Decision Date: 12th July 2021
What happened
Mr Y had multiple health conditions including diabetes, Parkinson’s and dementia. While at home in January 2019, he suffered a fall. His wife, Mrs Y contacted her GP surgery to organise support. A subsequent visit from a social worker and a nurse practitioner revealed Mr Y’s mobility was “very poor” and that he was at a high risk of falls.
The Council arranged for Mr Y to go to Cedar Court Residential and Nursing Home (Cedar Court) for respite. Mr Y was to be assessed for 24 hour care in a general residential setting; however, he was transferred to an intermediate ‘care plus’ bed soon after admission so he could receive therapy to improve his mobility.
In early February 2019, the day after returning home, Mr Y felt unwell and the next day he was admitted to hospital with a heart attack. His family were then advised that due to an earlier, untreated heart attack, his prognosis was poor. Mrs X (Mr & Mrs Y’s daughter) explained [to the LGO] that at that time Mr Y was fitted with a stent and prescribed anti-platelet medication (which may cause bleeding). Mrs Y advised Mr Y had recently sustained a head injury (not caused by a fall) which had bled. A week later Mr Y passed away. His family contacted his GP to query the previous heart attack that they had no knowledge of. The GP advised the Care Provider (Cedar Court) had made a call to 111 about prolonged, acute chest pains two days prior to Mr Y’s return home.
The family then complained to the Care Provider asserting their failure to obtain timely medical help for Mr Y had led to his death. Also, that they had failed to fully advise 111 of My Y’s multiple conditions, failed to inform the family of Mr Y’s chest pain or seek clarity about Mr Y’s diabetes, and failed to mention the various falls Mr Y had at Cedar Court. A subsequent Coroners investigation found Mr Y’s death was consequent upon “a fall or falls prior to 6th February 2019 contributed to by the administration of a necessary anti platelet therapy”.
The Care Provider’s records showed Mr Y’s goal on admission was to improve his mobility. Also, that his mental capacity fluctuated, impacting his ability to make decisions about his care and requiring the provider to regularly speak to Mrs Y to consent on his behalf. A mental capacity assessment had not been fully completed. However, a discharge assessment noted Mr Y did not want to stay at Cedar Court any longer; that he could make his own decision about this; that he returned home before the council could arrange care at home and that he experienced six falls while at Cedar Court.
Regarding Mr Y’s falls – The LGO noted the provider produced records stating: there had been ten falls – seven of which were during the ten days before he left; that Mr Y refused to use his call bell when he wanted to get up; that he was “constantly being caught by his sensor alarms as he gets up unsupervised”; that eight of the ten falls were unwitnessed, and nine happened in the bathroom before staff (alerted by the sensor alarms) got to him. At times the sensor mat failed to work or Mr Y managed to mobilise without triggering it. Incident reports were completed on each occasion and showed the family were not notified but consideration was given to reducing risk. Mrs X said batteries were missing from a sensor mat; another was faulty; and staff failed to respond when Mr Y pressed his buzzer, leading him to try to mobilise on his own.
The provider’s records indicated they had requested surgery visits regarding high blood pressure and falls. Also that a nurse practitioner had requested the Care Provider monitor Mr Y as he was not currently prescribed medication for his Parkinson’s. Records also showed a 48 hour head injury observation chart. No information was provided as to how Mr Y received this injury. Additionally, none of the Care Provider’s ten, topic-specific logs (e.g mobility, pain, nutrition etc.) covered Mr Y’s entire stay at Cedar Court. Instead, each log covered various days, leaving gaps in between. Furthermore, the Care Provider had no information about Mr Y’s family members, except Mrs Y who experienced hearing loss and struggled to hear the information the Care Provider sought to provide over the phone. However, Mrs X stated they could have communicated with her in person during any of her daily visits when she was consistently accompanied by another family member.
Regarding Mr Y’s chest pain – Mr Y had experienced chest pains two days before returning home. The Care Provider called 111 providing his observations. The 111 operator then spoke with Mr Y who responded to their questions directly. The 111 report notes indicated Mr Y was not in pain at the time of the assessment or within the previous 24 hours. The outcome of the call was for Mr Y to be given over the counter pain relief, for a further call to be made if his condition changed and that “within one hour” the Care Provider should speak to a primary care service. In turn the primary care service was satisfied that Mr Y was in a safe state but advised a call to 111 or 999 if his condition worsened. Care Provider records with a space for the dates and times when the family were informed were blank and the incident was not raised at the discharge meeting two days later.
Regarding Complaint Handling – In May 2019 Mrs X escalated her complaint to the Council after the Care Provider twice informed her they were still investigating her concerns. The Council responded that the Care Provider was investigating the situation but elected to oversee the investigation while asking its Strategic Commissioning Manager to monitor the outcome of the complaint. In July, the Council told Mrs X its investigation had been hampered by a lack of access to the 111 call transcript.
