Summary: A Council accepted several failings in the care one of its Care Home’s provided to an elderly resident. We found that the Council did not acknowledge the impact these failings had on the resident and her family. We did not find any fault in the care provided by a GP practice or an out of hours GP service. We recommend the Council takes steps to ensure improvements have been made to prevent recurrences.

The complaint

1. Mrs A was a resident of a City of Bradford Metropolitan Borough Council (Council) care home, Beckfield Resource Centre (the Care Home), from June 2021 to March 2022. During this time she also received care from the Rockwell and Wrose Medical Practice (the Practice) and Local Care Direct. Mrs A’s daughter, Mrs B, complains that:
1. The Care Home provided Mrs A with inadequate support with food and drink throughout her time there.
2. The Care Home provided Mrs A with inadequate pain relief throughout her time there.
3. Staff from the Care Home and the Practice failed to take appropriate steps to manage Mrs A’s urinary incontinence and, in turn, to prevent her from developing urinary tract infections (UTIs) and associated problems. Mrs B said the poor continence care also caused Mrs A to develop an avoidable moisture associated skin disorder.
4. Staff from the Care Home and the Practice failed to take appropriate steps to manage Mrs A’s faecal incontinence. In particular, Mrs B complains about the inappropriate over-use of oral laxatives and about a failure to refer Mrs A to specialist continence practitioners.
5. The Practice failed to diagnose Mrs A as suffering from an impacted bowel between October 2021 and 29 November 2021.
6. The Care Home acted inconsistently and unfairly in periodically preventing Mrs B from visiting Mrs A due to Covid restrictions. Mrs B said the Care Home’s interpretation and application of restrictions depended on which member(s) of staff were on duty.
7. On 28 December 2021 a member of Care Home staff told Mrs B to end her visit to Mrs A after 45 minutes. Mrs B said the member of staff shouted at her, told her to “get out” and continued to behave aggressively when Mrs B was in reception.
8. The Practice failed to respond appropriately to concerns Mrs B told an Advanced Nurse Practitioner (ANP) about, on 21 March 2022, about Mrs A having an impacted bowel again. Mrs B complained the ANP refused to re‑examine Mrs A but ruled out an impacted bowel.
9. A Social Worker failed to follow-up on an assurance she gave to Mrs B, on 21 March 2022, to discuss Mrs B’s concerns about Mrs A’s health with the Practice.
10. The Care Home failed to tell her about Mrs A’s worsening condition in late March 2022.
11. An on-call doctor from Local Care Direct provided inadequate care and advice on 29 March 2022.
12. Care Home staff failed to act on the advice of an on-call doctor on 29 March 2022. Specifically, that staff failed to monitor Mrs A and left her unattended for three hours.
13. Avoidable delays and procedural failings in the way Council staff completed a Continuing Healthcare Checklist for Mrs A.

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What I have and have not investigated

2. I have investigated issues (a) to (l).
3. I have not investigated issue (m) as there are too many variables and unknowns for the Ombudsmen to be able to say what would or would not have happened if a Checklist had been completed earlier or differently. We could only speculate on whether, and how, a different Checklist process would have altered Mrs A’s day‑to‑day care and, in turn, how those changes may have changed what happened. As such, there is no prospect of reaching a meaningful outcome by investigating this issue.

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The Ombudsmen’s role and powers

4. The Ombudsmen 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)
5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship. (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended) If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
6. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
7. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7))
8. 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

9. I considered Mrs B’s written complaint to the Ombudsmen and the additional information she provided by email. I also spoke to her on the telephone. I wrote to the Council, the Practice and Local Care Direct to explain what I intended to investigate and asked questions and for copies of records. I considered all the information I received in response. I considered relevant legislation and guidance. I took advice from an independent clinical adviser, a practising GP.
10. I shared a confidential copy of this draft decision with Mrs B and the Council, the Practice and Local Care Direct and invited their comments on it. I considered all the comments and evidence I received in response.

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What I found

Relevant legislation and guidance

11. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers who show they meet the fundamental standards of care, inspects care services and issues reports on its findings. I have used the Care Quality Commission (Registration) Regulations 2009 when considering this complaint. I have referred to these as the “Regulations”.
12. Regulation 14 relates to nutrition and hydration. The CQC guidance that accompanies this regulation says care providers must make sure people have enough to eat and drink to meet their nutrition and hydration needs and receive the support they need to do so.
13. Regulation 17 says care providers should “maintain secure” records. They should have “an accurate, complete and contemporaneous record in respect of each service user.” This should include “…a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.”
14. In 2013 the General Medical Council (the GMC) issued guidance on good medical practice (Good medical practice, 2013, updated 2020). This said where doctors “assess, diagnose or treat patients they must:

