Summary: Mrs A complains about the care and treatment of her mother, Mrs B. She also complains about how long North East and North Cumbria Integrated Care Board (the ICB) took to respond to her complaint. We found the ICB took too long to respond to Mrs A’s complaint which caused her unnecessary distress. I recommended and the ICB agreed to apologise and make a symbolic payment to remedy this injustice. We also found a doctor from St Albans Medical Group changed Mrs B’s medical records after her death. Staff from Wardley Gate Care Centre disposed of used medication in a way which caused Mrs A doubt about whether Mrs B’s medication had been given correctly. However, I have seen evidence both organisations have already made appropriate changes to their processes, so no further action is needed.

The complaint

1. Mrs A complains about the care her late mother, Mrs B, received at Wardley Gate Care Centre (the Care Centre). Mrs B part funded her care there with Gateshead Council (the Council), and she also received NHS Continuing Healthcare funding from North East and North Cumbria Integrated Care Board (the ICB). Mrs A also complains about a doctor from St Albans Medical Group (the Practice). Specifically, she complains;
• A doctor from the Practice went into Mrs B’s medical records and changed them after her death. The doctor admitted to this but has not explained why they did it and ignored guidelines.
• How staff gave Mrs B her medication. The Care Centre’s complaint response did not reassure her it was given as prescribed.
• The Care Centre is not keeping records in line with guidance; incidents she witnessed were not in Mrs B’s notes.
• She was made to feel like they were a nuisance to the Care Centre; they were asked to stop phoning and interfering. Mrs A feels this is unprofessional; she raised concerns because she worried about Mrs B.
• After Mrs B’s death, the Care Centre rushed the family to see her and they could not spend time alone with her to say goodbye. Collecting her belongings was also rushed. The Care Centre has not, to date, explained why this happened.
2. Mrs A says she has been denied closure. She received confusing responses to her complaints and has lost faith in the organisations. It took a long time to get a full complaint response and this caused more distress.
3. Mrs A wants reassurances the organisations have learnt from her complaint and completed service improvements to ensure the faults they have admitted will not happen again. She also wants financial recompense for the distress caused by needing to chase the complaint over many years.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. The Local Government and Social Care Ombudsman investigates complaints about adult social care providers. (Local Government Act 1974, sections 34B, and 34C, as amended).
6. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions. Part 3A is for complaints about care bought directly from a care provider by the person who needs it or their representative, and includes care funded privately or with direct payments using a personal budget. (Part 3 and Part 3A Local Government Act 1974; section 25(6) & (7) of the Act)
7. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended). If it has, we may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
8. We cannot question whether an organisation’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. 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))
9. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
10. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended).

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How I considered this complaint

11. I have considered information Mrs A provided in writing and by phone. I also considered documents and comments on the complaint from the Council, the Care Centre, the ICB and the Practice, as well as Mrs B’s records from her time in the Care Centre. I also considered relevant law, policies and guidance.
12. Mrs A and the organisations commented on my draft decision. I considered their comments before making a final decision.

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What I found

Complaint about the Practice

13. Mrs A complained a doctor from the Practice changed Mrs B’s medical records after her death.
14. I asked the Practice to explain what happened. It said the doctor added more information to Mrs B’s record after her death; to say they had seen Mrs B in person the day of her death. The Practice said the doctor has accepted their actions were wrong and this was an error in judgement.
15. The Practice said because of Mrs A’s complaint, it reminded all staff of the importance of making contemporaneous notes and that staff should not edit them after the event. It said it added an extra layer of security to trigger an audit message to the manager if access to notes is attempted after a patient’s death.
16. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17(2)(c) says “records relating to the care and treatment of each person using the service must be kept and be fit for purpose. Fit for purpose means they must: be complete, legible, indelible, accurate and up to date, with no undue delays in adding and filing information, as far as is reasonable.”
17. While I understand the doctor thought it a valid reason for editing the record, in this case adding detail, it was still wrong to do so. This is fault.
18. The doctor’s actions caused distress to Mrs A as she knew this should not happen.
19. The doctor has accepted they made a mistake and apologised. The Practice has also openly explained what happened to both Mrs A and the Ombudsmen, it has made changes to its process and reminded all staff of the importance of keeping good records.
20. I am satisfied the actions already taken by the Practice are enough to remedy the injustice caused.

