Discussions with the Care Home
26. On 24 November, Mr A says his sister found his mother in bed covered in food. We appreciate how distressing this must have been for them. Mr A’s outstanding complaint is the Care Home did not take his concerns seriously and simply said there was no record of it.
27. Mr A is confident of the date because he was abroad at the time, and his sister called him after visiting their mother.
28. There are no written records of the family raising concerns on 24 November, or at any other time in November.
29. Despite this, Mr A recalls his mother was better supported with her feeding in December, particularly after her hospital admission. He also told us it is not the kind of event you would wait to raise with staff.
30. The Care Home says it was not aware there were any issues until 24 December when the family met with management staff to discuss their concerns.
31. Mr A says he does not recall a conversation on 24 December. He thinks the Care Home has recorded the date of the discussion incorrectly, which makes him question its record keeping.
32. Both parties agree there was a discussion. We looked at the records in detail. The only record of the discussion that supports the Care Home’s response, is in an amendment to the nutritional component of the care plan. It says ‘24/12/19- spoke with daughter- staff are to support [Mrs A] with her meals due to decline in health’.
33. Mrs A died in January 2019, which means this date of this entry is wrong. There is also a note that appears to have been written after it dated ‘05/12/18’.
34. There is evidence the date is recorded incorrectly in the records. Mr A has provided persuasive evidence this discussion took place in November, not December. This means there is an indication of a failing in record keeping. The Care Home does not appear to have acted in line with our Principles of good administration.
35. We also think there are indications the complaint investigation did not give due consideration to Mr A’s account of what happened or look closely at the records. This does not appear to be in line with our principles of good complaint handling and it affected the complaint response.
36. Mr A says had the Care Home been honest about what happened, he would have been satisfied with an apology. Instead, he feels it has not taken his concerns seriously and it has shown it did not keep accurate records. This has caused further upset to the family. We appreciate why Mr A feels this way.
37. We have discussed this with the CCG. It has recognised the complaint response did not balance the evidence, specifically Mr A’s account. Having considered the evidence again, it said it wants to apologise to Mr A for the Care Home’s mistakes in its record keeping and its mistakes in the complaint handling.
38. It also told us it will consider how this happened and if there are any service improvements it should make, or should take up with the Care Home, to prevent this happening again.
39. The CCG’s acknowledgement of failings and consideration of service improvements are in line with the types of remedy set out in our principles for remedy. We are satisfied this resolves this element of Mr A’s complaint.
Mattress
40. In the afternoon on the day of her death, Mrs A was reviewed by a nurse. The nurse recorded they had called a tissue viability nurse to discuss the air mattress. We know from the records the air mattress had been suggested in an earlier assessment.
41. Later that evening there is a further note written by the nurse. It says staff changed the mattress for Mrs A, and she has the airflow mattress in place. It also says her daughter was not happy staff had to transfer her again.
42. The nurse’s notes say they explained to Mrs A’s daughter that the mattress was an emergency as they were not sure if the air flow mattress would come today. The nurse also wrote that they had told Mrs A’s daughter that without the mattress, there was a high risk of deterioration in her mother’s wounds and infection.
43. Very sadly, Mrs A died an hour later.
44. The records do not clearly state there were two mattress changes that day. The complaint response says Mrs A’s mattress was only changed once.
45. Considering the nurse’s comments, the family’s recollection of two mattress changes, and the notes referring to staff hoisting Mrs A twice, there is enough evidence to say it is more likely than not that Mrs A’s mattress was changed twice.
46. The evidence suggests the complaint investigation did not consider of all the facts or balance the evidence, as in line with our standards. This is an indication of a failing.
47. NMC Code says nurses should respond to the changing health needs of patients in the last stages of their life.
48. The records show the second change was an hour before Mrs A’s death. The notes make it clear the nurse was aware Mrs A was at the end of her life. In insisting on a further mattress change, to avoid infection, there is an indication the nurse did not act in line with the code. There is an indication of a failing in the mattress change.
49. Mr A says his mother experienced unnecessary discomfort. He says this was very difficult for her and for the family to see. We were sorry to hear about the family’s experience.
50. Mr A also says as the CCG denied there were two mattress changes in the complaint response, the situation became even more frustrating and led him to think it could happen again to someone else. We can appreciate why Mr A feels this way.
51. We have discussed this with the CCG. Again, it has recognised this part of its complaint response did not give due consideration to the evidence, or balance it appropriately. Having considered the evidence again, it has said it wants to apologise to Mr A for its mistakes in the complaint investigation, and the second mattress change.