• Adequately assess the patient’s condition, taking account of their history (including the symptoms…)…; where necessary, examine the patient
• Promptly provide or arrange suitable advice, investigations or treatment where necessary
• Refer a patient to another practitioner when this serves the patient’s needs.’” (Paragraph 15, Good Medical Practice)

Brief overview of events

15. We have summarised below the key events. This is not intended to be a detailed account.
16. Mrs B told us that, in early 2021, Mrs A was a “remarkably active and able 97‑year‑old”. In May 2021 she fell and broke her leg. She went into hospital and had surgery. Mrs A remained in hospital until late June 2021. She then moved to the Care Home for a temporary placement. Mrs A was unable to bear her own weight. She also had other long-term health issues including dementia, osteoarthritis and osteoporosis. At the time of her transfer from hospital to the Care Home Mrs A had prescriptions for a range of medications including codeine (for pain relief) and laxido (a laxative for constipation).
17. Mrs A continued to live in the Care Home until the end of March 2022 when she sadly died.

Analysis

Complaint (a) The Care Home provided Mrs A with inadequate support with food and drink throughout her time there

18. Mrs B complained that Care Home staff did not help Mrs A to eat and only left food for her to eat herself. Mrs B said it was difficult for Mrs A to feed herself the types of food the Care Home provided because of arthritis which restricted her use of a knife and fork. Mrs B said staff also left food and drink out of reach. In addition, Mrs B said the Care Home ignored the list of food preferences she provided in September 2021. In summary, Mrs B said staff did not make adequate attempts to help Mrs A to eat or to meet her specific needs in this area.
19. Mrs B said that, as a result, Mrs A avoidably lost a significant amount of weight and entered an ‘at risk’ category in terms of her weight.
20. The Council accepted there were failings here. It acknowledged that the relevant care plan did not properly reflect Mrs A’s diagnosis of dementia or the impact of arthritis in her hands. It noted that staff should have been aware of these issues and how they could impact Mrs A’s ability to eat. The Council also said the care plan should have included advice about how staff should have tried to support Mrs A.
21. The Council also acknowledged that charts did not reflect that Mrs A was consuming food. It said staff should have taken a consistent approach to completing these charts but this did not happen.
22. In terms of learning from this complaint and improving performance, the Council told us it had provided guidance to staff about improving record keeping and communication systems to ensure residents’ notes and care plans are updated promptly.
23. In terms of the individual impact of these failings on Mrs A, the Council said Mrs A’s weight remained consistent throughout the period. It did not provide any further analysis of the potential impact of the failings it had identified.
24. Information in the records about Mrs A’s weight is very limited. During a telephone call with the Practice in September 2021 Mrs B told a GP that Mrs A had weighed 59kg just before she went into hospital. I have seen two measures of Mrs A’s height in the records: 157cm and 157.5cm. I do not know which is more accurate. Depending on which height was more accurate, Mrs A’s Body Mass Index (BMI) score would have been between 23.7 and 23.9. This range is considered a healthy weight for a 97-year-old white woman.
25. The Care Home’s initial assessment did not include a record of Mrs A's weight, and neither did the hospital discharge summary. However, a hospital record from 15 June 2021 records Mrs A’s weight as 44.2kg. This would equate to a BMI of between 17.8 to 17.9, which is deemed to be underweight. On balance, it is unlikely that Mrs A’s weight significantly changed before she entered the Care Home one week later.
26. I have also not seen any record of Mrs A’s weight throughout July or the first half of August 2021. The note of the telephone call between a GP and Mrs B in September 2021 says Mrs A weighed:

• 45.9kg on 19 August 2021 – a BMI of between 18.5 and 18.6 which is considered a healthy weight,
• 45.7kg on 29 August 2021 – a BMI of between 18.4 and 18.5 which, for the higher number, is considered a healthy weight, and the lower figure is felt to be underweight, and
• 45.5kg on 9 September 2021 – a BMI of between 18.3 and 18.4 which is considered underweight.

