made a retrospective entry with an incorrect note of the time, but that she called an ambulance soon after she noticed the ‘bruise’ was enlarged and swollen. This is because the entry timed 17:10 said that she did observations, called an ambulance, the ambulance arrived, and she called Mrs L three to four times. The ambulance records and the Home’s telephone bill place all these events soon after 6pm.
  6. The ambulance records include the following information.
    • There was a 999 call at 18:06.
    • The observations the ambulance crew took at various points indicated Mr L may have sepsis.
    • The ambulance crew’s assessment considered Mr L may have had a perforated bowel and that he did not have capacity to make decisions about his treatment at that time.
    • Mr L arrived at hospital at 19:04.
  7. Mr L’s hospital medical records indicate:
    • Mr L was barely conscious and very poorly when admitted;
    • the doctors at hospital examined him and gave him antibiotics and fluids intravenously (delivered straight into a vein) soon after admission;
    • the doctors decided that Mr L should get medication for pain relief and to relieve anxiety if needed, but that there was no other investigation (such as scans) or treatment that would benefit him;
    • the hospital contacted Mrs L to advise her that Mr L was very ill, so she could visit him; and
    • later that evening the doctors decided that the best and kindest treatment for Mr L was to make him as comfortable as possible by stopping unnecessary observation and medication, moving him to a side room and providing pain relief.
  8. Mr L died the next day. Mrs L says the coroner’s office has told her that the mark the Home described as a bruise was a cyst. She believes that Mr L would have received successful treatment for sepsis and bowel perforation and would not have died, had he gone into hospital sooner.