The Care Provider, having taken legal advice, was waiting for the outcome of the Coroner’s investigation. The Council apologised for the care provider’s delay in updating the family about their own investigation. In August 2019, the complaint and the Council’s monitoring of it were paused, pending the outcome of the Coroner’s investigation. Subsequently, in July 2020, Mrs X complained to the LGO as the Council had still not completed the complaints procedure. The LGO waited until the Council’s complaint procedure was completed before reopening Ms X’s complaint in December 2020.
What was found
Regarding Mr Y’s falls – The LGO noted the Care Provider had undertaken appropriate risk assessments and implemented actions to minimise Mr Y’s risk of falls. When he had fallen, it had recorded the falls, considered whether any changes were necessary and taken appropriate advice from health professionals. As such, the Care provider was not at fault. However, they were at fault regarding the failure to notify the family about the falls. The LGO was particularly concerned with the blank head injury observation form and the lack of consistent logs, and noted its expectation that head injuries would be reported to the CQC.
Therefore, the LGO stated Mr Y had been put at undue and significant risk of harm and the family had been left with uncertainty about the impact of this upon his health and wellbeing.
The LGO further noted that the Care Provider – as noted on incident forms – had actively decided not to inform the family about Mr Y’s falls (as opposed to forgetting to do so). This meant Mrs X was unable to provide accurate information to those caring for Mr Y, which in turn may have contributed to a significant negative impact on his health and wellbeing and caused Mrs X and Mrs Y avoidable distress and uncertainty.
Regarding Mr Y’s chest pains – The LGO was satisfied the Care Provider took appropriate action when contacting 111 for the chest pains but once again failed to inform the family of the incident. This was fault which caused significant, avoidable distress and uncertainty.
Regarding Complaint Handling – The Care Provider failed to keep Mrs X informed about her complaints progress. This lack of communication was fault which caused significant, avoidable distress and frustration given Mrs X’s belief that the Care Provider had caused Mr Y’s death – a matter ultimately for the Coroner to decide.
To remedy the identified injustices, the LGO recommended that the Council apologise to Mrs Y and Mrs X, ensure the Care Provider also apologised and reimburse 50% of Mr Y’s Cedar Court fees. Also, that the Care Provider’s practice should be reviewed to ensure that relatives or others supporting residents were consulted with and kept suitably informed, and that their records and documentation were properly completed – particularly around personal information; falls and head injuries; contact with family and others; mental capacity; and daily logs.
Additionally, the LGO required that both the Council’s and Care Provider’s complaints processes should consider potential conflicts with investigations by other bodies at the earliest opportunity to ensure that complaints were only put on hold where essential. Also, that a review of social workers’ practice should take place to ensure care providers had all necessary information about individuals referred by the Council.
Finally, as the nature of the failures identified fell “significantly short of acceptable”, a potential breach of regulations 12, 17 and 20 was raised, leading the LGO to send a copy of its final decision to CQC.
Points to note for councils, professionals, people using services and their carers, advocacy groups, members of the public
The first thing to say here is that it is always a sad situation if people who are grieving have to go through a lengthy process to get answers about social care.
The LGSCO could have made more here about the central question of Mr Y’s capacity to make decisions about risk. It seems that Mr Y wanted to get up and move around, and was able to do so. However, when he did this he frequently experienced falls. Those falls resulted in injury and ultimately contributed to his death.
If someone has mental capacity to make a decision about whether to move around and risk injury, then they can get on with it. In this situation, we are told that Mr Y had fluctuating capacity. This indicates, in our mind, that the Council and Care Provider should have undertaken a clear process to determine how day-to-day decisions would be made to manage this risk.
There are risks involved with not mobilising and restricting free mobility, including by having sensors as Mr Y did, can lead to a loss of freedom and control. This makes it all the more important to ensure that the options have been considered and weighed up and a clear set of decisions that cover day-to-day scenarios has been drawn up.
Ideally, Mr Y would be able to agree what would happen to cover those times that his mental capacity fluctuated. Mrs Y would be fully involved, likely along with Mrs X. This would be written up and followed by the Care Provider.
None of this appears to have happened in a clear way. As a consequence, the record keeping about falls and injuries was not grounded in a clear understanding of what the Care Provider should have been doing to follow Mr Y’s wishes and/ or in Mr Y’s best interests. The LGSCO found that appropriate risk assessments and actions had taken place. However, in our view, the foundation for saying they are appropriate is a personalised one, which relies on having done the person-centred work that takes into account Mr Y’s capacity.
The issues that the LGSCO focuses in on as fault – lack of communication, limited recording and lack of clarity about the complaints process – are sadly all too familiar. The LGSCO has a huge backlog to work through and this would likely be much shorter if every Council could talk to its customers, write down enough to show risk is managed to their own commissioners and the end users and families and give regular updates about complaints. If we sound a bit frustrated about this, it is because these are fundamental public law principles of transparency and accountability (as well as basic customer service), and Councils should be resourced to be able to follow them.
The full Local Government Ombudsman report on the actions of Durham County Council can be found here: 20 002 566 – Local Government and Social Care Ombudsman