27. In her initial complaint about the GP Practice, in November 2021, Mrs B said she raised concerns about Mrs A losing weight in early September 2021. The Practice records confirm this, noting that Mrs B said she had been upset and shocked by Mrs A’s frail and thin appearance. The GP agreed to refer Mrs A to a dietician, to see whether they could offer any support to ensure Mrs A maintained a healthy weight. However, several days later the Practice told Mrs B its referral had been rejected as Mrs A did not meet the criteria for the service. During this call the GP also said Mrs A did not meet the criteria for nutritional supplements. They told Mrs B that Mrs A’s weight loss and frailty was not surprising given: her age; a recent significant injury; recent surgery; a long stay in hospital; and, a move to a new care home. The GP said they might not be able to achieve weight gain or even maintenance, and the focus should be on Mrs A’s comfort.
28. On the same day an ANP from the Practice completed a weekly ward round at the Care Home. The Care Home said Mrs A often told staff she was not hungry and the amount she ate varied from day to day.
29. On 20 September 2021 Mrs B spoke to the ANP and shared her concerns about Mrs A’s weight loss. The ANP completed another ward round and had a “long chat” with Mrs A. Mrs A told the ANP she only ate when she felt hungry. The ANP also recorded that Care Home staff were “giving her the options set out by [Mrs B] but often doesn’t want these”.
30. On the same day a District Nurse visited Mrs A and completed several care plans, including a nutrition plan to monitor Mrs A’s weight. It planned to do this by measuring the circumference of the middle of Mrs A’s upper arm monthly. This is a method of estimating BMI or estimating weight change over time. The nutrition care plan also asked Care Home staff to keep a food diary.
31. On 25 September 2021 a District Nurse recorded that Mrs A weighed the same as on 9 September. I have not seen any further measurements, or estimates, of Mrs A’s weight from this date until late December 2021. The only evidence I have seen is:

• An entry in the Practice records on 11 October 2021 when an ANP noted Mrs A’s weight was ok,
• Mrs B’s summary of events states that Mrs A’s BMI was 18.2 in November 2021 [this would equate to a weight of around 44.9 to 45.1kg, depending on her height],
• An entry in the Practice records on 8 November 2021 when an ANP noted there was no measurable change in Mrs A’s weight.

32. A Care Home weight chart records that Mrs A’s arm circumference was:

• 21cm from 21 and 29 December 2021,
• 20cm from 5 January 2022 to 16 February 2022, and
• 19.5cm from 21 February to 23 February 2022.

Mrs B made an audio recording of a meeting on 21 March 2022 where she and her husband met a social worker and a member of Care Home staff to complete a CHC Checklist. In during this meeting Mrs B noted that Mrs A’s arm circumference had been measured the previous day and found to be 17.5cm. Mrs B has also provided a photograph taken on 27 March 2022 which shows a measurement of around 16.5cm. However, from my independent perspective, I cannot say whether the methodology used to take this measurement was the same as previous measurements.

33. At the end of February 2022 the Practice ANP noted the reduction in Mrs A’s arm circumference. They noted that a food diary was in place and that Mrs A ate regularly but only small amounts. The ANP said Mrs A’s weight loss appeared to relate to her frailty and advanced age. They agreed to try a fortified juice and to review the situation in a week.
34. Overall, the evidence suggests Mrs A initially gained a little weight after entering the Care Home, but later lost weight. Because of the nature of the latter measurements it is not possible to say how much weight she lost. However, we can see she went from a healthy weight (in mid- to late-August) to being underweight. As such, the Council’s conclusion that Mrs A’s weight remained stable is not supported by the evidence.
35. The evidence shows the medical and nursing professionals involved in Mrs A's care did not consider her weight loss to be particularly surprising in the context of her age and recent medical and social history. As noted above, there is evidence to show that, at times, Mrs A did not want to eat. In these situations staff could not force her to do so. As such, Mrs A may still have lost weight even if there had not been failings in her nutritional care.
36. I cannot say whether staff did all they should have done to support and encourage Mrs A to eat. I would not expect care staff to write a lengthy, detailed record entry about all the efforts they made to support a resident to eat. Nevertheless, because of the shortcomings the Council has already acknowledged (in care planning and record keeping) Mrs B has been left with avoidable and lasting uncertainty about whether more could have been done to encourage Mrs A to eat and drink. She is also left with uncertainty about whether this caused avoidable discomfort to Mrs A. This impact on Mrs B was not acknowledged or addressed through the complaints process. I have made a recommendation to address this, below.

Complaint (b) The Care Home provided Mrs A with inadequate pain relief throughout her time there

37. Mrs B complained the decision to keep using an ‘as required’ prescription for codeine for Mrs A was inappropriate. She said dementia prevented Mrs A from effectively communicating to Care Home staff when she needed pain relief. Mrs B said she raised this concern repeatedly with staff but nothing ever changed.
38. The Council has already acknowledged that the protocol for Mrs A’s prescription for codeine ‘as required’ should have been better. Specifically, the Council said the protocol should have recorded how staff could tell if Mrs A was in pain. The Council did not address the potential impact of this failing.
39. The Council also completed a review of Mrs A’s medication records to look at when staff gave her pain relief. From this it did not identify any failings.
40. The Care Home’s medication records show that Mrs A regularly received paracetamol throughout her stay. The records are incomplete; of the 280 days Mrs A was in the Care Home there are records for 224 days. These show that Mrs A had:

• 1 dose of paracetamol on 4 days (2%),
• 2 doses of paracetamol on 19 days (9%),
• 3 doses of paracetamol on 80 days (36%), and
• 4 doses of paracetamol on 121 days (54%).

