PSOW Individual Decisions

Ms C complained that Monmouthshire County Council declined to investigate her complaint about a care home’s decision to prevent her from visiting her mother, in what transpired to be the final days of her mother’s life. The Ombudsman decided that because the Council funded the placement it should have responded to Ms C’s complaint, and considered the rights of both Ms C and her late mother. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Council’s agreement to offer Ms C an apology and acknowledge her complaint within 1 week, and to provide a formal response in line with its complaints procedure.

Mrs A complained about fees charged by the Care Home for her father’s care. The Care Home had charged from acceptance of the placement, rather than from admission. Mrs A said she had not been informed that fees would be charged from the date of acceptance and felt unfairly treated. The Ombudsman found that the documentation provided to Mrs A from the Care Home was unclear and did not confirm the date from which the charges would apply. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Care Home’s agreement to waive the fee charged from acceptance to admission and provide updated correspondence directly to Mrs A to confirm this within 2 weeks. In addition, the Care Home agreed to, within 4 weeks, review the documentation provided to all new residents regarding fees and amend aspects of the contract and policy relating to fees to ensure that they are clear on when fees chargeable.

Mrs C complained about the care and treatment her late mother, Mrs B, received from a care home (“the Care Home”), in the area of Powys Teaching Health Board. The investigation considered whether the nursing care and treatment received by Mrs B at the Care Home was of an appropriate standard in the 2 weeks before she sadly died on 21 March 2023.  Mrs C said that concerns about Mrs B’s dehydration were not appropriately managed and that the Care Home did not contact the GP soon enough for a more timely re-assessment of her diuretic medication (that increases the amount of urine produced). The Ombudsman found that the nursing care and treatment received by Mrs B at the Care Home from 7 to 21 March 2023 was of an acceptable standard and that concerns were appropriately discussed with the GP.  The Ombudsman did not uphold this complaint.

Mrs B complained that she submitted a complaint to the Health Board in July 2023. This was regarding the care and treatment her late father received at Neath Port Talbot Hospital, and his premature discharge to a care home, which she said contributed to his death. Mrs B had still not received a response to her complaint a year later. Mrs B wanted this to be completed, and amongst other things, to have an opportunity to speak to staff to discuss the complaint outcome. The Health Board agreed to issue the complaint response within 20 workings days and, as part of that response, to offer Mrs B a meeting to discuss the complaint outcome. The Ombudsman considered this to represent an appropriate outcome and closed the case on this basis.

Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately manage her mother’s skin integrity, leading to the development of a grade 4 pressure sore, and failed to inform the family that Mrs B had developed this level of sore. Similarly, Mrs A raised concerns that the Care Home did not recognise that her mother was at the end of her life and provide appropriate nursing care, or provide clear communication with the family on this matter. Mrs A also complained that the Health Board, which had funded Mrs B’s stay at the Care Home, had failed to provide appropriate oversight of her mother’s condition while she was a resident. In addition, Mrs A raised concerns about the Health Board’s handling of her complaint. Lastly, the investigation considered Mrs A’s complaint that her mother’s GP Surgery failed to carry out appropriate consultations with Mrs B in July 2021 (which included the prescription of primidone) and so had been unaware of her deteriorating condition. The Ombudsman found that there was a lack of clear direction in managing Mrs B’s pressure areas at the Care Home and that it was not clear whether the referral to the Tissue Viability Team had been made in a timely way. Although the Ombudsman could not conclude that the later development of Mrs B’s grade 4 pressure sore was avoidable, there were lost opportunities to maximise the effectiveness of Mrs B’s pressure area care. Furthermore, the Ombudsman found that it did not appear that staff at the Care Home had recognised the grade of pressure sore, and so by extension did not fully inform Mrs B’s family of the severity of it. As a result, the Ombudsman upheld these aspects of Mrs A’s complaint. The Ombudsman also found that whilst staff recognised that Mrs B was possibly nearing the end of her life,

Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately manage her mother’s skin integrity, leading to the development of a grade 4 pressure sore, and failed to inform the family that Mrs B had developed this level of sore. Similarly, Mrs A raised concerns that the Care Home did not recognise that her mother was at the end of her life and provide appropriate nursing care, or provide clear communication with the family on this matter. Mrs A also complained that the Health Board, which had funded Mrs B’s stay at the Care Home, had failed to provide appropriate oversight of her mother’s condition while she was a resident. In addition, Mrs A raised concerns about the Health Board’s handling of her complaint. Lastly, the investigation considered Mrs A’s complaint that her mother’s GP Surgery failed to carry out appropriate consultations with Mrs B in July 2021 (which included the prescription of primidone) and so had been unaware of her deteriorating condition. The Ombudsman found that there was a lack of clear direction in managing Mrs B’s pressure areas at the Care Home and that it was not clear whether the referral to the Tissue Viability Team had been made in a timely way. Although the Ombudsman could not conclude that the later development of Mrs B’s grade 4 pressure sore was avoidable, there were lost opportunities to maximise the effectiveness of Mrs B’s pressure area care. Furthermore, the Ombudsman found that it did not appear that staff at the Care Home had recognised the grade of pressure sore, and so by extension did not fully inform Mrs B’s family of the severity of it. As a result, the Ombudsman upheld these aspects of Mrs A’s complaint. The Ombudsman also found that whilst staff recognised that Mrs B was possibly nearing the end of her life,

Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately manage her mother’s skin integrity, leading to the development of a grade 4 pressure sore, and failed to inform the family that Mrs B had developed this level of sore. Similarly, Mrs A raised concerns that the Care Home did not recognise that her mother was at the end of her life and provide appropriate nursing care, or provide clear communication with the family on this matter. Mrs A also complained that the Health Board, which had funded Mrs B’s stay at the Care Home, had failed to provide appropriate oversight of her mother’s condition while she was a resident. In addition, Mrs A raised concerns about the Health Board’s handling of her complaint. Lastly, the investigation considered Mrs A’s complaint that her mother’s GP Surgery failed to carry out appropriate consultations with Mrs B in July 2021 (which included the prescription of primidone) and so had been unaware of her deteriorating condition. The Ombudsman found that there was a lack of clear direction in managing Mrs B’s pressure areas at the Care Home and that it was not clear whether the referral to the Tissue Viability Team had been made in a timely way. Although the Ombudsman could not conclude that the later development of Mrs B’s grade 4 pressure sore was avoidable, there were lost opportunities to maximise the effectiveness of Mrs B’s pressure area care. Furthermore, the Ombudsman found that it did not appear that staff at the Care Home had recognised the grade of pressure sore, and so by extension did not fully inform Mrs B’s family of the severity of it. As a result, the Ombudsman upheld these aspects of Mrs A’s complaint. The Ombudsman also found that whilst staff recognised that Mrs B was possibly nearing the end of her life,

Mrs A complained that Cwm Taf Morgannwg University Health Board (“the Health Board”) failed to resolve her long-standing concerns about her mother’s care and treatment whilst she was a resident at a Care Home. The Ombudsman found that the Health Board failed to advise Mrs A that it could not investigate her concerns about the care home. Instead, it told her that her complaint was out of time. The Ombudsman said that this caused delays to Mrs A. She decided to settle the complaint without an investigation. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs A with an apology, within 10 working days.

Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to ensure appropriate assessments were undertaken in a timely manner and her return to her own home was inappropriately and unreasonably delayed, all of which impacted on her health and welfare. In addition, Mrs A complained about the care Mrs B received from a care home in the Health Board area (“the Care Home”) in that, between 1 and 28 November 2020, the Care Home did not meet Mrs B’s needs (as set out in her Care Plan) and did not ensure its staff used Personal Protective Equipment (“PPE”) appropriately and in-line with legislation and guidance. The Ombudsman found that there were some shortcomings on the part of both the Health Board and Care Home, in meeting the needs set out in the Care Plan, but that this was largely due to measures needed to stop transmission of the COVID-19 infection. The Ombudsman did not uphold these complaints. The Ombudsman found that although appropriate assessments were completed, there were avoidable delays in the assessment and discharge process and so, to that extent, upheld this complaint. The Ombudsman also found that for a period of time while Mrs B was in the Care Home, and while she was nursed in a bed, the Care Home did not to adhere to her Care Plan. The Ombudsman also found that although it was not possible to say the extent to which this was the case, the correct PPE was not appropriately worn consistently in the communal areas of the Care Home. The Ombudsman upheld this complaint. The Ombudsman recommended that, within 1 month, both the Health Board and Care Home apologise to Mrs A for the failings identified.

