HC-One Ltd (18 009 105d)

Category : Health > Other

Decision : Upheld

Decision date : 15 Jan 2020

The Ombudsman's final decision:

Summary: The Ombudsmen consider Dudley Group NHS Foundation Trust’s (the Trust) communication with Mr C about Mrs D’s prognosis was poor which caused confusion and distress. Also, the Trust’s lack of care planning for Mrs D on discharge to two care homes caused Mr C uncertainty. Trinity House Care Centre’s diabetes care plan lacked detail and did not escalate Mrs D to a GP in a timely manner which caused Mr C distress at witnessing his mother suffer pain and distress. The Ombudsmen consider Dudley Metropolitan Borough Council’s (the Council) safeguarding investigation and safeguarding adults review caused Mr C uncertainty and distress. The Council, the Trust and Summerhill Surgery’s complaint handling compounded Mr C’s distress.

The complaint

  1. Mr C complains on behalf of his late mother, Mrs D, about the actions of Dudley Group NHS Foundation Trust (the Trust), Netherton Green Residential & Nursing Home (Netherton Green), Trinity House Care Centre (Trinity House), Summerhill Surgery (the Surgery) and Dudley Metropolitan Borough Council (the Council) between October 2014 and April 2015.
  2. Mr C says the Trust should not have discharged Mrs D in December 2014, twice in February 2015 and March 2015 as she was not fit. Also, it did not provide good instructions to Trinity House to manage Mrs D’s diabetes on 13 February 2015.
  3. Mr C says Netherton Green should have referred Mrs D to a GP sooner in December 2014. The GP employed by the Trust (the Trust GP) should have referred Mrs D to hospital sooner or provided care to her. Also, Netherton Green delayed getting Mrs D’s medication on 17 December.
  4. Mr C says Trinity House did not manage Mrs D’s diabetes well. Also, a GP employed by the Surgery (the Surgery GP) should have referred Mrs D to hospital in March 2015 with raised capillary blood glucose (CBG).
  5. Mr C says the organisations’ care and treatment caused Mrs D pain and distress and worsened her condition. Their failings either led to or exacerbated her death.
  6. Mr C says the Council’s safeguarding investigations were not robust. The Council did not investigate his concerns or find any failings. Also, the Council agreed to conduct an independent investigation, but later changed its mind.
  7. Mr C says he disagrees with the Safeguarding Adults Board (SAB) decision to not carry out a safeguarding adult review (SAR). The SAB did not follow its own policies and procedures because the incident on 17 December 2014 met the threshold for a SAR. Mr C also says the SAB did not share the threshold for a SAR with him, and there was a conflict of interest in the SAB panel.
  8. Mr C says the Council’s safeguarding investigation and review caused him distress.
  9. Mr C also says the organisations complaint handling was poor. They delayed providing him with responses, and those responses were brief or did not address his concerns. This caused him distress.
  10. Mr C would like all the organisations to recognise and apologise for their failings. They should carry out service improvements to avoid similar failings.

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The Ombudsmen’s role and powers

  1. 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).
  2. 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.
  3. The Ombudsmen may investigate, and question the merits of, action taken in the exercise of clinical judgement.
  4. The Ombudsmen cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant responsible body has to make. Therefore, my investigation has focused on the way that the body made its decision.
  5. 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. 
  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 complaint information Mr C has provide to me in writing and over the phone. I have asked the Council, Trust, HC-One, Surgery and Netherton Green to comment on the complaint, and provide supporting documentation. I have taken the relevant law and guidance into account. I also sought independent clinical advice from a stroke consultant, emergency department consultant, endocrinologist (a specialist in diabetes), nurse and GP.
  2. I have also written to Mr C with and the organisation with two copies of my draft decision (except HC-One) and considered their comments.

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What I found

  1. The Dudley Diabetes Management Guidelines for Adults with Type 2 Diabetes (2014) provided general information and direct for the clinical management of people with type 2 diabetes in the Dudley region. All the organisations involved in Mr C’s complaint told me they considered these guidelines when providing care and treatment for Mrs D’s diabetes.