41. As Mrs B notes, Mrs A also had a prescription for codeine, a more powerful painkiller. Mrs A initially had an ‘as required’ prescription for codeine. On 18 October 2021 the Practice ANP completed a ward round review of Mrs A. They noted that Mrs B had concerns about Mrs A’s pain control and they agreed to prescribe codeine to be taken regularly, twice a day, as a trial.
42. Mrs A had been in the Care Home for 117 days up to this point. The Care Home’s records show that during that time Mrs A:

• Did not receive any codeine on 83 days (71%),
• Received one dose of codeine on 32 days (27%), and
• Received two doses of codeine on 2 days (2%).

43. In the 35 days after the ANP prescribed regular codeine, from 17 October to 21 November, Mrs A:

• Received one dose of codeine on 3 days (9%), and
• Received two doses of codeine on 32 days (91%).

44. When the ANP reviewed Mrs A during another ward round on 25 October they noted Mrs A was taking codeine twice a day and asked if it had improved her pain. Mrs A said she had not noticed any difference. Staff said it was causing daytime sedation.
45. On 8 November the ANP reviewed Mrs A again. They recorded there was no measurable change in Mrs A’s pain management. The ANP queried whether there had been any noticeable benefit since Mrs A had started having regular codeine and said they would review this in a week.
46. When the ANP reviewed Mrs A on 22 November she had vomited the previous night and that morning and had refused food. The ANP took Mrs A’s observations (measuring the body’s vital signs, such as temperature, pulse and blood pressure) and examined her and noted she had been having regular codeine. The ANP felt Mrs A might be constipated due to taking codeine and that this might have caused her to vomit. The ANP advised the Care Home to stop giving Mrs A codeine.
47. The next day Mrs B emailed the Practice and asked for Mrs A’s pain medication to be reviewed. Two days later a GP reviewed Mrs B’s email and Mrs A’s care. They spoke to staff at the Care Home who said Mrs A was comfortable and had had a good day. The GP said that, as Mrs A was not currently in any pain, they did not think codeine was necessary. The GP requested a trial without codeine to see if this helped with Mrs A’s constipation.
48. On 29 November the ANP reviewed Mrs A who denied any pain and reiterated several times that she did not want any additional pain relief. During a ward round on 5 January 2022 Care Home staff told the ANP they were regularly asking Mrs A if she was in pain and said she only asked for pain relief infrequently.
49. At the end of December 2021 Mrs B wrote a letter to the Practice and raised concerns about several matters, including Mrs A’s pain relief. The Practice replied in the middle of January 2022. It said that, while Mrs A had dementia, “it seems quite clear that she is capable of expressing pain and the staff do look for signs of pain when they see her”. The Practice noted that codeine can lead to side effects including significant constipation. It noted this had been a problem for Mrs A in the past. The Practice said that, because of this, it was better to take codeine on an ‘as required’ basis. The Practice said it also meant Mrs A could have more relief when she needed it.
50. The Care Home’s medication records from 22 November 2021 (when the Care Home was advised to stop giving Mrs A regular codeine) to 29 March 2022 are incomplete. Of the 128 days there are records for 76 days. These records show a similar pattern to the period up to 17 October, with Mrs A receiving:

• No codeine on 46 days (61%),
• 1 dose of codeine on 20 days (26%),
• 2 doses of codeine on 9 days (12%), and
• 3 doses of codeine on 1 day (1%).

51. Overall, the evidence shows that managing Mrs A’s pain was not straightforward, and the benefits of pain relief had to be carefully balanced against side effects. The evidence shows the Practice considered these issues carefully and took account of relevant information from Mrs A, Mrs B and the Care Home. This included a trial period of giving regular codeine and a review of this. I have not seen any fault by the Practice.
52. In terms of the Care Home, I have not seen any fault over and above what the Council has already identified in terms of the protocol for pain relief. In addition, based on the evidence available to me, I cannot link this fault with the protocol to any measurable negative impact on Mrs A.
53. As part of good practice the Care Home should have created, maintained and effectively stored complete medication records. It is concerning that there are some gaps in the medication records. This is fault. However, this fault does not appear to have had any specific impact as the available records allowed an adequate review of these events. As such, I have not made any recommendations in relation to this.