52. It also told us it will consider how this happened and if there are any service improvements it should make, or should take up with the Care Home, to prevent this happening again.
53. The CCG’s acknowledgement of failings and consideration of service improvements are in line with the types of remedy set out in our principles for remedy. We are satisfied this resolves this element of Mr A’s complaint.
CHC assessments
54. The National Framework sets out how the CCG should assess an individual’s eligibility for CHC funding. It says the overall assessment and eligibility decision-making process should, in most cases, not exceed 28 calendar days from the date that the CCG receives the positive checklist.
55. It also says that when a fast track application is received, action should be taken urgently to agree and commission the care package. It says given the nature of the needs that this time period should not usually exceed 48 hours from receipt of the completed application.
56. The CCG received the positive checklist on 29 November 2018. It says it did not complete that assessment as it received and accepted a fast track application on 4 January 2019.
57. The CCG considered and accepted the fast track application on the date of receipt. It completed costing checks on 6 January, and it approved two suitable placements that day. It did not confirm the placements or notify the family until 9 January. By that time sadly Mrs A had died.
58. The CCG did not complete the initial assessment within 28 calendar days of 29 November. It has not provided a reason why it could not complete the assessment in this timeframe. This shows it has not acted in line with the National Framework.
59. The CCG did not complete the fast track assessment process, and commission care, within 48 hours of receiving the fast track tool. Again, this shows it has not acted in line with the National Framework.
60. There is an indication of failings in how the CCG processed the regular and fast track assessments.
61. Mr A says, had the CCG assessed his mother sooner, she would have been placed in a permanent placement, received the right care, and lived longer.
62. The complaint responses recognised these delays and apologised that this meant Mrs A was prevented from spending her last few days in a home of her choice. It also looked at service improvements it could make to prevent this happening again.
63. The CCG did not recognise that completing the assessments, within the timeframes set out in the guidance, may have resulted in a better experience for Mrs A and the family.
64. We do not know what care Mrs A would have received if there had been an opportunity for her to move to a permanent placement, in a home of her and her family’s choice.
65. Given there were issues with her care and treatment in the Care Home, it is possible she would not have experienced these issues if she had moved. She might have had a better experience. Because of our decision on the specific aspects of the complaint, considered elsewhere in this report, we do not think it likely she would have lived longer if she had been transferred. We will never be able to say if this transfer would have enabled her to live longer.
66. We have discussed this with the CCG. Having considered the evidence again, it has said it wants to recognise the family may have had a better experience at a different home, had it completed the CHC assessments in line with the guidance.
67. The CCG’s further acknowledgement of the impact its delays, along with its initial apology, and service improvements are in line with the types of remedy set out in our principles for remedy. We are satisfied this resolves this element of Mr A’s complaint.
End of life medication
68. On 6 December the hospital discharged Mrs A to the Care Home, with direction for a GP to monitor her potassium levels. There was no reference to end of life care or medication in the discharge summary, and no end of life medication had been prescribed.
69. The GP, who is not part of our investigation or this complaint, saw Mrs A regularly throughout December and in early January. Daily notes show that Mrs A had a cough and her fluid and nutrition intake had been reducing. There is no reference to end of life care or medication in any of the notes relating to these visits.
70. NMC code that says nurses should assess and respond to individual’s needs.
71. Mrs A was reviewed regularly by the care staff, including nurses, and her GP. Prior to the 6 January, there is no record of Mrs A being in pain or discomfort.
72. At the point she became acutely unwell, care staff showed they responded to her needs by contacting an emergency doctor. This doctor decided end of life medication was appropriate.
73. NICE guidance says GPs will take overall responsibility for prescribing policies. What to prescribe, and its availability, was the decision of the GPs, not the Care Home.
74. We recognise there was a time on 6 January where Mrs A may have benefited from end of life medication. There is no evidence to suggest the Care Home could have given Mrs A this medication at any point before it was prescribed.
75. The prescription was ‘to be given as needed’. From the point it was available to give, care staff assessed if the medication was needed and determined it was not needed at that time. Staff acted in line with the NMC code and the GP’s prescription.
76. We have not seen any indications of failings in this part of the complaint so we will not be taking any further action. We hope our explanation clearly explains our reasons and provides reassurance to Mr A that the nurses acted in line with the relevant guidance.
Conclusion
77. It is clear the circumstances that lead to Mr A’s complaint were upsetting and serious. We hope the steps we have taken to resolve the outstanding concerns, along with our explanations, offer reassurance his concerns have been looked at in detail, and followed up with the CCG. In addition, his complaint has also resulted in changes being made to improve the service provided.