Decision Date: 23rd September 2024
Summary
Mr X complained that Chichester Grange Care home did not properly support Mrs Y in her transition from hospital to its care home. After hospital discharge the care home failed to mitigate the risk of further falls and failed to recognise her symptoms of dehydration or her deteriorating neurological health. Mr X complained that these faults and their generally poor communication contributed to the death of Mrs Y.
What happened
Mrs Y was a resident of Chichester Grange Care Home, run by the care provider. She suffered from dementia and a neurological condition. Mrs Y required surgery after a fall and was set to be discharged from hospital when Mr X contacted the care home to ask what steps they would take to prevent future falls. The care home advised it would carry out a full assessment to determine what measures would be suitable to mitigate these risks.
At the time of Mrs Y’s discharge the care provider said an assessment of Mrs Y’s needs had been carried out over the phone. There was no record of this assessment. Additionally there is no record of any mitigation measures explored nor was Mrs Y’s internal care plan updated.
Mrs Y fell on her first night back in the care home.
After the fall Mr X reported to the care home that earlier that day Mrs Z, a relative, had visited and relayed to Mr X that no sensor mats or other safety measures were in place. Mr X was told by the care home that they would investigate and respond to him within 7 days. There is no record of the care home taking any such action.
Mrs Y was readmitted to hospital after her fall, and the care home delayed in notifying Mrs Y’s family about her fall and admission. This caused Mrs Y significant distress as she was not clear as to what was happening to her.
The day Mrs Y returned to the care home bed rails were fitted, following an assessment, to prevent her from falling in the night.
Following her return to the care home, Mrs Z raised concerns that Mrs Y was experiencing escalated symptoms of her neurological condition and the care home met with her to discuss this. The care home increased Mrs Y’s medication as advised by her neurologist on a previous occasion, who was also contacted for an urgent review.
Records show that the care home attempted to chase the neurological review before Mrs Y eventually attended the appointment.
Mr X had contacted the care home concerned that Mrs Y’s swallowing difficulties would lead to dehydration. Two days later Ms Z took Mrs Y to the hospital again, for the same reason. Mrs Y was admitted and sadly passed away a few days later.
Mr X and Ms Z made a complaint to the Care Provider regarding the inadequate care Mrs Y had received – namely, failure to plan for her discharge from hospital, failure to mitigate fall risks and failure to notify relatives when Mrs Y was readmitted to hospital.
In its response the Care Provider acknowledged that Mrs Y’s care plan should have been reviewed post-discharge but maintained that mitigation measures were put in place. They apologised for their delayed communication.
Unhappy with the response, Mr X and Ms Z escalated their complaint. The Care Provider then apologised for not conducting a face to face assessment of Mrs Y’s needs post- discharge and for failing to keep appropriate records. The management explained that less restrictive measures are often considered before bed rails and that sensor technology had now been installed. It also recognised that the care home had failed to follow the Care Provider’s own complaints procedure and aimed to improve communication with families.
What was found
As the Care Provider had failed to keep appropriate records of its actions or correspondence the LGSCO could not be satisfied that Mrs Y’s needs were properly reconsidered when she was discharged from hospital.
Importantly, as there is no evidence of any discussion of Mrs Y’s needs by care home management the LGSCO found that the care home failed to follow the Care Provider’s own procedure. The LGSCO explained that this sort of omission is a potential breach of the Care Quality Commission’s Fundamental Standard for person-centred care.
Whilst it could not say that future falls would have been prevented if a proper reconsideration had been carried out, the LGSCO found that this fault will have caused distress to Mr X and Ms Z, in any event.
The LGSCO was satisfied that the Care Home reacted appropriately to the relapse of Mrs Y’s neurological condition.
However, the LGSCO found no evidence of the care home’s response to concerns that Mrs Y was becoming dehydrated. it could not therefore evaluate the adequacy of hydration care Mrs Y received in the days leading up to her death.
It concluded that the care home’s failure to keep a record of care delivered prior to Mrs Y’s death, for whatever reason, amounted to fault. The LGSCO held that this fault will have caused distress and uncertainty to Mr X and Ms Z.
Similarly, the lack of communication from the care home was also fault. Failure to notify Mr X or Ms Z of Mrs Y’s admission to hospital not only caused distress to Mrs Y herself but also to her relatives. As Mrs Y had since passed away this injustice could not be remedied.
The Care Provider was told to provide Mr X and Ms Z with written apologies reflecting the distress and uncertainty caused by its failures. It would also make a symbolic payment of £250 to each of them. It would remind its care homes of the importance of following proper procedure when assessing residents’ needs and review its record keeping practices to ensure any specific concerns about a resident’s health and welfare are included in the record. Finally, improvements would need to be made in the care home’s communication with residents’ families.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
This is a sad indictment of what CAN happen when there is no local authority or NHS commissioner involved in private clients’ care. There is never any likelihood of a finding by the Ombudsman that the neglect caused the death, but we wonder what the Coroner would make of this sequence of events, and whether a civil court would find it to be negligent, at the behest of the person’s estate, regardless of the fact that damages for the death would be minimal.
No reference to any safeguarding referral by the home or the family is mentioned, we note; the investigator did not say anything about that aspect of the events.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s Care UK Community Partnerships Limited (23 009 055) report.
If you are affected by the issues in this report, please consider asking a free, one-off question, anonymously, at a level of principle, here. Our experts’ response will give you an opinion which may then help you and the broader community, when posted.
Did you enjoy this analysis? Want to stay informed with our weekly Alert Service?Then do click here to find out how you can receive the latest insights from experts and commentators and stay updated on key judicial decisions, ombudsmen’s reports, and critical law and policy changes, all for just £50 per YEAR and sent straight to your inbox or WhatsApp!