Complaint (c) Staff from the Care Home and the Practice failed to take appropriate steps to manage Mrs A’s urinary incontinence

54. Mrs B said the Care Home used the wrong type and size of incontinence pads. Mrs B said the pads the Care Home used cut into Mrs A’s skin. In addition, Mrs B said guidelines from the National Institute for Health and Care Excellence (NICE) (Clinical Guideline 148 - Urinary incontinence in neurological disease: assessment and management (August 2012)) were not followed but no one has ever adequately explained why. Mrs B said she reported her concerns to staff several times but nothing improved. Mrs B said the poor continence care caused Mrs A to develop a moisture associated skin disorder.
55. In response to my enquiries the Practice said that when Mrs A registered with it she was already known to the Continence Service. The Practice said it re-referred Mrs A to the Continence Service on 30 November 2021 and this resulted in a review the same day which, in turn, led to a change in the continence products for Mrs A. The Practice did not identify any failings in its actions.
56. The Council did not identify any shortcomings in relation to this aspect of Mrs A’s care. It explained the eligibility criteria for the Continence Service and said Care Home staff had challenged this. The Council said Care Home staff acted on the advice specialist staff provided.
57. The Council’s complaint response acknowledged that Mrs A developed a moisture associate skin disorder while in the Care Home. The response focused on how staff reacted once they noticed this but did not comment on whether it could have been avoided.
58. The Practice records show the Continence Service spoke with a senior carer at the Care Home on 12 August 2021. They noted the continence products Mrs A had and did not suggest any changes or any further input.
59. Mrs B said that:

• around a week later, she sent samples of incontinence products to the Care Home and asked it to assess them and order some,
• in early September she raised concerns with the Care Home about its management of Mrs A’s continence needs and said Mrs A needed suitable products.

60. On 20 September a District Nurse reviewed Mrs A and noted she had a moisture associated skin disorder (MASD) to her left buttock. The District Nurse created a care plan to address this and provided an alternative mattress as part of this. District Nurses came back to review Mrs A on 25 September and, as part of this, completed a detailed review of Mrs A’s continence needs and care. They did not make any alternations to, or suggestions about, Mrs A’s continence products but said how often staff should reposition Mrs A and help her with her toileting needs.
61. On 1 October the Continence Service spoke with staff at the Care Home. They noted when Mrs A’s incontinence products had last been delivered and were next due to be delivered. The Continence Service advised the Care Home to use its buffer stock and did not provide any further input.
62. On 24 November District Nurses noted that Mrs A had a new MASD to her left buttock.
63. On 28 November a member of staff at the Care Home spoke to Mrs B about Mrs A’s continence needs. They said the Continence Team would not assess Mrs A until she was in a permanent placement. Mrs B said she did not feel the pads the Care Home was using were right for Mrs A and suggested an alternative. The next day the Care Home called the Continence Service for advice. At the end of the month the Continence Service spoke to the Care Home and decided there did not need to be a change in the type of incontinence products Mrs A had.
64. Overall, there is evidence to show that both the Care Home and the Practice sought support from the Continence Service in relation to Mrs B’s concerns about whether Mrs A’s continence needs were being properly managed. It is clear from the records that none of the professionals involved in Mrs A’s care, including Care Home staff, Practice staff and District Nurses (or Continence Service staff during telephone calls), had concerns about the types of incontinence product being used for Mrs A.
65. Mrs A developed MASD’s on more than one occasion. However, given her age, frailty and immobility, this could have happened without there being any failings in her continence care. The records I have seen do not provide any evidence of Mrs A suffering from urinary tract infections during her time in the Care Home, or any other features which should have prompted any specific action according to NICE Clinical Guideline 148.
66. In summary, I have not found any evidence of fault in the way the Care Home and the Practice managed Mrs A’s urinary incontinence.

Complaint (d) Staff from the Care Home and the Practice failed to take appropriate steps to manage Mrs A’s faecal incontinence

67. Mrs B complained the Care Home and the Practice failed to refer Mrs A to specialist continence practitioners at an early stage. Mrs B said this resulted in a failure to perform periodic irrigation and skin care by suitably qualified professionals and meant Mrs A’s care was not in line with NICE guidelines (CG49 – Faecal incontinence in adults: management (June 2007)).
68. Mrs B also complained about the about the inappropriate over-use of oral laxatives. She said this caused episodes of diarrhoea which, in turn, caused Mrs A to experience distress, anxiety and a loss of dignity. Mrs B said the episodes of diarrhoea also caused an additional dehydration risk.
69. As with the issue about urinary incontinence, Mrs B complained there were long periods when dual use pads should have been used but the Care Home only used urinary incontinence pads. Mrs B said she had to provide the correct pads at her own cost.
70. In response to my enquiries the Practice said Mrs A had a prescription for laxido when she left hospital and it said Mrs A started having this regularly on 22 November 2021. The Practice did not identify any failings in its actions.
71. The Council acknowledged that the Care Home should have had a more detailed care plan about this aspect of Mrs A’s care. It said the care plan should have included signs and symptoms for staff to look out for in terms of constipation, dehydration or diarrhoea so they could then seek further advice and input. The Council noted it would have been for nursing or medical professionals to adjust Mrs A’s prescribed medication. It did not comment on the potential impact of the failing it had identified.
72. The records show that Care Home staff kept records about Mrs A’s bowel habits and the Practice also considered Mrs A’s needs in this area.
73. The use of laxido in people with constipation is in line with a NICE Clinical Knowledge Summary on the management of constipation in adults. As with the medication charts, the records showing the Care Home’s administration of laxido are incomplete. For the 280 days Mrs A was in the Care Home I had records for 252 days. These show that Mrs A received:

• No doses of laxido on 153 days (61%),
• 1 dose of laxido on 88 days (35%),
• 2 doses of laxido on 10 days (4%), and
• 3 doses of laxido on 1 day (less than 1%).