Mrs A complained about the actions of Aneurin Bevan University Health Board (“the Health Board”) in relation to the care provided to her late mother, Mrs B. Specifically, Mrs A complained that Mrs B’s needs (as set out in her Care Plan) were not met, there was a failure to ensure appropriate assessments were undertaken in a timely manner and her return to her own home was inappropriately and unreasonably delayed, all of which impacted on her health and welfare. In addition, Mrs A complained about the care Mrs B received from a care home in the Health Board area (“the Care Home”) in that, between 1 and 28 November 2020, the Care Home did not meet Mrs B’s needs (as set out in her Care Plan) and did not ensure its staff used Personal Protective Equipment (“PPE”) appropriately and in line with legislation and guidance. The Ombudsman found that there were some shortcomings on the part of both the Health Board and Care Home, in meeting the needs set out in the Care Plan, but that this was largely due to measures needed to stop transmission of the Covid-19 infection. The Ombudsman did not uphold these complaints. The Ombudsman found that although appropriate assessments were completed, there were avoidable delays in the assessment and discharge process and so, to that extent, upheld this complaint. The Ombudsman also found that for a period of time while Mrs B was in the Care Home, and while she was nursed in a bed, the Care Home did not to adhere to her care plan. The Ombudsman also found that although it was not possible to say the extent to which this was the case, the correct PPE was not appropriately worn consistently in the communal areas of the Care Home. The Ombudsman upheld this complaint.

Mrs A complained to the Health Board about the delay on the part of its Mental Health Service in getting her mother the correct urgent medical attention and required nursing care, whilst she was resident in a care home. In her complaint submission to the Ombudsman, Mrs A said that she disagreed that the Health Board had followed The National Health Services (Concerns, Complaints and Redress Arrangements) (Wales) Regulations 2011 (“the Regulations”) in its investigation of her complaint. The Ombudsman found that the complaint response from the Health Board did not comply with the Regulations. It failed to specifically address Mrs A’s complaint about delays on the part of the Health Board in getting her mother medical/nursing care, and it appeared to be a chronology of events only. Further, it did not comment on whether the Health Board considered that there were missed opportunities to intervene in her mother’s care, or if the deterioration in her mother’s physical condition were noted at the time of the visits from the Health Board staff. Additionally, it made no comment on whether there was any qualifying liability on the part of the Health Board, which the Regulations stipulate that the response should include. The Ombudsman sought and gained the Health Board’s agreement to provide Mrs A with a response to her complaint, in accordance with the Regulations, within 20 working days.

Mr X complained about aspects of care provided to his late father Mr Z, by the Care Home between April 2020 and May 2021. The Ombudsman found that there was no failure to consider the interaction between trazadone (an antidepressant) and lamotrigine (epilepsy medication) and that it was, ultimately the role of the prescribing clinicians, as opposed to the Care Home staff, to consider and monitor these issues before prescribing. However, there was no written record to satisfy the Ombudsman that appropriate discussions were held with either Mr Z or the family surrounding the deterioration in his behaviour, how it might be managed or the potential impact of the medication. This was maladministration which left Mr X in some uncertainty about whether this might have been different had there been better communication from the Care Home. This was an injustice and this complaint was upheld to this extent. The Ombudsman did not uphold a complaint about the decision to take Mr Z to hospital in April 2021 following a fall. She acknowledged the family’s concern about Mr Z being admitted but noted that the nature and circumstances of the fall were such that calling an ambulance was warranted, and following clinical assessment by paramedics, they (as opposed to Care Home staff) concluded that transfer to hospital for further investigations was necessary. In relation to a complaint about the failure to identify that Mr Z was suffering from delirium in May 2021, the Ombudsman found that, whilst Care Home staff did not consider or record the possibility that delirium was the cause of the symptoms displayed, they took appropriate action to address Mr Z’s symptoms through investigations and referrals. On this basis, she found that a formal diagnosis of delirium would not have altered the care he received, which was appropriate. Whilst this complaint was not upheld, the Ombudsman invited the Care Home to familiarise itself with relevant guidance on recognising and preventing delirium a

