Summary: We will not investigate Miss X’s complaint about the care provided to her mother, Ms Y. This is because an investigation by the Ombudsmen would be unlikely to identify fault by the organisations involved in some aspects of Ms Y’s care. With regards to other parts of the Ms Y’s care, an investigation by the Ombudsmen would be unlikely to add anything to the investigations already carried out by the organisations Miss X is complaining about.

The complaint

1. The complainant, who I will call Miss X, is complaining about the care provided to her mother, Ms Y, by Amberley Care Home (the care home) and Manchester University NHS Foundation Trust (the Trust). The care home placement was funded and arranged by Trafford Metropolitan Borough Council (the Council),
2. Specifically, Miss X:

• complains that the care home administered medication to Ms Y that had not been prescribed for her;
• queries why Ms Y’s condition deteriorated so rapidly and why, if it did, the care home failed to seek medical assistance sooner;
• complains that the care home failed to inform the ambulance crew that Ms Y lacked capacity and was under Deprivation of Liberty Safeguards (DoLS);
• complains that the Trust decided Ms Y was not suitable for resuscitation when she would not have understood the implications of this;
• complains the Trust undertook unnecessary procedures that were distressing for Ms Y; and
• queries whether the Trust carried out an invasive procedure that caused Ms Y to cry out in pain.

3. Miss X says these events have been extremely distressing for her and her family and have had a long-term impact on her health.

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The Ombudsmen’s role and powers

4. 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).
5. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe it is unlikely we would find fault, or it is unlikely we could add to any previous investigation by the organisations concerned. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

6. In making my final decision, I considered information provided by Miss X and discussed the complaint with her. I also considered information from the Trust and care home. I invited comments from Miss X on my draft decision and carefully considered her response.

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What I found

Relevant guidance and legislation

Mental Capacity Act 2005

7. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions.
8. The MCA starts by presuming individuals have capacity unless there is proof to the contrary. People who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.

Deprivation of Liberty Safeguards (DoLS)

9. The Deprivation of Liberty Safeguards (DoLS) is an amendment to the Mental Capacity Act 2005 that came into force on 1 April 2009. The safeguards provide legal protection for individuals who lack mental capacity to consent to care or treatment and live in a care home, hospital or supported living accommodation. The DoLS protect people from being deprived of their liberty, unless it is in their best interests and there is no other less restrictive alternative.

Background

10. In March 2021, Ms Y was resident in the care home.
11. On 25 March 2021, Ms Y’s condition deteriorated rapidly. She was admitted to hospital that evening.
12. Ms Y was treated for severe sepsis. Despite treatment with oxygen, fluids and antibiotics, Ms Y did not recover and died in hospital soon after.
13. Miss X complained about Ms Y’s care to the Parliamentary and Health Service Ombudsman (PHSO) in October 2021.
14. In April 2023, PHSO decided not to investigate Miss X’s complaint. This was because Miss X appeared to be seeking to take legal action and PHSO decided it would be more appropriate for her to do so rather than pursue a complaint.
15. Miss X subsequently made enquiries with solicitors. However, she was unable to find a solicitor to take the case forward.
16. Miss X submitted a further complaint to PHSO in July 2023 and this was passed to the Joint Working Team in January 2024.

My analysis

Medication

17. Miss X complains that the care home administered medication to Ms Y that had not been prescribed for her. Miss X said the care home administered Diazepam medication as a way of sedating Ms Y. She also said she overheard care home staff saying they were administering antibiotics but that these had not been prescribed for Ms Y.
18. In its complaint response, the care home explained that, on 24 March 2021, it had arranged for Ms Y to be reviewed by a GP. This is because she was becoming increasingly tired and had reduced appetite. The GP prescribed an antidepressant medication. The care home confirmed that Diazepam was not administered at any time. Rather, Ms Y’s condition was deteriorating. This is what led the care home to seek input from the GP.
19. The care home also acknowledged that Ms Y sometimes took antibiotics as prescribed by her GP. This would be a common treatment for an infection.
20. We will not investigate Miss X’s concerns about the management of Ms Y’s medication. This is because we consider it unlikely an investigation would identify evidence of fault by the care home.