74. The records do not demonstrate any specific pattern suggesting the medication was either given or withheld as a set rule. Rather, the records suggest each administration of the drug was in response to Mrs A’s condition at the time.
75. Overall, I have not found any evidence that either the Care Home or the Practice needed to seek any further specialist help or advice in this area. I have not identified any failings over and above what the Council highlighted in its complaint response. Having reviewed the Practice’s regular weekly reviews of Mrs A, I cannot link the failings the Council found in care planning to any negative impact on Mrs A. This is because, on balance, it is unlikely any more detailed care plans would have led to any further intervention or different care.

Complaint (e) The Practice failed to diagnose Mrs A as suffering from an impacted bowel between October 2021 and 29 November 2021

76. Mrs B said Mrs A had symptoms of this condition from October 2021 and the Practice should have been able to diagnose the problem.
77. In response to my enquiries the Practice did not suggest there had been any failings in its care of Mrs A during this time.
78. Throughout October and November the Practice regularly reviewed Mrs A and spoke to staff at the Care Home about her condition and health. In the middle of October an ANP noted that Mrs A had had loose stools for several days. They considered whether Mrs A had any abdominal pain and whether there had been any other concerning symptoms. Around a month later, in the middle of November, the ANP had a long chat with Mrs A and she denied any problems or being in pain.
79. On 22 November the ANP reviewed Mrs A and noted she had vomited the previous night and that morning. The ANP took Mrs A’s observations and examined her. They felt Mrs A might be constipated due to taking codeine and that this might have caused her to vomit. The ANP had planned to carry out a rectal examination but was not able to as there was no lubricant available. The ANP advised the Care Home to stop giving Mrs A codeine and to give her regular laxido, to monitor her symptoms, and to have a low threshold to request a review.
80. On 26 November a GP reviewed Mrs A due to concerns from staff about deteriorating bowel symptoms. Mrs A had had loose bowels for the last two days and had been sick once. The GP examined Mrs A and noted she seemed quite bright and chatty and had a drink. The GP noted Mrs A did not have a fever, was not in distress, did not have abdominal pain or tenderness and was passing urine. The GP advised staff to observe her.
81. On 29 November the ANP reviewed Mrs A and noted there had been no further vomiting. The ANP recorded that Mrs A was not unwell, are there were no obvious signs of her having an acute illness or delirium. Mrs A denied having any pain. The ANP told Mrs A she was worried about her vomiting and faecal smearing and felt this could be a result of immobility and lack of fibre and the use of codeine. The ANP said Mrs A could be faecally impacted. The ANP completed a rectal examination and found Mrs A’s rectum was loaded with hard faeces that was brittle and with overflow fluid. The plan was to use an enema and suppositories and re-start laxido. The ANP asked District Nurses for their support with this.
82. Overall, the records show the Care Home sought medical support when they were concerned about Mrs A. The Practice completed appropriate examinations when required and interpreted the results reasonably. I have not found any evidence of fault or delays in relation to this issue.

Complaint (f) The Care Home acted inconsistently and unfairly in periodically preventing Mrs B from visiting Mrs A due to Covid restrictions

83. When the Council looked at this part if Mrs B’s complaint, it noted in an internal document that Care Home staff said the Care Home had classed Mrs B as an essential visitor. However, the Council noted there was no written evidence to show that the Care Home considered Mrs B to be an essential visitor, contrary to what staff had said. The Council said that if the Care Home had deemed Mrs B to be an essential visitor, Mrs B “would have been allowed to visit at any time, for however long and without the need to make an appointment and she would have been informed of this. The whole team would have been aware of this”. The failure to properly categorise Mrs B as an essential visitor amounts to fault.
84. I have not seen detailed evidence about when Mrs B attempted to see Mrs A and was prevented from doing so. However, on balance, I accept Mrs B’s account that there were times when restrictions prevented her from visiting. In line with the Council’s findings, this would not have happened if the Care Home had applied the relevant policy correctly. This means that Mrs A and Mrs B were denied time together, which was an injustice to them both. I have made a recommendation to address this below.

