The Ombudsman's final decision
Summary: We investigated a complaint about the care a Care Home, Council and Trust provided to Ms G before her death. We found fault with the Trust who did not tell Miss F her mother could decline quickly and what she should expect. The Trust has already remedied this. We also found fault in the Trust’s complaint handling; it did not check the facts in the documents it sent to the Care Home. We found no fault with the Council or Care UK. These faults caused distress and confusion to Miss F. We recommended an apology and service improvements to address this injustice.
The complaint
Miss F complains about the circumstances leading to her mothers, Ms G’s, death. Ms G went from hospital to a ‘rehabilitation bed’ at Highmarket House Care Home, owned by Care UK (the Care Home) on 8 December 2021. The placement was arranged by Oxfordshire County Council.
Miss F complains Oxford University Hospitals NHS Trust (the Trust): Did not explain her mother was at the end of her life or why such a bed was suitable Did not give her mother any palliative medication Caused her avoidable stress and frustration by not explaining the funding arrangements for the placement or it could withdraw NHS funding at short notice Miss F also complains about the Care Home. She complains: Paramedics could not find her mother’s care plan or do not attempt cardiopulmonary resuscitation (DNACPR) form The Care Home did not know Ms G was diabetic Staff thought Ms G dehydrated when she was hyperglycaemic The events denied Miss F the opportunity to say goodbye to her mother because she did not know she was dying. She saw her mother die in horrible circumstances which could have been avoided. Miss F was caused further distress in pursing the complaint as the organisations did not provide clear explanations, blaming each other rather than accepting responsibility.
Miss F wants the organisations to be accountable for the failings in her mother’s care and to apologise. She wants service improvements to ensure no one else goes through what she has.
The Ombudsmen’s role and powers The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA) 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.
The Ombudsmen cannot question whether a decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the organisation reached the decision. (Local Government Act 1974, section 34(3), as amended, and Health Service Commissioners Act 1993, sections 3(4)- 3(7)) 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)
How I considered this complaint
I considered the complaint Miss F made to the Ombudsmen and information she provided on the telephone and by email. I also considered the information the Council, the Trust and Care UK provided in response to my enquiries.
I shared a confidential draft with Miss F, the Council, the Trust and Care UK to explain my provisional findings and invited their comments. I considered the comments I received before making a final decision.
What I found
Discharge of Ms G to a ‘rehabilitation bed’ at the Care Home Miss F complains her mother went from hospital into a ‘rehabilitation bed’ at the Care Home.
Ms G went from hospital to the Care Home on 8 December 2021. Ms G’s care plan explained staff were to keep Ms G comfortable and give her pain medication when needed. The Council found this bed for Ms G and arranged it under its ‘discharge to assess’ pathway. This pathway was suitable because although Ms G was still very unwell, she no longer needed active medical treatment and did not need to stay in hospital.
The Council and the Trust say this placement was to be temporary whilst they could assess Ms G’s longer term needs and find a suitable long-term placement for her. Ms G died before this could happen.
Miss F explains she does not understand why they called the bed a ‘rehabilitation bed’ if they knew she would soon die. She said this added distress as it implied Ms G would get rehabilitation while there.
I reviewed the records from the Trust, the Care Home and the Council. I found one reference to the placement in such a way, and this is in the Trust’s complaint response of 9 June 2022. The Trust admit communication with Miss F about what to expect should have been better. The Trust apologised to Miss F.
In summary, the placement the Council arranged for Ms G to the Care Home for when she left hospital was suitable but unclear explanations may have caused confusion to Miss F. The Trust accepted this during local complaints resolution and apologised, which I consider a suitable remedy for the injustice caused to Miss F.
No communication about Ms G reaching end of life Miss F complains the Trust did not talk to her about what Ms G was likely to experience when she reached the end of her life, and what signs she may show.
The General Medical Council provides guidance on treatment and care towards the end of life. In its good practice in decision making guidance it says “it is important that you and other members of the healthcare team acknowledge the role and responsibilities of people close to the patient. You should make sure, as far as possible, their needs for support are met and their feelings respected”’.
In its complaint response 9 June 2022, the Trust accept “there was a missed opportunity for the Medical Team to discuss a change to your mother’s treatment escalation plan with you and your mother prior to leaving hospital.” It added “it should have been explained that your mother was now likely to be in the last weeks and months of her life.” The Trust added that although doctors did not expect Ms G to die soon, they could have prepared Miss F for the possibility her mother could decline suddenly and unexpectedly.
Miss F explained she did not have opportunity to say goodbye to her mother properly because she did not know she was going to die so soon. The Trust accept if doctors had spoken to Miss F, her mother’s quick decline may not have been such a shock and apologised to her during the local resolutions process.