Mrs A complained that Wrexham County Borough Council (“the Council”) had not done enough to ensure that her late partner, Mr B’s needs were being met and monitored, particularly when she later raised concerns about his care home placement at a care home in England. Although the Ombudsman found evidence of good working on the part of the Council, she concluded that the Council should have taken steps to ensure that review arrangements around Mr B’s needs were put in place. The Ombudsman recognised that there were factors, including the COVID-19 pandemic, which would have affected Mr B’s move to another care home. However, given Mrs A’s increasing concerns about the ability of the Care Home to meet Mr B’s needs, the Ombudsman was clear that the Council’s eventual decision to carry out a telephone review could have been made sooner than in fact occurred. That said, the Ombudsman could not say that Mr B’s delayed move from the Care Home would not have happened, if the administrative shortcomings (around the review) had not occurred. However, she could not exclude the possibility that earlier decision-making by the First Council, especially in relation to the review arrangements, might have led to a different outcome. This uncertainty was the injustice for Mrs A and Mr B and to that extent the Ombudsman upheld Mrs A’s complaint. The Ombudsman recommended that the Council apologise to Mrs A and change its processes for out of county care home placements to ensure that appropriate review arrangements and/or contingency measures were put in place at the earliest opportunity.

Mr E complained about the healthcare staff’s behaviour towards him and the visiting restrictions placed on him during his wife’s inpatient admission. He also complained about aspects of his wife’s care which included nursing care. In addition, he was dissatisfied with the process that had led to his wife being discharged into a care home and the Health Board’s handling of his complaint. The Ombudsman discontinued the investigation as the court proceedings Mr E had taken meant he had exercised an alternative legal remedy (“ALR”). The limitations that apply under the legislation that gives the Ombudsman her powers meant she could no longer investigate the complaint. Based on the court findings the Ombudsman also concluded that the parts of Mr E’s complaint relating to his wife’s care should also be discontinued. Finally, the Ombudsman concluded that even if the ALR did not apply to the complaint handling issues Mr E had raised, it was not proportionate to continue the investigation into those matters on their own.

Ms X complained about her discharge from hospital in May 2020, specifically that she was not fit to be discharged and that it was not appropriate to move her to [Y] Care Home. Ms X was re-admitted to hospital just a day after her discharge. The Ombudsman found that Ms X was not fit for discharge – she was in great pain, was frail and her mobility and her ability to carry out activities of daily living were limited; she was also having dialysis 3 times per week. The Health Board had given Ms X only 2 options – to move to the Care Home, despite her expressed wish not to do so, or to go home with an inadequate package of care. The Ombudsman found that the Health Board did not satisfy itself that the Care Home could meet Ms X’s needs; it was not appropriate to discharge her to a care home which could not meet her needs and against her wishes. She upheld the complaint. The Ombudsman recommended that the Health Board apologise to Ms X for the failings identified and offer her a redress payment of £500 in recognition of the distress caused. She also recommended the Health Board take action to remind staff of the importance of carrying out discharge assessments, involving patients in discharge decisions and ensuring the discharge destination is suitable. The Health Board agreed to implement the recommendations.