Complaints about the Care Centre

Medication

21. Mrs A raised concerns about how staff are the Care Centre gave Mrs B her medication. Mrs A found medicine in Mrs B’s room rubbish bin and worried this meant Mrs B had not taken it. She spoke to staff who did not reassure her about what happened. She raised this as part of her complaint to the Care Centre, but the response has failed to reassure her Mrs B did receive her medication as prescribed.
22. The Medication Administration Record (MAR) sheet lists a patient’s medication, the quantity of tablets received, the dose, frequency and time of administration over a four-week period. The pharmacy or GP surgeries usually print the MAR. Home staff sign it, acknowledge receipt of medication, to record when they give it or to record if, for any reason, it is not given.
23. I asked the Care Centre to explain what happened. It said one of Mrs B’s medications had to be inhaled. After it was taken it left an empty shell behind. It was this shell that Mrs A found in Mrs B’s rubbish bin, as it had accidentally fallen in there instead of being disposed of by staff in the usual way. Mrs A disputes this and says the capsule was unused. In the absence of independent evidence, we are unable to verify which it was.
24. The Care Centre said this is why Mrs A found it unusual, because she would not have seen the empty shell before. The Care Centre apologised for the confusion caused and reminded all staff to make sure no medication packaging was left behind.
25. Because of Mrs A’s complaint to NHS England in November 2022, which it asked the Council to investigate, a medications support officer from the Council visited the Care Centre in January 2023. The purpose of the visit was to examine its MAR and care plan for Mrs B.
26. The audit found overall “the medicines management and record keeping for Mrs B complies with the Care Quality Commission standards Regulation 12 HSCA RA Regulations 2014 Safe care and treatment 2(2)(g) the proper and safe management of medicines; Staff responsible for the management and administration of medication must be suitably trained and competent and this should be kept under review. Staff must follow policies and procedures about managing medicines, including those related to infection control.”
27. The audit found there was only a change to the times Mrs B was given her medication when there had to be a gap between doses (time sensitive medication). An example from Mrs B’s records is the medication round was completed before a four-hour gap had elapsed, so it was not safe to give another dose at this round. Mrs A disputes this, saying staff were often late giving medication which then impacted on when Mrs B could have the next dose.
28. The Care Quality Commission highlights the importance of giving time sensitive medications to make sure they are safe and effective. Care Centre staff acted in line with guidance, but I can understand why Mrs A may have worried about this if it was not fully explained at the time.
29. I also understand Mrs A has concerns about Mrs B’s oxygen being on the wrong setting. In its complaint response, the Care Centre said it could not find out how this had happened. The Council’s audit came to the same conclusion, and I have not seen any evidence to add to this.
30. In summary, the Care Centre managed Mrs B’s medication correctly. I find no fault.

Record keeping

31. Mrs A worries the Care Centre is not keeping records in line with guidance; she says many incidents she witnessed were not in Mrs B’s notes. This concern arose after Mrs A found out Mrs B had fallen in the Care Centre, but it was not recorded in the notes she saw. She also explained staff did not record family concerns when they raised them with staff.
32. Mrs A said there were other incidents when Mrs B fell and staff did not records these in her notes. In the absence of independent evidence, I am unable to ascertain what happened but I can understand why this worried Mrs A and do not dispute her account of what happened.
33. The Care Centre partly responded to this issue in its complaint response of 18 January 2023, sent via the Council. Mrs A was not reassured by this response and wants reassurances the Care Centre has learnt from her experience.
34. The Care Centre explained all accidents or incidents are recorded on an electronic incident form. This system is checked on a monthly basis by the Home Manager to identify any risks to residents. After this, the review is checked and signed off by the senior management.
35. In its letter to the Council of 16 November 2022, the Care Centre explained it had reviewed all the records and found for the incident Mrs A referred to, she had only seen part of Mrs B’s records. The letter explained “all accidents and incidents are recorded on an electronic system … Family state they only seen a risk assessment following a fall on 27/7/2022 but if requested to see other forms they would have been given them.”
36. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17(2)(c) states providers must “maintain securely an accurate, complete and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided.” For the fall Mrs A refers to, the Care Centre recorded Mrs B had fallen and the reasons why they believed this happened. This was linked to the risk assessment, the document Mrs A saw. After the family raised concerns, the Care Centre spoke to Mrs B’s doctor about their concerns.
37. I can understand why Mrs A worried if she only saw part of the documents about the fall Mrs B had, however I am reassured the Care Centre did keep records in line with guidance. It would have been good practice to explain this to Mrs A, which would have relieved her concerns and prevented the need for the complaint. I find no fault.