My analysis

  1. NMC (2015) “The Code. Professional standards of practice and performance for nurses and midwives” (the Code) says that nurses must:
    • “complete all records at the time or as soon as possible after the event, recording if the notes are written some time after the event”;
    • “identify any risks or problems that have arisen and the steps taken to deal with them”;
    • “complete all records accurately”;
    • “accurately assess signs of normal or worsening physical and mental health in the person receiving care”; and
    • “make a timely and appropriate referral to another practitioner when it is in the best interests of the individual needing any action, care or treatment”.
  2. The Regulations say that care homes must:
    • provide care and treatment in a safe way (Regulation 12);
    • not provide care or treatment in a way that significantly disregards a person’s needs (Regulation 13); and
    • keep accurate and complete records of care given to residents (Regulation 17).
  3. I consider that the mark spotted on 28 March is more likely than not to be different from the mark spotted on 30 March because the available descriptions are so different. However, the nursing records of the mark spotted on 28 March are poor, do not include a body map or photographs and do not detail any steps the nurse took to deal with the sore. My view is that this was fault because the nursing records do not meet the requirements of the Code or Regulations.
  4. The independent nursing adviser has commented that a nurse would not usually call for emergency medical help for a “sore on the stomach” unless a person was otherwise unwell and displaying other symptoms such as pain, dizziness, low blood pressure and high pulse. There is no documentary evidence that Mr L was unwell in this way on 28 or 29 March. Having taken into account the available records for 28 and 29 March, and the comments from the nursing adviser, my current view is that the poor record keeping of 28 March did not cause Mr L harm.
  5. By midday on 30 March a carer had noticed what they considered was a bruise on Mr L’s lower left abdomen, correctly alerted the nurse and recorded it in Mr L’s notes. At this point, to act in accordance with the Code and Regulations, the Home should have:
    • accurately recorded the appearance of the mark and completed an incident report; and
    • taken and recorded observations (measurements such as heart rate, blood pressure, breathing rate, temperature) to accurately assess whether Mr L’s health was worsening.
  6. The independent nursing adviser has commented that it is more likely than not that such an assessment around midday on 30 March would have prompted a call for an ambulance at that time. This is because Mr L was largely immobile without help, so was unlikely to have injured his lower abdomen by himself and it is likely the assessment would have identified pain and abnormal observations.
  7. There is no evidence the Home accurately recorded the appearance of the mark or observed Mr L’s vital signs until the mark grew and developed into a large swelling at about 6pm. When the nurse was alerted to the change in the mark, she acted promptly by taking observations and calling an ambulance.
  8. I have asked an experienced surgeon, whose normal practice includes treating patients with bowel perforation, for advice on whether getting to hospital six hours earlier would have made a difference for Mr L. I have summarised his advice below.
    • It is very unlikely that the hospital would have made different decisions or given Mr L different treatment had he been admitted six hours earlier.
    • This is because it is unlikely Mr L would have been offered emergency surgery for the bowel perforation as he had incurable liver cancer and other significant illnesses and was already being considered for palliative care.
    • Treatment with antibiotics is the correct treatment for sepsis. But earlier treatment with antibiotics would not have made any difference to this as perforation of the bowel would not get better without an operation. It is unlikely that Mr L would have been fit for surgery, even if he had arrived in hospital six hours earlier.
    • This means that getting to hospital earlier would not have improved Mr L’s chances of survival.
    • It is likely that Mr L would have been in pain and that earlier hospital admission would have allowed better pain relief.
  9. Having considered evidence including ambulance, Home and hospital records made at the time, information from Mrs L, staff statements made after the event, and the advice from independent clinical advisers, I have set out my view on this part of the complaint below.
    • There was fault in the Home’s record keeping on 28 March because there are no accurate descriptions, photographs or body maps showing the “red sore” of 28 March. There is also fault in record keeping because the nursing records for 30 March are inaccurate and do not make it clear that they were written several hours after the event. The nursing records for 30 March incorrectly state that the mark, first noticed at about midday, was an old bruise, even though there are no previous records of a bruise in that area.
    • The Home acted with fault in failing to take observations of Mr L’s vital signs and in failing to properly document the “big bruise” as soon as the carer alerted a nurse to it at about midday on 30 March. It is more likely than not, had the Home done so then, that the results of the observations would have prompted a call for an ambulance straight away.
    • Failure to do so caused an unnecessary delay of up to six hours in Mr L being admitted to hospital.
    • It is more likely than not that Mr L would not have survived, even if he had gone into hospital earlier on 30 March. However, Mr and Mrs L may have had more time together before he died, and Mr L may have had access to stronger pain relief in hospital.
    • There is nothing that can be done now to remedy the injustice to Mr L. To remedy the injustice to Mrs L, the Home should write to her acknowledging what went wrong and offering her a meaningful apology.
  10. The Ombudsmen will not recommend further service improvements at the Home. This is because the Home has already acted to improve its procedures in light of Mr L’s experience and the safeguarding enquiry that followed. I have summarised the improvements below.
    • The Home has shown us improved recording sheets for wound care, weight monitoring and the auditing of continence care. An inspection by the Care Quality Commission (care home regulator) in late 2018 noted improvements in record keeping.
    • A local NHS clinical commissioning group (CCG) has trained the Home’s nurses in the use of a national early warning system, NEWS 2. This is a scoring system already used by hospitals and ambulance services to help identify when people’s vital signs indicate they are at risk of deteriorating.
    • The Home has shown us the detailed observation and escalation charts it uses to help staff take all relevant observations and decide when to seek more qualified or emergency medical help.