The PHSO’s Principles of Remedy states “where maladministration or poor service has led to injustice or hardship, public bodies should try to offer a remedy that returns the complainant to the position they would have been in otherwise.” Due to the circumstance of the complaint, the Trust could not return Miss F to her original position, but it has accepted there was fault and apologised.
In summary, the Trust did not discuss with Miss F what may happen to Ms G after she left hospital. It did not prepare her for what may happen, and this left her unprepared and caused her distress. The Trust did not recognise the importance of Miss F’s role in line with guidance, this is fault which caused an injustice to Miss F. The Trust’s apology is an adequate remedy for the injustice caused to Miss F.
No palliative medication given by hospital Miss F complains the Trust did not prescribe her mother with any palliative medications when she left hospital to go to the Care Home.
Ms G went to the Care Home on the ‘discharge to assess’ pathway. The Trust explained although she was very unwell, doctors did not expect her to die immediately, and the professionals managing her care were seeking a long-term placement for her. General Medical Council (GMC) guidance explains “patients are ‘approaching the end of life’ when they are likely to die within 12 months.”
In its complaint response of 9 June 2022, the Trust said Ms G “was in the final stages of her life when she was discharged but was not actively dying at that time”. Her care plan shows she left hospital without any palliative medications.
National Institute of Clinical Excellence (NICE) and British National Formulary (BNF) Prescribing in palliative care guidance states “careful assessment of symptoms and needs of the patient should be undertaken by a multidisciplinary team” before prescribing palliative medication.
Ms G’s records show doctors assessed her before she left hospital. The Trust’s complaint response explained doctors did not feel Ms G was ‘actively dying’ and did not prescribe palliative medication. On 16 December, Care Home staff noted a rapid decline in Ms G and they contacted her GP to order ‘anticipatory’ medication. NICE guidance explains ‘anticipatory’ medications are designed to give a patient rapid relief whenever distressing symptoms develop. In Ms G’s case, when it was felt she was reaching the end of her life, the Care Home ordered the medication so it could give them to her, however she went into hospital before this could happen.
Seeing her mother’s decline distressed Miss F and she believes medication could have helped. I can appreciate it would have been very distressing for Miss F to see her mother in pain but evidence shows the Care Home had access to palliative medications through Ms G’s GP.
In summary, the Trust did not prescribe Ms G palliative medication on her discharge from hospital. Doctors assessed her and determined she was not going to die in the immediate future. This is in line with guidance. When the Care Home realised Ms G was declining quicker than expected, staff ordered the medications from her GP. I found no fault with the actions of the Trust.
Funding not fully explained Miss F complains the Trust caused her unnecessary stress and frustration by failing to explain the funding arrangements for the Care Home placement. She explains it did not properly tell her it could withdraw NHS funding at short notice or the implications of this to her and her mother.
The NHS’s Continuing Healthcare (CHC) funded Ms G’s care until 19 November 2021, when the Council’s social care department took over. Ms G was then in hospital until 8 December before moving to the Care Home. Miss F emailed the Council on 29 November and on 30 November it told her she needed to send the ‘financial circumstances form’ or it would charge the placement at full cost.
I asked the Trust to explain what information it provided to Miss F about CHC funding. It explained when Miss F asked about CHC funding it told her it was another Trust who managed the CHC. The Trust told Miss F for any questions or concerns she had about CHC funding and about it potentially being withdrawn, she would need to speak to the other Trust and it could not help her. The Trust provided evidence of this advice.
In summary, the Trust under investigation is not responsible for the CHC funding Miss F is complaining about. It advised Miss F who she needed to speak to about this and we are aware Miss F has spoken to the other Trust. This is what we would expect. I found no fault.
Paramedics could not find Ms G’s care plan and DNACPR form Miss F complains when paramedics attended on 18 December 2021 Care Home staff could not find her mother’s care plan or DNACPR form.
I have reviewed Ms G’s daily care notes from the 18 December 2021. An out of hours GP attended to Ms G as Care Home staff noted she was not passing much urine. The GP changed her catheter, and staff told the GP she had not been drinking a lot. The GP told staff to give Ms G lots of fluids and make a note if she passed urine. In this entry a note says “She has a DNAR in place. She has anticioarory [sic] medications but its unclear if she is for hospital admission or not.”
The next entry refers to Miss F, who was with her mother, and explains she had been encouraging her mother to drink. Staff were also continually offering Ms G drinks. Miss F remained concerned so asked a nurse to come and assess Ms G. The nurse did so and then called an ambulance. Paramedics arrived at 17:30, and during their assessment Ms G became unresponsive. After speaking with Miss F, they took Ms G to hospital. There is no mention in any record about staff not being able to find her care plan or DNACPR form.
I asked the Care Home if it was possible the documents might not have been available. It explained the Care Home Manager and the Nurse who was present have left and so we cannot ask them what happened. Procedure on admission to the Home is for staff to complete an individual care plan and risk assessment. Staff print a copy and keep it in the residents own care folder in a secure location in the nurse’s station. The original of the DNACPR form should also be in this folder. These documents were only accessible to Care Home staff with suitable access.