Deterioration

21. Miss X queries whether Ms Y’s condition deteriorated as rapidly as the care home said it did. If so, she asks why the care home failed to seek medical assistance sooner.
22. As explained above, the care home was sufficiently concerned about Ms Y’s condition on 24 March to seek a GP review.
23. However, the care home explained that Ms Y condition appeared to deteriorate more quickly on the evening of 25 March. The care home arranged for an ambulance for Ms Y and she was admitted to hospital later that day.
24. It is entirely understandable that Miss X was upset by Ms Y’s rapid deterioration. However, the evidence I have seen suggests the care home sought appropriate clinical input from a GP when they were concerned about Ms Y’s wellbeing. The care home then arranged for hospital admission when Ms Y’s condition deteriorated.
25. We will not investigate this part of Ms Y’s complaint as, again, we consider an investigation would be unlikely to identify fault by the care home.

DoLS

26. Miss X said care home staff failed to inform the ambulance crew that Ms Y lacked capacity and was under DoLS.
27. The care home did not address this issue explicitly. However, it said a nurse had given a “thorough handover” to the paramedics who transported Ms Y to hospital.
28. I am unable to comment on exactly what information the nurse gave to the paramedic. However, the Trust’s subsequent complaint response makes clear that hospital staff were aware that Ms Y lacked capacity at the time of her admission in March 2021.
29. We will not investigate this part of Ms Y’s complaint as we consider it unlikely an investigation would identify fault by the care home.

Do Not Attempt Cardiopulmonary Resuscitation (DNACPR)

30. Miss X complains that the Trust decided Ms Y was not suitable for resuscitation. She says Ms Y lacked capacity at the time of her admission and would not have understood the implications of this.
31. In its response, the Trust said that a DNACPR order had been in place for Ms Y since a previous admission in August 2020. At that point, hospital staff were satisfied Ms Y had capacity to make decisions about her care. The Trust said a doctor discussed the DNACPR with Ms Y and that she agreed her frailty would mean any attempt at resuscitation would be unlikely to be successful.
32. The Trust went on to explain that, by the time of her admission in March 2021, Ms Y’s had deteriorated significantly and that the DNACPR order remained appropriate.
33. It is important to be clear that a DNACPR decision is ultimately made by a doctor. However, there is evidence to show that a doctor did discuss this with Ms Y in 2020 during her previous admission.
34. We consider an investigation by the Ombudsmen would be very unlikely to identify fault by the Trust with regards to this issue. As a result, we will not investigate this matter.

Unnecessary procedures

35. Miss X said hospital staff undertook unnecessary procedures that were distressing for Ms Y, who was near the end of her life. This included several attempts to insert a cannula and an attempt to take a chest X-ray.
36. The Trust acknowledged staff made attempts to insert a cannula to administer antibiotics intravenously and that Ms Y found this distressing. The Trust explained that staff then administered antibiotics orally instead.
37. The Trust also explained that a doctor arranged for a chest X-ray to be carried out on 28 March. This was carried out using a mobile X-ray decision that meant Ms Y did not have to be moved from the ward. The Trust said this had been a straightforward procedure and was not invasive.
38. I note the Trust also apologised to Miss X for any distress caused to her by the care provided to Ms Y.
39. We consider that an investigation by the Ombudsmen would be unlikely to add to the investigations already undertaken by the Trust. We will not investigate this issue, therefore.

Invasive procedures

40. Miss X reported having heard Ms Y scream out in pain and queried whether the Trust had carried out an invasive procedure that caused Ms Y this level of distress.
41. The Trust said Ms Y was very unwell by 28 March and that her sepsis may have caused her some level of distress. However, the Trust confirmed that it did not carry out any invasive procedures (such as heart procedures).
42. We consider it unlikely that an investigation by the Ombudsmen would find fault by the Trust and we will not investigate this issue.

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Final decision

43. We will not investigate Miss X’s complaint about the care provided to Ms Y. This is because we consider an investigation would be unlikely to identify fault by the organisations involved, or would be unlikely to add to the investigations they have already undertaken.

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Investigator's decision on behalf of the Ombudsman