Complaint (g) A member of Care Home staff behaved unreasonably on 28 December 2021

85. Mrs B said she visited Mrs A on 28 December, which was Mrs A’s birthday. She said a member of staff came into Mrs B’s room after 45 minutes and demanded that she leave immediately due to a booking error. Mrs B said the member of staff shouted at her, told her to “get out” and continued to act in an aggressive way when Mrs B was in reception. Mrs B said this incident happened in front of Mrs A who was extremely disturbed and upset by it. Mrs B said an acting manager of the Care Home witnessed the incident, apologised for it and said she would report it to the manager.
86. Mrs B also said the Council told her, verbally, that there had been a formal investigation of this matter, including an interview of the member of staff and “action taken”. I asked the Council for evidence of this but it has not been able to provide any specific evidence. I have seen it spoke to other members of staff, about other issues, but I have not seen evidence of an interview with this member of staff, about the incident on 28 December.
87. However, the Council has provided evidence of a ‘Lessons Learned’ discussion session which took place at the Care Home in May 2022. This included discussions about how to manage a situation where a relative’s visit had been delayed and overlapped with another family’s visit. It noted examples of actions that could be taken to resolve the situation in a respectful and helpful way.
88. The Council’s ‘Lessons Learned’ discussion suggests that, on balance, it is more likely than not that Mrs B’s account of this event is accurate. This situation should not have happened and it was appropriate that a more senior member of staff apologised to Mrs B at the time. That was a proportionate response.
89. I have no way of knowing whether the individual member of staff was spoken to about the event and their conduct. Again, the ‘Lessons Learned’ discussion suggests that it is probable they were. The completion of a ‘Lessons Learned’ discussion was appropriate, to encourage wider learning from the event. In view of this, and as Covid restrictions no longer apply, I have not recommended any further action.

Complaint (h) The Practice failed to respond appropriately to concerns Mrs B raised with an ANP on 21 March 2022, about Mrs A having an impacted bowel again

90. Mrs B said she raised concerns about this with an ANP but they refused to examine Mrs A and simply said she did not have an impacted bowel. Mrs B said Mrs A died from a small intestinal infarction (obstruction of blood supply) on 30 March 2022. She said this can be caused by a bowel obstruction.
91. In response to my enquiries the Practice said its records did not include any reference to a discussion about bowel problems. It said the ANP could no longer recall the conversation. The Practice said it was sorry if its records were not accurate.
92. The Practice records include a note from the ANP on 21 March. This note says the ANP reviewed Mrs A with Mrs B present. The ANP noted that Mrs B had concerns about malnutrition. The ANP said Care Staff assured her that Mrs A’s arm circumference had increased the last week and said the food diary appeared satisfactory. They noted Mrs A was having fortified drinks and that all her food was fortified. The ANP recorded that Mrs B asked for a referral to a dietician and the ANP agreed to this, but said the referral might be rejected because Mrs A was in a care home. A member of staff at the Care Home made a brief note about the ANP’s visit.
93. The Practice’s records – for this encounter and for the period as a whole – contain an adequate level of detail. I have not seen any evidence to suggest that records have been altered afterwards.
94. Overall, from our independent perspective, I cannot resolve the differing accounts of what happened at this review.

Complaint (i) A Social Worker failed to follow-up on an assurance she gave to Mrs B, on 21 March 2022, to discuss Mrs B’s concerns about Mrs A’s health with the Practice

95. Mrs B said she relied on the Social Worker following this up effectively. She said, because of this, she did not act to escalate her concerns or intervene by calling an ambulance.
96. As with the issue above, the Social Worker’s note of their meeting with Mrs B does not include reference to the undertaking Mrs B says was made. As before, I cannot resolve the differing accounts of what was said.

Complaint (j) The Care Home failed to advise Mrs B of Mrs A’s worsening condition in late March 2022

97. Mrs B said that, if the Care Home had told her about Mrs A’s worsening condition, she could have told the on call doctor (or emergency services) about Mrs A’s previous diagnosis of an impacted bowel.
98. In the late afternoon / early evening of 29 March 2022 Mrs A was sick and said she felt unwell. Care Home staff called an out of hours health service which arranged for a GP to visit and assess Mrs A in the evening.
99. The Council’s investigation found that a member of Care Home staff failed to call Mrs B to tell her a GP had been to see Mrs A. It said this was not in keeping with protocols and codes of conduct and it recommended a disciplinary hearing and retraining.
100. However, the investigation also found that, by the time the GP visited and after that, there were no clear signs that Mrs A was in pain or distress. The investigation noted the records described Mrs A as being alert and said she did not feel unwell or sick. It said that, other than when she vomited, Mrs A remained comfortable and received appropriate care. The investigation did not make any wider findings that staff failed to contact Mrs B, other than about the GP visit.
101. The Council has provided evidence of a ‘Lessons Learned’ discussion session which took place at the Care Home in May 2022. This included discussion about what should happen when a GP sees a patient, in terms of informing the family.
102. There was fault here which the Council has already identified and has addressed with the individual concerned. I am satisfied that the records support the Council’s wider findings and that its actions to address the fault were proportionate and appropriate. I cannot say what Mrs B would have done, or what would have happened after that, if the Care Home had called her about the GP visit. There are too many variables for me to be able to say, even on the balance of probabilities, that any one outcome would have happened.
103. From the information available I could not see the Council had ever fed its findings about this issue back to Mrs B, in terms of it upholding her concerns. It should have done. It was not enough to simply say, as it did in a letter in January 2023, that a disciplinary hearing had taken place and it had concluded its investigation. The Council was under no obligation to share the details of the disciplinary hearing or the outcome of this – it was right that those matters remained private. However, it could and should have confirmed which elements of Mrs B’s complaints it had upheld. Its failure to do so was fault and caused Mrs B frustration which is an injustice. I have made a recommendation to address this.