The Care Home also explained it stores electronic copies of the care plan and the DNACPR form and staff can quickly access and print if the folder was not available.
The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17 states organisations should “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.”
Care UK’s Admission and Discharge Policy 3.9 states “complete the transfer documentation and include a copy of the MAR sheets, details if end of life care e.g., advance care plan, DNACR documents”.
Care UK’s Move In & Transfer policy states if a patients needs an emergency transfer to hospital “any paper care documentation is photocopied and the photocopies sent with the resident not the originals with the exception of the DNAPR which stays with the resident. A copy of the DNACPR should be taken but the original must be sent with the resident”.
I have seen no evidence in the written records the forms the paramedics needed were not available to them. As the staff members who were there have left the organisation, I cannot ask them what happened.
I understand Miss F found the events distressing and can sympathise with why if she thought the documents were not available this would be harmful to the care her mother received. However, I found no evidence the documents weren’t available, and it is clear the paramedics decided to take her to hospital based on her clinical presentation and discussion with Miss F. I cannot see any impact on the care Ms G received regardless of whether the documents were available. I found no fault.
Lack of diabetic care at end of life Miss F complains the Care Home did not know her mother was diabetic. As she neared the end of her life, staff thought Ms G could be dehydrated and staff encouraged her to drink, when she was in fact hyperglycaemic.
Miss F further complains the Trust provided contradictory responses to her complaint. Because of this, she still does not understand what happened to her mother in her final hours. Her blood sugar level on admission to hospital was 8.7mmol/L, a normal blood sugar level for someone without diabetes is 4 to 6 mmol/L In their complaint correspondence to Miss F, the Trust explained Ms G “had pancreatitis which increases the risk of developing diabetes, she was not on any diabetic medication. Diabetes is listed as a ‘potential’ problem on her discharge summary.” The Trust repeated this explanation in its complaint response letter of 9 June 2022. In this letter, the Trust explained the doctor “had discussed your mother’s cause of death with the Medical Examiner, and it had been agreed that low blood sugar at presentation to the hospital on your mother’s last admission was due to poor oral intake and an element of severe infection and was not due to her being diabetic.” The Trust added “as your mother was not diabetic, it would not have been handed over that there was a requirement to check her blood sugars.”
I have reviewed Ms G’s discharge summary which the Trust sent to the Care Home, her care plan, and her daily records; none of these documents refer to Ms G being diabetic. The Trust did not ask the Care Home to check her diet or blood sugar.
In Ms G’s medical records provided to the Ombudsmen, a discharge summary dated 9 December 2021 lists diabetes as ‘provisional’. This discharge summary is not the one the Trust sent to the Care Home, which is dated 8 December. The Trust explained it listed diabetes as a ‘potential’ problem on the discharge summary, but I cannot see this on the copy provided to the Care Home.
I understand seeing her mother’s rapid decline would have been distressing for Miss F and on finding out she had high blood sugar levels, she would have wanted to know why. When she asked the organisations, the Trust caused confusion and further distress when it said it was a ‘potential’ problem and the Care Home said it was not aware of any diabetic concerns. I understand why this would have been confusing for Miss F and added to her distress.
PHSO’S Principles of Good Complaint Handling state organisations should ‘be open and honest when accounting for their decisions and actions. They should give clear, evidence-based explanations, and reasons for their decisions.’ In trying to reassure Miss F, the Trust caused further distress as it did not check the discharge summary it sent to the Care Home. When it referenced this document in its account, Miss F referenced the same document to the Care Home who told her it did not list diabetes as a ‘potential’ problem. If the Trust had checked its evidence first, it would not have made this statement and not caused Miss F confusion and further distress. This is fault which caused an avoidable injustice to Miss F.
In summary, there is no evidence Ms G was diabetic. However, the Trust caused avoidable confusion and distress to Miss F when it tried to explain its actions without checking what it had told the Care Home.
Agreed actions
The Ombudsmen recommended and the Trust agreed the following actions.
Within one month of the date of the final decision, the Trust will write to Miss F to acknowledge the faults identified by the Ombudsmen and apologise for the avoidable distress and frustration this caused her both at the time of the events and in the local complaint’s resolution process.
Within two months of the date of the final decision, the Trust will: Provide evidence complaints handling staff have received training in complaint handling in line with Ombudsmen guidance Provide evidence to the Ombudsmen and Miss F of changes implemented to discharge recording sheets The Trust should provide evidence to the Ombudsmen it has completed these recommendations.
Final Decision
I partly uphold Miss F’s complaint. I found fault which led to an avoidable injustice to Miss F. The agreed actions will provide a suitable remedy.
Investigator's decision on behalf of the Ombudsman