Mrs T complained that the Adult Safeguarding Team (“the AST”) at Wrexham County Borough Council (“the Council”) mismanaged 4 Safeguarding referrals it received in respect of her late friend, Mr D – for whom Mrs T held Lasting Power of Attorney for Health and Welfare (“an LPA”). The referrals alleged that Mr D, who had progressive dementia, suffered abuse/was at risk of abuse from Mrs T as the result of her interactions with him (following his placement in a Care Home). Mrs T complained that: 1. The Safeguarding referrals should not have met the threshold for investigation as they were vexatious in nature. 2. The Safeguarding investigations were not conducted in accordance with the Social Services and Wellbeing (Wales) Act 2014. 3. A Safeguarding officer inappropriately reported the received referrals to the Office of the Public Guardian (“the OPG”), which is responsible for registering and regulating LPAs. 4. Mr D was not informed of the referrals or of the subsequent investigations and so his views on the events in question were not obtained. Also, evidence was not obtained from witnesses whose input might have favourably influenced the investigations. 5. Mrs T was not updated on the progress or conclusions of the investigations. The Ombudsman did not uphold any of Mrs T’s complaints. His investigation found that: 1. There was no evidence that the referrals, as received, were vexatious in nature. The AST was obliged to investigate whether Mr D was an adult at risk and (in 2 of the 4 referrals) recommended appropriate protective measures to restrict Mrs T’s contact with Mr D. 2. The Ombudsman found that the AST dealt with the referrals it received in accordance with procedures set out in Part 7 of the Social Services and Wellbeing (Wales) Act 2014 (and in accordance with Volume 6 of statutory guidance issued by the Welsh Government). 3. The Ombudsman found that the decision to report the received referrals to the OPG was not unreasonable (as the regulator of LPAs).

Mr X’s complaint to the Ombudsman was in relation to a number of matters concerning his late mother, Mrs Y. Mrs Y’s care and complaint handling Mr X complained about aspects of his late mother, Mrs Y’s, care while she was an inpatient at the Hergest Unit between July and September 2013. In particular, he complained that the Health Board did not: • “Section” Mrs Y when she was admitted. • Manage her nutritional care and falls risk appropriately. • Address a ligature risk posed by the Unit’s blinds. • Tackle a potential safeguarding issue raised by a large bruise on Mrs Y’s forehead. • Manage her discharge from the Unit to a care home properly. Mr X also complained about the way in which his complaint to the Health Board had been handled. The Ombudsman began an investigation of Mr X’s complaints about Mrs Y’s care and the handling of his complaint. During the investigation he identified the following failings in Mrs Y’s care: • There was a failure to follow national guidelines for the prevention of malnutrition and no clear evidence that Mrs Y’s nutritional needs were appropriately provided for. The malnutrition form was incomplete, brief and poorly written; food charts were incomplete; there appeared to have been no nutrition screening and the national guidelines (the MUST tool) were not used. • As Mrs Y was prone to falls at home before she was admitted to the Unit, she should have had a falls assessment on admission and after a potential fall on 30 August. She did not have such an assessment until 8, 9 and 10 September, and even then the records were brief and incomplete. • No patient safety incident report was completed in relation to Mrs Y’s bruising on 22 September, and a more robust falls assessment should have been carried out at this point. • There was no overall comprehensive assessment to inform an overall care plan for Mrs Y; although there were some standalone plans, they were not goal orientated or focused on the outcome of any interventions. Such record

Mr X’s complaint to the Ombudsman was in relation to a number of matters concerning his late mother, Mrs Y. Mrs Y’s care and complaint handling Mr X complained about aspects of his late mother, Mrs Y’s, care while she was an inpatient at the Hergest Unit between July and September 2013. In particular, he complained that the Health Board did not: • “Section” Mrs Y when she was admitted. • Manage her nutritional care and falls risk appropriately. • Address a ligature risk posed by the Unit’s blinds. • Tackle a potential safeguarding issue raised by a large bruise on Mrs Y’s forehead. • Manage her discharge from the Unit to a care home properly. Mr X also complained about the way in which his complaint to the Health Board had been handled. The Ombudsman began an investigation of Mr X’s complaints about Mrs Y’s care and the handling of his complaint. During the investigation he identified the following failings in Mrs Y’s care: • There was a failure to follow national guidelines for the prevention of malnutrition and no clear evidence that Mrs Y’s nutritional needs were appropriately provided for. The malnutrition form was incomplete, brief and poorly written; food charts were incomplete; there appeared to have been no nutrition screening and the national guidelines (the MUST tool) were not used. • As Mrs Y was prone to falls at home before she was admitted to the Unit, she should have had a falls assessment on admission and after a potential fall on 30 August. She did not have such an assessment until 8, 9 and 10 September, and even then the records were brief and incomplete. • No patient safety incident report was completed in relation to Mrs Y’s bruising on 22 September, and a more robust falls assessment should have been carried out at this point. • There was no overall comprehensive assessment to inform an overall care plan for Mrs Y; although there were some standalone plans, they were not goal orientated or focused on the outcome of any interventions. Such record