Staff attitude towards family

38. Mrs A and her family felt they were a nuisance to the Care Centre; they were asked to stop interfering with her care. Mrs A feels this is unprofessional; she raised concerns because she worried about Mrs B.
39. I asked the Care Centre to comment on Mrs A’s complaint and if it had any notes from meetings or conversations with the family. The Care Centre said there was a meeting with the family when they raised concerns. In this meeting, staff tried to emphasise the importance of spending quality time with Mrs B and to allow the staff to provide her care. They added they were aware of the closeness of the family and wanted to prepare them, if they could, as Mrs B’s health was worsening.
40. I can find no notes in Mrs B’s records the family were unhappy with staff at the time when she was in the Care Centre other than the meeting mentioned above. Mrs A disputes this and says the family often told staff they were unhappy with Mrs B’s care. While I do not dispute her account, in the absence of independent evidence, I cannot establish what may have happened.
41. Mrs A also complained after Mrs B’s death that staff rushed the family and they could not spend time alone with her to say goodbye. Mrs A also feels when they collected her belongings it was also rushed. She said the Care Centre has not, so far, explained why this happened.
42. I asked the Care Centre to comment. It explained it disagreed with Mrs A’s recollection of events, but does accept the circumstances were very distressing. It explained staff took tea and biscuits to the family while they sat with Mrs B, and said it would not have done this if staff were trying to hurry them.
43. I understand Mrs B’s passing was sudden. Her records show her health was worsening, but she was not expected to die that night. This was undoubtedly distressing for the whole family. I cannot decide if the attitude of staff from the Care Centre was suitable or if things were rushed because the accounts differ and there is not enough evidence.
44. I am reassured by the sensitivity with which the Care Centre responded to the complaint and the compassion it showed to the family after Mrs B’s death in its communication with them.

Complaint about the ICB

45. Mrs A complains the ICB took years to provide her with a full response to her complaint. She also complains it has not fully explained why it took so long or recognised the added distress this has caused.
46. Mrs A made her complaint to NHS England on 8 November 2022, this was against several organisations, and NHS England asked the Council to respond. It did so on 26 January 2023. Mrs A was not happy she had had a full response, so sent another letter to NHS England on 1 June 2023.
47. On 1 July 2023, the complaint responsibility passed to the ICB from NHS England. The ICB passed the complaint about the doctor to the Practice to reply. Mrs A received a response from the Practice on 28 July 2023, but this was not passed to her until the ICB issued its response. The ICB did write to her with reassurances it was dealing with her complaint, but when it provided timescales for completion, these passed without contact.
48. The ICB responded to Mrs A’s complaint on 11 October 2024 (15 months later). In this letter, it said “The investigations into your late mother's care took place during the transition of primary care complaints handling responsibilities from NHS England to ICBs, and due to an administrative oversight which occurred during an unplanned period of reduced staffing in the team, the practice's response to your additional concerns was not sent to you. For this we must apologise. The transition of these responsibilities to the ICB happened during a period when we have also seen a very significant increase in primary care complaints, and as such we have recently appointed additional staff into our complaints function to improve the experience of people like yourself, who have taken the time and trouble to make us aware of your experience.”
49. This response did not reassure Mrs A so she brought her concerns about the ICB’s complaint handling to us.
50. I asked the ICB to explain why it had taken so long to respond to Mrs A’s complaint. It said the delays were because of the transfer of complaint handling responsibilities to the ICB, staff absence and recruitment issues. It added that from 1 April 2025, the primary care complaint team had joined with the ICB’s to help them manage complaints better.
51. The ICB’s complaint policy which covers this period is dated February 2023. It says at 5.7.1.2 that after a written complaint is received and acknowledged an action plan for handling the complaint should be completed, and this should include when the investigation is likely to be completed. At 5.7.1.4 it adds “the agreed action plan and timescales for response will be confirmed in writing to the complainant”. At 5.7.2.1 it adds “the investigation will be conducted in a timely manner, proportionate to the complaint”.
52. The updates the ICB sent to Mrs A were not in the timescales it indicated and she had no choice but to chase the ICB for updates. This is an injustice to her, particularly taking into account the prolonged period of time involved.
53. I faced significant delays when trying to get information from the ICB for this investigation. This, added to the experience of Mrs A, does not reassure me the ICB is meeting its statutory complaints responsibilities and I am not satisfied it has learnt from Mrs A’s experience. This is fault.

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Action

54. Within one month of the final decision, the ICB should write to Mrs A and acknowledge the fault identified in paragraph 50. It should recognise and apologise for the injustice described in paragraph 49. In providing this apology, the ICB should take account of the NHS Complaint Standards and the related Good Complaint Handling guides on “Providing a remedy” which includes information about making a meaningful apology.
55. The ICB should also pay Mrs A £100 as a symbolic, tangible recognition of the avoidable distress she experienced because of the delay in responding to her complaint.

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Decision

56. I find fault with the ICB for the delays in its complaint handling which caused an injustice to Mrs A. I made and the ICB agreed to action recommendations to remedy this injustice. I have seen evidence the faults identified by the GP Practice and the Care Centre have already been addressed. I am satisfied these actions remedied the injustice and propose no further action is necessary.

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Investigator's decision on behalf of the Ombudsman