Safeguarding enquiry

Summary of key issues and events

  1. Mrs L says the Council failed to look more widely at the care Mr L received before 30 March 2018, that the enquiry was biased and not supported by the evidence. Mrs L says this has caused her distress.
  2. Mrs L raised safeguarding referrals through her support worker and the Care Quality Commission (CQC) between April and May 2018. The CQC referral contained concerns about Mr L’s continence care and about what happened on the day before Mr L died.
  3. 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. The Council must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.
  4. As part of its safeguarding investigation, the Council reviewed:
    • the Home’s daily care records, medication records and care plan for Mr L;
    • the Home’s assessments of Mr L for; manual handling, oral health/care, falls risk, malnutrition screening, personal evacuation planning, infection prevention, risk and pressure ulcer prevention;
    • the ambulance service report;
    • hospital notes; and
    • information the hospital’s safeguarding practitioner obtained from the coroner’s office by telephone.
  5. The Council also:
    • interviewed Mrs L and her support worker;
    • interviewed the nurse who had cared for Mr L at the Home on 30 March 2018 and the Home’s manager;
    • got information from Mr L’s GP and the community matron who cared for Mr L while he was in his own home and in the nursing home; and
    • asked the Home’s manager to provide a safeguarding enquiry report.
  6. The report considered the following allegations (in summary).
    • That a carer told Mr L not to ring the bell again after Mr L had rung it several times, and refused to change him, leaving him in urine and excrement.
    • That carers would not help Mr L into bed one night when it was changeover time so he had to struggle into bed on his own.
    • £20 went missing from Mr L’s room.
    • The Home delayed seeking medical help when Mr L became very ill with sepsis on 30 March 2018 and failed to let Mrs L know that he had been taken to hospital.
  7. The report said the allegations were not substantiated for the following reasons.
    • Mr L had the capacity to complain and had done so about two carers not attending to him one early morning when he needed frequent help with personal care. The carers and Mr L had differing accounts of what happened, but the Home resolved this by ensuring those carers were supervised by a nurse for any future personal care they gave to Mr L. The Home says Mr L raised no further concerns about this. OmH
    • Mrs L could not provide the dates and times for two other allegations (about a refusal to transfer Mr L to bed and missing money) so the Home could not investigate them further.
    • Mr L did not show signs of sepsis or internal bleeding until the afternoon of 30 March 2018. The care and nursing staff who saw Mr L on that day acted appropriately by calling an ambulance as soon as they became aware he had deteriorated.
  8. As a result of the safeguarding enquiry, the Home said it would take the following actions.
    • More robust use of mapping charts and more detailed documentation around the size and appearance of any markings.
    • Give all staff “information about documenting accurately and detailing any changes that occur and regular monitoring by senior staff”.
  9. The Home has provided sample record sheets which indicate it is now doing this.
  10. The Council held a safeguarding planning meeting on 26 April 2018 and a review meeting on 28 June 2018. The records of those meetings and the Council’s ‘safeguarding referral closure form’ show that the Council:
    • initially considered the concerns about continence care;
    • decided early during its investigation that the concerns about continence care did not meet the threshold for safeguarding action. This was because they related to an incident which the Home had dealt with by responding to Mr L direct; and
    • considered that the Home had acted appropriately and without delay in response to Mr L’s symptoms on the day he was admitted to hospital.
  11. The Council therefore decided that there was a lack of evidence to support the allegation of neglect or omission of care in the way the Home acted.
  12. The Council reminded the Home about the importance of good record keeping and informed the CQC of the problems with records so that CQC could take this into account in future inspections.

My analysis

  1. None of the records I have seen, or the evidence Mrs L has provided by telephone indicate the safeguarding enquiry was biased. The law allows the Council to ask a care home where the alleged neglect has happened to investigate locally and provide a report.
  2. The Council properly considered whether to include wider concerns, including those about poor continence care, lack of help from carers and missing money, in the safeguarding enquiry. It considered the relevant evidence thoroughly and its conclusions are supported by the evidence. So, there was no fault in the way the Council decided not to include these concerns in the safeguarding enquiry.
  3. The Council concluded the Home called an ambulance as soon as it became aware that Mr L was very unwell. This conclusion is supported by evidence. However, the available documentary evidence does not show the safeguarding enquiry adequately considered whether the Home did all it should have, including taking observations, when the carer first drew the nurse’s attention to a “big bruise” on 30 March. The Council says it is certain its enquiry did consider this properly, although the documentary records may not reflect this in detail. This was fault, but not one that affected Mr L, who had sadly died before the safeguarding enquiry took place. It is also unlikely to have affected other residents as the Home has made service improvements in response to the safeguarding enquiry.
  4. Had the fault not happened, Mrs L may have received a more comprehensive explanation of events sooner. I have made a recommendation to address this below.

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Recommendation

  1. Within one month of the date of this decision, the Home and Council should write to Mrs L to acknowledge the faults identified in this decision and to offer a meaningful apology.

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Final decision

  1. Mrs L complained that faults by the Home in caring for her late husband, Mr L, led to his death. She also complained that there were faults in the Council’s safeguarding enquiry. There were faults in the Home’s record keeping and some of its care of Mr L, but these did not cause his death. There was also fault in the Council’s safeguarding enquiry causing some injustice to Mrs L. The Home and Council have accepted our recommendations, so the Ombudsmen have completed their investigation.

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Investigator's decision on behalf of the Ombudsman

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