Ms A complained about a GP Practice (“the Practice”) in the Aneurin Bevan University Health Board (“the Health Board”) area who provided care and treatment to her father, Mr B, while he was a resident at a care home (“the Care Home”). His residency at the Care Home was funded by Torfaen County Borough Council (“the Council”). Specifically, Ms A complained that: • The Practice failed to provide timely and appropriate care and treatment to Mr B between January and May 2019, when Mr B had a below the knee amputation. • The Care Home failed to provide timely care and treatment to Mr B in terms of pressure area management and wound management, failed to communicate with, and involve her, in decision making including failing to allow her to view Mr B’s foot, and failed to act upon concerns raised by Ms A. • The Council failed to review/monitor Mr B’s care while he was a resident at the Care Home. The investigation found that the care provided by the Practice was appropriate with timely and appropriate investigations conducted, that test results were reviewed in a timely manner and actioned appropriately, and it was appropriate not to refer Mr B to hospital before 13 May. As such, the complaint against the Practice was not upheld. The investigation found that the Care Home acted in a timely manner by seeking assistance from the District Nurse (“DN”) Team when Mr B’s heel wound was first noticed and acted promptly in seeking GP input when an infection was suspected. The investigation found that Mr B did not initially want his information shared with Ms A without his consent, and, therefore, it would not have been appropriate to share and involve Ms A in decision making regarding his health, care and treatment. The investigation found that the Care Home did not fail to act upon concerns raised by Ms A about Mr B’s foot. As such, these aspects of the complaint were not upheld. However, Mr B was not subject to a prompt and thorough skin assessment by Care Home staff when he wa

Ms A complained about a GP Practice (“the Practice”) in the Aneurin Bevan University Health Board (“the Health Board”) area who provided care and treatment to her father, Mr B, while he was a resident at a care home (“the Care Home”). His residency at the Care Home was funded by Torfaen County Borough Council (“the Council”). Specifically, Ms A complained that: • The Practice failed to provide timely and appropriate care and treatment to Mr B between January and May 2019, when Mr B had a below the knee amputation. • The Care Home failed to provide timely care and treatment to Mr B in terms of pressure area management and wound management, failed to communicate with, and involve her, in decision making including failing to allow her to view Mr B’s foot, and failed to act upon concerns raised by Ms A. • The Council failed to review/monitor Mr B’s care while he was a resident at the Care Home. The investigation found that the care provided by the Practice was appropriate with timely and appropriate investigations conducted, that test results were reviewed in a timely manner and actioned appropriately, and it was appropriate not to refer Mr B to hospital before 13 May. As such, the complaint against the Practice was not upheld. The investigation found that the Care Home acted in a timely manner by seeking assistance from the District Nurse (“DN”) Team when Mr B’s heel wound was first noticed and acted promptly in seeking GP input when an infection was suspected. The investigation found that Mr B did not initially want his information shared with Ms A without his consent, and, therefore, it would not have been appropriate to share and involve Ms A in decision making regarding his health, care and treatment. The investigation found that the Care Home did not fail to act upon concerns raised by Ms A about Mr B’s foot. As such, these aspects of the complaint were not upheld. However, Mr B was not subject to a prompt and thorough skin assessment by Care Home staff when he wa