Care and treatment

Key facts

  1. Mrs D had complex health problems, including diabetes and chest infections.
  2. In October 2014 the Trust admitted Mrs D after a stroke. The Trust discharged Mrs D to Netherton Green on 2 December for rehabilitation.
  3. Mrs D was at Netherton Green for two weeks. The Trust GP kept Mrs D under review. On 17 December 2014, the Trust GP made an urgent prescription for Mrs D but staff did not collect the prescription. Later that day, the Trust readmitted Mrs D after she suffered a seizure.
  4. The Trust treated Mrs D and on 6 February 2015 discharged her to Trinity House.
  5. On 13 February 2015 Trinity House sent Mrs D to the Emergency Department at the Trust with high capillary blood glucose (CBG). The Trust’s diabetic specialist nurse (DSN) lowered Mrs D’s CBG and said she could return to Trinity House the same day. The Trust told staff to give Mrs D some medication to lower her CBG. Trinity House disagreed with the medication recommendation and sent Mrs D back to the Trust. The Trust readmitted her.
  6. The DSN monitored Mrs D’s CBG. On 7 March 2015 the Trust discharged Mrs D back to Trinity House. During her stay her CBG rose and fell. The Trust readmitted Mrs D on 18 March with raised CBG. She stayed there until 6 April when the Trust discharged her to a hospice. Mrs D died at the hospice on 24 April.

The first admission at the Trust (19 October to 2 December 2014)

  1. I have reviewed the Trust’s medical records. After 11 November Mrs D’s temperature and standard observations remained stable.
  2. The Trust said Mrs D was medically fit for discharge on 14 November. Between then and 2 December, staff regularly reviewed Mrs D. Also, before the Trust discharged Mrs D, her CBG level was between 7 and 19, which was in line with the Royal College of Physicians (RCP) National clinical guideline for strokes (2012). Therefore, I consider Mrs D was medically fit for discharge from the Trust when it discharged her on 2 December and there was not fault by the Trust when it took this decision.
  3. However, Mrs D diabetes was always going to be difficult to manage at Netherton Green. Therefore, the Trust should have written a detailed care plan to help manage Mrs D’s diabetes. The care plan should have included references to support services. The failure by the Trust to write a care plan was fault and not in line with the RCP guidelines.
  4. I will consider the injustice caused by this fault at the end of the ‘Care and treatment’ section.

Netherton Green and the Trust’s GP (2 to 17 December 2014)

  1. The Trust GP kept Mrs D under regular review. He visited her and communicated well with staff. From the social care records, I do not agree Netherton Green missed the opportunity to contact the Trust GP or escalate any concerns.
  2. I consider the Trust GP provided care and treatment to Mrs D in line with good clinical care and practice. He reviewed Mrs D on several occasions, changed her treatment plan and referred her to the DSN when necessary.
  3. On 17 December 2014, Mrs D’s oxygen saturation was 90%. If her normal oxygen saturation was around 98% (like most people), then she should have been admitted to the Trust. However, Netherton Green’s records showed Mrs D’s normal oxygen saturation was 91%. Therefore, I do not consider the GP should have referred Mrs D to the Trust.
  4. The GP urgently prescribed a nebuliser and antibiotics to treat Mrs D’s infection on 17 December 2014. Netherton Green was responsible for collecting the prescription.
  5. Netherton Green later told Mr C it should have done more to get Mrs D’s medication from the pharmacy. It said, in future it would chase up any urgent requests for medication. If medication did not arrive when it should, staff would use a taxi to collect it.
  6. Netherton Green’s failure to collect the medication was fault. Netherton Green asked an epilepsy specialist if it had administered the nebuliser on 17 December 2014 could the admission to the Trust on 17 December 2014 have been prevented. The epilepsy specialist said it would have taken two days for the nebuliser to take effect if it was administered properly on 17 December. Therefore, it would not have relieved any pain or distress for Mrs D. I still consider events would have been distressing for Mr C. However, I am satisfied Netherton Green has put steps in place to avoid similar fault reoccurring.

The second admission to the Trust (17 December 2014 to 6 February 2015)

  1. On 24 December 2014 the Trust said Mrs D was medically fit for discharge. The Trust’s medical records show that before it discharged Mrs D, her observations and CBG were stable. Therefore, I do not consider the discharge on 6 February 2015 was unsafe.
  2. When Mrs D was readmitted on 17 December, she was most likely not going to recover from the massive stroke. In addition, she had problems swallowing and was a constant risk of chest infection. I consider the Trust’s stroke team missed the opportunity to explain why Mrs D’s prognosis was so poor and she was unlikely to recover. The Trust also should have discussed whether a palliative approach to manage Mrs D’s symptoms would be better. This was fault.
  3. Also, the Trust missed the opportunity to write a detailed care plan to help Trinity House manage Mrs D’s diabetes. Again, this was fault.
  4. I will consider the injustice caused by this fault at the end of the ‘Care and treatment’ section.

Trinity House (6 to 13 February 2015)

  1. When the Trust discharged Mrs D to Trinity House on 6 February, she was placed on a nursing bed. As she was on a nursing bed at that time, she automatically received funded nursing care (FNC) from the local clinical commissioning group. FNC is provided to meet the cost of care provided by registered nurses in all types of care homes.
  2. Trinity House completed a care plan for Mrs D, which included a management plan for her diabetes. The care plan said staff should aim to keep Mrs D’s CBG between 4 and 7. This range was in line with the national target CBG level for people with type 2 diabetes. However, it may not have been achievable for Mrs D considering her complex health problems.
  3. Mrs D’s care plan also said if her CBG remained “persistently high”, stop the enteral feed (her PEG tube) and pass water through it. However, “persistently high” was open to interpretation, and the care plan did not explicitly state when staff should refer to a GP. This was fault.
  4. Between 6 and 8 February 2015 Mrs D’s CBG was persistently high, reaching 14.1 on 8 February. On 8 February staff should have stopped Mrs D’s feed and passed water through the tube. However, it took until 11 February for Trinity House to do that. I do not consider staff were following Mrs D’s care plan.
  5. Trinity House did not recognise Mrs D’s worsening condition or make a timely referral to her GP. This was fault and not in line with sections 13.1 and 13.2 of the Nursing and Midwifery Councils The Code: professional standards of practice and behaviour for nurses and midwives (2015).
  6. I will consider the injustice caused by the fault at the end of the ‘Care and treatment’ section.

The Emergency Department visit (13 February 2015)

  1. Mrs D arrived with high CBG and the Trust appropriately arranged for a DSN to assess and treat her. The DSN said Mrs D could safely return to Trinity House if her CBG fell below 15.
  2. At 1.03pm, Mrs D’s CBG was 18, and at 8.30pm it was 13.7. It would have been preferable for the Trust to have documented the CBG on discharge at 3.20pm. However, on the balance of probabilities, Mrs D’s CBG fell below 15. When she returned to Trinity House, at 5.20pm and 5.35pm her CBG was 14.2 and 12.2 respectively.
  3. The Trust, in its complaint response, acknowledged it should not have copied and pasted the DSN’s notes into the Emergency Department’s discharge letter. Those notes were meant for the Emergency Department, and not Trinity House.
  4. The notes included a recommendation to the Emergency Department to administer a specific medication for Mrs D’s diabetes. This led to Trinity House sending Mrs D back to the Trust. Including the DSN’s notes in the discharge letter was not in line with the General Medical Councils Good Medical Practice (2014) guidelines which state doctors should transfer patients safely between healthcare providers. The Emergency Department should have formally contacted Trinity House before discharge to ensure it could carry out the DSN’s instructions. This was fault.
  5. I am satisfied the Trust has recognised this and communicated the fault with the Emergency Department in a weekly operational meeting to ensure learning. The Trust also spoke with the consultant responsible for the discharge letter and diabetes instructions. However, from the evidence I have seen, the Trust has not formally apologised to Mr C for the distress caused by its miscommunication. I have recommended a remedy to address this.

The third admission to the Trust (13 February to 7 March 2015)

  1. On 7 March 2015, Mrs D was alert and her CBG and clinical observations were stable. Mrs D’s insulin treatment during the admission was also in line with Joint British Diabetes Societies Glycaemic management during the inpatient enteral feeding of stroke patients with diabetes (2012). The medical records show Mrs D was medically fit for discharge on 7 March.
  2. The Trust wrote a care plan so Trinity House could safely manage Mrs D’s diabetes in the community. It said her CBG should be between 6 and 14. This was good clinical care and treatment. However, the Trust again missed the opportunity to discuss Mrs D’s prognosis with the family and consider a palliative approach to manage Mrs D’s symptoms in the community. This was fault.
  3. I will consider the injustice caused by the fault at the end of the ‘Care and treatment’ section.

Trinity House and the Surgery’s GP (7 to 19 March 2015)

  1. Mrs D’s diabetes was again unstable between 7 and 19 March 2015.
  2. Before 11 March, Trinity House followed the Trust’s instructions and administered insulin in the evening. The care records showed this reduced Mrs D’s CBG.
  3. Between 11 and 16 March, Mrs D’s CBG remained higher than 14. However, Trinity House correctly sought input from the GP and DSN. Trinity House followed their instructions which did reduced Mrs D’s CBG. This was not fault.
  4. When Trinity House staff referred Mrs D to the Surgery’s GP, I consider the GP provided good clinical care and treatment. The GP prescribed insulin in line with the local diabetes protocol, sought advice from the DSN, and then followed their advice. I do not agree the Surgery GP should have referred Mrs D to the Trust.

Injustice

  1. The Trust missed the opportunity at all the admissions to have an open conversation with the family about Mrs D’s poor prognosis. I consider this caused confusion among Mr C’s family about Mrs D’s health and potential for recovery. This is linked to the Trust’s missed opportunity to consider a palliative approach to manage Mrs D’s complex health needs in the second and third admissions. On the balance of probabilities, palliative care would have reduced some pain and distress Mrs D suffered at Trinity House. Mr C and the family suffered distress at witnessing Mrs D’s pain and distress.
  2. After the first and second admissions, the Trust did not write a detailed care plan about how Netherton Green and Trinity House should manage Mrs D’s diabetes. Trinity House did not always manage Mrs D’s diabetes well. A detailed care plan would have most likely led to Trinity House providing better care to Mrs D. This has caused Mr C uncertainty of never knowing what care and support his mother could have received.
  3. Between 6 and 13 February 2015 Trinity House’s diabetes care plan was not detailed enough to say when staff should seek professional support. This led Mrs D to become hyperglycaemic. Mr C suffered distress at watching Mrs D’s distress then.
  4. The Council and the Trust have both denied responsibility for funding Mrs D’s nursing bed at Trinity House between 6 and 13 February 2015. However, I consider the fault I have identified above was the responsibility of Trinity House. The registered nurse at Trinity House was managing Mrs D’s health needs (including her diabetes) and would have been responsible for seeking support from a GP. I would not have expected a standard social care worker at Trinity House to have made those decisions for Mrs D.
  5. As Mrs D’s FNC was paying for the nursing care, I consider Trinity House was responsible, as a health provider, for the fault I have identified.
  6. In February 2015, Trinity House was owned by HC-One Care Limited (HC-One). When HC-One sold Trinity House to Trinity House Care Limited, it agreed to take responsibility for all liabilities until it sold Trinity House in July 2016. Therefore, I consider HC-One is responsible for remedying the injustice to Mr C.
  7. Mr C told me failings in his mother’s care and treatment led to or worsened her death. I cannot agree with Mr C’s claimed injustice. I have not seen evidence that links the fault I have identified above to this claimed injustice.

The safeguarding investigations

Relevant law and guidance

  1. Section 42 of the Care Act 2014 says that a council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk.
  2. The Council followed the “Multi-agency policy and procedures for the protection of adults with care and support needs in the West Midlands” when exploring Mr C’s safeguarding alerts.

Safeguarding alert 1

  1. In December 2014, Netherton Green raised a safeguarding alert (Alert 1) for Mr C’s sister about Mrs D’s personal care and issues with medication on 17 December 2014.
  2. After a safeguarding case conference in November 2015, the Council noted:
    • Record keeping was inconsistent but Netherton Green now used daily notes to record care. Also, it provided training to improve staff record keeping. The family were satisfied this was resolved as best it could (but Mr C contests this).
    • It would complete a timeline of events for 17 December 2014 and arrange another meeting to discuss that with the family.
    • Netherton Green would take disciplinary action if staff did not chase prescriptions in future.
  3. In August 2016 the Council held another case conference. It noted Netherton Green tried to answer questions about the decision making on 17 December 2014. Netherton Green said it would take disciplinary action against staff who did not chase up urgent prescriptions in future. It also agreed to provide further information to Mr C about numerous issues.
  4. In September 2017, the Council held another case conference. The Council was satisfied Netherton Green should have chased the prescription on 17 December 2014 and made improvements.

Safeguarding alert 2

  1. On 17 February 2015, Trinity House raised a safeguarding alert (Alert 2) about the Trust’s discharge plan on 13 February (when it sent Mrs D back to the Emergency Department).
  2. After a safeguarding case conference in November 2015, the Council noted the Trust agreed the 13 February discharge was flawed and would review its procedures. There was evidence of neglect, but the Trust had identified learning. It took no further action.

Safeguarding alert 3

  1. In March 2015, the Trust raised a safeguarding alert (Alert 3) for Mr C and his sister. The concern was about Trinity House’s management of Mrs D’s CBG and lack of GP support, resulting in neglect.
  2. After a safeguarding case conference in November 2015, the Council noted:
    • The family said they had to check Mrs D’s CBG as Trinity House were not. Trinity House said the family should not have interfered.
    • Trinity House said Mrs D’s CBG was unstable but checked them regularly. This was common for people with a PEG feed.
    • It was responsive to Mrs D’s needs and discussed this with the family and professionals at the time.
    • There should be another meeting to discuss new issues with Alert 3.
  3. In August 2016, the Council held another case conference, the Council noted Trinity House’s management of Mrs D’s diabetes was not neglectful. The safeguarding should not be used to challenge clinical decisions. The Council referred Mr C to make complaints to the Trust or take legal action.

Analysis

  1. Mr C said the safeguarding investigation into Mrs D’s care was not robust. It did not investigate the allegations of neglect or find failings in her care.
  2. The Council said the first safeguarding meeting showed failings by the Netherton Green and Trinity House when managing Mrs D’s diabetes. The Council held a meeting in September 2017 as Mr C still had concerns about the safeguarding process.
  3. I have reviewed the Council’s safeguarding records and will consider each Alert.
  4. The social worker visited Netherton Green in April 2015 to discuss Alert 1 and review Mrs D’s records. It should not have taken the Council until August 2016 to confirm the timeline to Mr C. This was fault. However, I consider the Council robustly considered Mr C’s concerns in August 2016 and September 2017. The Council carried out a thorough investigation which identified failings and how Netherton Green had improved its practice.
  5. I consider the Council provided a robust response to Alert 2. The Trust agreed the discharge was flawed and would show how it learnt from the fault.
  6. I also consider the Council provided a robust response to Alert 3. It included the relevant professionals as best it could. The minutes from each meeting show the Council thoroughly considered Mr C’s issues. When there were disagreements, it carried out further work to bridge any gaps.
  7. However, there were significant delays during the safeguarding process. I understand the complexity of the issues in Mrs D’s care and the many agencies involved. Also, the family were raising new issues which the Council agreed to look at. However, I do not think this justified taking nearly three years to decide Alert 1, and nearly 18 months to finish Alert 3.
  8. The gaps between the case conferences stemmed from the fractured communication between the social worker leading the investigations and the clinical commissioning group’s safeguarding contact. Mrs D’s social care records show the Council made no progress in June or August 2015. This was fault. I appreciate how the delays would have been distressing for Mr C.
  9. The Council also took too long to refer Mr C to the Trust and Surgery complaints processes. It was clear Mr C had concerns about the quality of his mother’s care and treatment provided by NHS organisations from March 2015. The Council missed that opportunity, which could have reduced the time it spent addressing clinical concerns.
  10. Mr C said the Council agreed to conduct an independent investigation, but later changed its mind without telling him.
  11. The Council told me it did not agree to carry out an independent investigation. Rather, the Council asked a team manager to review the safeguarding investigations.
  12. I have reviewed the March 2018 conference minutes, and a call recording Mr C provided to me. I do not doubt Mr C’s version of events. The council agreed to “review how the safeguarding process was undertaken” in the March 2018 minutes. Also, during the call recording the Council mentioned the phrases ‘independent review’ ‘internal investigation’ and ‘tabletop review’. I do not consider the way the Council carried out the review of the safeguarding investigation was fault. The team manager was not involved in the initial safeguarding investigations and was far enough removed from them to provide an objective review of how the safeguarding investigations were handled. I do not think the Council misrepresented how it would handle that review.

The safeguarding adults review

  1. The Safeguarding Adults Board (SAB) must arrange a safeguarding adult review (SAR) when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.
  2. The Dudley Safeguarding Adult Review referral flowchart shows on receiving a referral, the SAR panel considers the referral and decides whether to accept or reject the referral. If the SAB panel rejects the referral, it should give its reasons in writing to the independent chair and consider alternative ways to address the issues contained in the SAR referral. The SAB should also confirm its result in writing to the referrer.
  3. Mr C disagreed with the SAB’s decision to not carry out a SAR. He said the events on 17 December 2014 met the threshold. The Council told me the SAB panel did not carry out an SAR because it did not meet the threshold for a review.
  4. The Ombudsmen cannot say the decision to carry out an SAR was right or wrong. This is a matter of professional judgement and a decision that the relevant responsible body must make. Therefore, my investigation has focused on the way that the SAB made its decision.
  5. I have considered the SAR referral, the panel’s initial screening and the outcome letter to Mr C. The panel robustly considered Mr C’s concerns against the criteria. It explained why it could not add anything to the learning already identified from events on 17 December 2014. Also, why it did not agree the cause of death was linked to the safeguarding concerns. This was not fault.
  6. Mr C said the SAB has not followed its own policies and procedures. Mr C referred his SAR form to the SAB after July 2018. The SAB considered Mr C’s comments at the initial screening in December 2018. The panel was unanimous that Mr C’s case did not meet the threshold for a review. Therefore, it did not refer the case to the independent chair. The SAB provided the reasons for not carrying out an SAR to Mr C in April 2019.
  7. Mr C has provided evidence to show the independent chair was not involved in the SAB’s decision to not carry out the SAR. When the SAB declined Mr C’s review it should have given its reasons in writing to the independent chair and consider alternative ways to address Mr C’s issues. This did not happen, despite the SAB saying it did in its outcome letter to Mr C. This was fault and not in line with the local policy. I understand how this would have been frustrating for Mr C.
  8. I also consider the Council took too long to confirm the outcome of the SAR screening to Mr C and the independent chair. The SAB made its decision in December 2018 and did not provide Mr C with the outcome until April 2019. The SAB’s policy does not mention timescales for getting back to the referrer. However, four months is too long, and this was fault. The delay was an oversight by the SAB which caused Mr C distress.
  9. Mr C said the SAB did not share the threshold for a SAR with him. I consider the Council explained what the threshold was in section 1.5 of the SAR request form.
  10. Mr C said there was a conflict of interest in the SAB panel. I do not consider there was a conflict of interest in the SAB panel. Various professionals decided not to carry out the SAR, not just the Council. This was not fault.

Complaint handling

The Trust

  1. The Trust held two meetings with Mr C in March and August 2017 to resolve his concerns. The Trust provided copies of the meeting recordings to Mr C.
  2. In February 2018 the Trust wrote to Mr C. It said as Mr C had copies of the meeting recordings, it would not detail what was discussed. However, the Trust provided a brief history of various clinician’s responses to Mr C’s concerns.
  3. I consider the Trust significantly delayed providing a written response after the meetings in March and August 2018. This was fault and caused Mr C uncertainty. The Trust apologised to Mr C.
  4. I also consider the Trust should have provided a more robust written response to Mr C. The audio recordings of meetings were not an appropriate response to Mr C’s complaint. Also, the Trust did not attach a transcript or minutes from the meeting to its response. This was fault. I understand Mr C discussed the issues with various clinicians. However, the lack of a written response caused Mr C uncertainty about the Trust’s care and treatment.
  5. During my investigation, I raised the lack of detailed response with the Trust. The Trust told me it has changed its practice. It now provides a detailed letter addressing complaints alongside copies of meeting recordings. I am satisfied the Trust has learnt from the fault in this case. However, the Trust needs to do more to remedy Mr C’s injustice.

Netherton Green

  1. Mr C did not make a formal complaint to Netherton Green. Rather he sought documents from them to help the Alert 1 safeguarding investigation. After asking why Mr C needed his mother’s care records, I understand Netherton Green provided them to him within a suitable time frame.
  2. In October 2017 Netherton Green wrote to Mr C after a safeguarding meeting. It apologised for the distress caused by events on 17 December 2014. I consider this was a proportionate response to Mr C’s concerns. Also, the safeguarding investigation minutes included more detail about the care Netherton Green provided. I do not agree Netherton Green was at fault.

The Council

  1. The Council’s Adults and community health and social care complaints and representations policy and procedures (2018) says:
    • It can decide if issues would be better managed outside the complaints process, such as safeguarding.
    • An independent investigator may be appointed to investigate the complaint
    • It will try to resolve complaints within 20 workings day from receiving the complaint. However, it may take longer than this if the issues are complex.
  2. In February 2018, Mr C complained to the Council. He disagreed Alert 1 was concluded and considered it had shown evidence of neglect. In March 2018, the Council’s head of safeguarding adults chaired a safeguarding conference. He agreed to review how the Council handled Alert 1.
  3. In June 2018, a team manager not involved with Mr C before, told Mr C she would check if the Council followed the relevant policy when investigating all the Alerts.
  4. In August 2018, the Head of Adult Safeguarding wrote to Mr C. He said the team manager found failings during the safeguarding process. However, these would not have changed the result for Mrs D. The Council had and will improve through training and supervision.
  5. In September 2018 Mr C asked why the reopened safeguarding investigation had morphed into a complaint response. Two days later the Council said the team manager’s review was an appropriate way to deal with Mr C’s complaint.
  6. The Council took four months to tell Mr C how it was going to investigate his concerns about their safeguarding investigations. It then took another two months to provide its response to him. I understand how the case would have taken longer than 20 working days to investigate. However, the Council has not explained why it took the team manager six months to complete her investigation. That delay was fault. I agree that would have been distressing for Mr C.
  7. The Council asked someone not involved with the safeguarding investigations to review them, and report to the Head of Adult Safeguarding. That was an appropriate way to address Mr C’s complaint. It was in line with the Council’s policy. However, the August 2018 response to Mr C referred to “failings in our processes” and it “will improve through training and supervision”. However, the Council did not detail what those failings were or explain how training and supervision would improve its practices. This was too vague, and I consider it was fault. I agree this would have caused Mr C uncertainty about the Council’s safeguarding investigations.

The Surgery

  1. In February 2017 Mr C told the Surgery he wanted to discuss the GP’s diabetic care while Mrs D was at Trinity House. In response, the Surgery provided Mr C with Mrs D’s medical records to address his issues. The Surgery then held a meeting with Mr C a month later to discuss his concerns.
  2. After phone conversations in February 2018, the Surgery wrote to Mr C. It said the GP addressed his concerns in the March 2017 meeting.
  3. The Surgery’s letter to Mr C in February 2017 suggested the medical records would address his concerns. This was fault. To provide medical records was not an appropriate response to Mr C’s concerns. I understand the Surgery held a meeting with Mr C in March 2017. However, the Surgery should have followed up with a letter addressing his specific concerns. This was fault and the lack of a written response caused Mr C uncertainty about the Mrs D’s care and treatment.

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Recommendations

The Trust

  1. Within four weeks, the Trust should apologise and pay £1,000 to address the injustice Mr C suffered, which includes:
    • Confusion about Mrs D’s prognosis caused by the lack of open communication.
    • Distress caused to Mr C on 13 February 2015 by the miscommunication in the Emergency Department.
    • Distress at witnessing Mrs D suffer pain and distress at Trinity House caused by the lack of consideration of palliative care during the second and third admissions.
    • Uncertainty at what care and treatment Mrs D would have received at Trinity House had the Trust completed detailed care plans during the first and second admission discharge process.
  2. Within eight weeks, the Trust should create an action plan to improve the way it communicates a patient’s poor prognosis with families. Also, ensure it creates care plans in line Royal College of Physicians for patients (who have suffered a stroke) when it discharges them to a community setting.

The Council

  1. Within four weeks, the Council should apologise and pay £500 to address the injustice Mr C suffered, which includes:
    • Distress caused by significant delays during its safeguarding investigation, SAR and complaint handling.
    • Frustration caused by not following the local policy when the SAB decided to not carry out an SAR.
    • Uncertainty caused by the vague complaint response in August 2018.

HC-One

  1. Within four weeks, HC-One should apologise to Mr C and pay £500 to address the distress he suffered at witnessing Mrs D suffer distress caused by Trinity House’s poor diabetes management.
  2. We would normally include a recommendation that HC One introduces a systemic remedy to avoid similar fault happening to others. As HC-One is no longer responsible for Trinity House, we will not be making a system remedy in this case. However, in response to my draft decision, HC-One said it has implemented accredited diabetes management training across its care teams (accredited by the Nursing and Midwifery Council). It has also revised its diabetes management policies and procedures. This ensures staff understand the condition, reduce risk and respond to escalated observations.

The Surgery

  1. Within four weeks, the Surgery should acknowledge and apologise and pay £250 for the uncertainty Mr C suffered from its poor complaint handling.
  2. Within eight weeks, the Surgery should create an action plan to show how it will change its practice to ensure complainants receive a detailed written response after making a formal complaint.

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Final decision

  1. I found fault with the Trust’s communication with the family, its lack of care planning when it discharged Mrs D in December 2014 and February 2015, its miscommunication with Trinity House on 13 February and its complaint handling. This caused Mr C an injustice which it needs to remedy.
  2. I have not found fault with the Netherton Green’s management of Mrs D’s diabetes or its complaint handling.
  3. I found fault with the Council’s safeguarding investigation and the SAR. This caused Mr C an injustice which it needs to remedy.
  4. HC-One was responsible for Trinity House’s poor diabetes care planning and escalation to the GP. This caused Mr C an injustice which it needs to remedy.
  5. I found fault with the Surgery’s complaint handling. This caused injustice to Mr C which it needs to remedy.

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Investigator's decision on behalf of the Ombudsman

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