Complaint (k) An on-call doctor from Local Care Direct provided inadequate care and advice on 29 March 2022

104. Mrs B said she does not believe the on‑call doctor reviewed Mrs A’s medical records or made appropriate enquiries about her medical history.
105. I wrote to Local Care Direct and asked for its comments on this aspect of Mrs B’s complaint. Despite allowing extra time and chasing for a response, I did not receive one. Local Care Direct said this was because: it had not previously had an opportunity to investigate the complaint and its efforts to respond to my queries were affected by staff leave and difficulty in obtaining advice from its Medical Defence Union (which ordinarily would have happened as part of the local resolution process). Regardless of the reasons, the records the Practice provided included records from Local Care Direct on 29 March 2022; from the point of triage up to and including the GP visit. The records are detailed and have allowed an adequate review of these events.
106. In the days leading up to 29 March 2022 the Care Home’s daily records regularly recorded that Mrs A was settled and comfortable. On 27 and 28 March staff noted she had loose bowels movements but also noted that she was settled and had eaten and drunk reasonably. The Practice ANP reviewed Mrs A on 28 March as part of a ward round and did not have any concerns.
107. In the late afternoon of 29 March 2022 Mrs A vomited twice. The Care Home called the out of hours service and a GP assessed her. The GP noted the calls to the out of hours service that day, and the observations that had been taken. The GP had access to Mrs A’s records with her past medical history and medication details. The GP noted Mrs A had had abdominal pain, the time this started, and that Mrs A had vomited. They also recorded that Mrs A had opened her bowels that morning. The GP examined Mrs A’s abdomen, noting it was distended (swollen or bloated). They diagnosed Mrs A as being constipated and advised staff to give her laxido once or twice a day. They also advised staff to call 111 or the GP if things changed.
108. The GP’s examination and assessment was reasonable and appropriate and in line with guidance. Our independent adviser said they felt the GP’s assessment had been in line with GMC guidance. The GP’s interpretation of the results of the assessment, and their advice to the Care Home staff, was also appropriate. I have not seen anything in the assessments, examination and observations that should have prompted the GP to arrange a transfer to hospital at this time. Overall, I have not found fault here.

Complaint (l) Care Home staff failed to act on the advice of an on-call doctor on 29 March 2022

109. Mrs B said staff failed to monitor Mrs A and left her unattended for three hours. Mrs B said there were brown stains on Mrs A’s pillow when she was found. She said these suggested Mrs A may have choked while alone and unmonitored.
110. The Council’s investigation did not support this complaint. It reviewed the Care Home records and interviewed staff who were on duty. It concluded that staff checked on Mrs A regularly and did not have any concerns about her. The investigation said there was no indication that Mrs A’s condition deteriorated to the point where she needed constant staff presence.
111. From the records available I cannot see that the out of hours GP gave the Care Home staff any specific instructions about how often they should monitor Mrs A. Given their working diagnosis was that Mrs A had constipation, this is not unexpected. The Care Home records suggest staff were monitoring Mrs A throughout the night and I have not found any evidence of fault here.

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Agreed actions

112. At the draft stage of this investigation I recommended the Council apologise for the impact of the failings at the Care Home. However, Mrs B said that she would not welcome an apology and asked for one not to be issued. This is why I have not asked the Council to provide an apology.
113. Before the complaint came to the Ombudsmen the Council had accepted, at various stages, there had been failures to:

• Produce adequate care plans in relation to Mrs A’s nutritional needs, use of codeine and bowel care,
• Maintain adequate food charts,
• Adhere to its Covid visiting policy,
• Ensure staff acted professionally during a family visit, and
• Call a member of the family after a GP visit.

The Council noted it had provided feedback and guidance to staff with the intention of improving performance and preventing recurrences.

114. Within three months of the final decision the Council should complete proportionate work to check whether there have been improvements in these areas. It should advise the Ombudsmen of the results of this work.

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Decision

115. I have completed this investigation on the basis that there was fault which caused an injustice which will be remedied by the recommendations I have made.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman