Summary: Mrs X complains Oakland Primecare’s Woodland Grove failed to provide appropriate contact with her mother in the weeks leading up to her death, causing unnecessary distress to her family. Oakland Primecare’s policies on visiting at the end-of-life did not reflect Government guidance in place at that time. This prevented Mrs Y’s family from visiting as often as should have been possible, causing avoidable distress. Oakland Primecare needs to apologise, pay financial redress and improve its working practices.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains Oakland Primecare’s Woodland Grove failed to provide appropriate contact with her mother in the weeks leading up to her death, causing unnecessary distress to her family.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers. If there has been fault, we consider whether it has caused an injustice and, if it has, we may suggest a remedy. (Local Government Act 1974, sections 34B, 34C and 34H(4), as amended)
3. This complaint involves events that occurred during the Covid-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether Oakland Primecare followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to Covid-19”.

Back to top

How I considered this complaint

4. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents Oakland Primecare has provided in response to my enquiries;
• shared a draft of this statement with Mrs X and Oakland Primecare, and taken account of the comments received.

Back to top

What I found

5. Oakland Primecare’s visiting protocol was based on Government guidance issued on 5 November 2020. It says, whenever possible, visits would be in the summerhouse, but a room was available if the weather prevented this. It also said:
• “For a very small minority of residents, who are unable to attend the summerhouse or the appointed indoor room, due to physical or psychological reasons, the Home Manager will assess whether a visit in the resident’s bedroom is appropriate. This assessment will be based on the professional assessment of the Home Manager and the outcome of their assessment is final.”
• “Visitor numbers must be limited to a single constant visitor wherever possible, with an absolute maximum of 2 constant visitors per resident. This is in order to limit the overall number of visitors to the home and/or the resident, and the risk of infection this would bring.”
• “Visits will be 30 minutes long. This is because the longer the visit takes, the higher the risk of any asymptomatic transmission.”
• “Any exceptions to the above protocol, for example allowing other family members to visit where a resident is in the last hours of life must only be made by the Director of Operations.”
6. On 1 December 2020 the Government updated its guidance on Visiting care homes during COVID-19. This said:
• all care homes – regardless of tier – and except in the event of an outbreak – should seek to enable:
1. indoor visits where the visitor has been tested and returned a negative result; and
2. outdoor visiting and ‘screened’ visits;
• visits in exceptional circumstances including end-of-life should always be enabled;
• “Families and residents should be supported to plan end of life visiting more deliberately, with the assumption that visiting will be enabled to happen not just towards the very end of life”;
• tests would be available for two visitors per resident twice a week;
• limiting numbers to a maximum of two constant visitors wherever possible; and
• interim measures for indoor visiting without testing only applied in Tier 1 areas.
7. Oakland Primecare’s risk assessment for visiting is dated 22 December 2020. It identifies these control measures for indoor visits:
• visitors to have two negative lateral flow tests on arrival;
• a single constant visitor allowed; and
• the Director of Operations could agree exceptions for residents in the final stages of end-of-life care.

Key facts

8. Mrs X’s mother, Mrs Y, went to stay in Woodland Grove in September 2020. Initially this was for respite but her stay became permanent as Mr Y could not look after her at home again. She had Alzheimer’s disease. She went into hospital on 3 November 2020 with “reduced responsiveness”. She tested positive for COVID‑19 on 10 and 21 November but had no serious symptoms. She was found to be at high risk of aspiration pneumonia and the hospital recommended actions to reduce the risks. She was also found to have a fractured wrist, which was treated with a splint. The hospital discharged Mrs Y back to Woodland Grove on 26 November.
9. Before going into hospital Mr Y had been able to see his wife in a summerhouse for 30 minutes once a week.
10. Woodland Grove kept records of the care provided to Mrs Y. I summarise the key contents:
• Mrs Y remained in her room after returning from hospital;
• she needed a lot of help with personal care;
• she found it increasingly difficult to eat and by 14 December she could no longer swallow food, and drank very little;
• she was occasionally distressed, shouting and/or hitting staff but on the whole remained calm.
11. On 2 December Mrs X wrote to Woodland Grove. She noted bringing Mrs Y to the summerhouse for her husband’s visits was no longer feasible because of the decline in her condition. She asked if her father could have bedside visits, as Mrs Y was nearing the end of her life. Woodland Grove said it would seek advice from Oakland Primecare.
12. Mrs X e-mailed Woodland Grove again on 4 December, as she had received no response. She also said they wanted some information about Mrs Y’s condition as they knew very little since she had been in hospital, other than that her condition had declined. Woodland Grove said there had been various conversations about Mr Y visiting and she would receive a call.
13. Woodland Grove called Mr Y and told him he could visit his wife in her room at least once a fortnight, depending on her condition. Mrs X says it told him there would be no time limit and he could see her being fed. She says Woodland Grove told her he could visit once a week, which she said was not enough.
14. Mr Y visited his wife on 5 December but was asked to leave after an hour. He was allowed to stay a bit longer (Mrs X says an hour, Woodland Grove’s records say 15 minutes) but did not see his wife being fed.
15. On 11 December Oakland Primecare wrote to families saying:
• it had not yet received lateral flow tests in all its homes, but had purchased tests which it had been using in some of its homes to test staff and residents;
• the results of widescale testing showed the lateral flow tests only picked up 5 out of 10 cases detected by laboratory tests, and 7 out of 10 cases for people who were shedding high levels of the virus;
• its own small-scale use of lateral flow tests returned both false negatives and false positives;
• relying on personal protective equipment was not enough to reduce the risk of spreading COVID-19;
• it would not therefore be using lateral flow tests to resume widescale inhouse visiting;
• it would continue to arrange bedside visiting for those in the last days of their life and use lateral flow tests for those visitors as an added precaution.
16. Mrs Y ate most of her breakfast (cereal) on 11 December. She ate no lunch but ate most of her soup in the evening.
17. On 12 December Mrs Y would not swallow her breakfast cereal and spat out her tea. She ate no lunch and would not swallow the soup offered later in the day. She drank little.
18. On 13 December Mrs Y ate no breakfast, would not swallow her lunch and ate very little of the soup offered later. She drank little.
19. Mrs X e-mailed Woodland Grove on 14 December asking why her father could only visit once a fortnight. She said she understood the rapid testing of family members was not going ahead, which was disappointing. Mrs Y ate no breakfast, would not swallow any lunch and drank little.
20. There is no record of Mrs Y having breakfast on 15 December, she declined lunch (refused to swallow) and supper. She drank little.
21. Mrs X sent a further e-mail on 16 December, as she had received no response. She said her father should be able to visit his wife in her room once a week. Woodland Grove said:
• Mr Y could visit every 10 days “as per Government guidelines”;
• he would have to swab test for COVID-19 on each visit;
• it would consult a Director.

It sent Mrs X a photograph of her mother.

22. Mrs Y ate most of her cereal at breakfast on 16 December, 50 ml of soup at lunchtime but declined supper. She drank little.
23. On 17 December Mrs Y would not swallow her breakfast, spat out her tea, and declined lunch and supper.
24. Oakland Primecare says Woodland Grove did not receive supplies of lateral flow tests until 18 December. Woodland Grove called NHS 111 as it was concerned about Mrs Y’s condition. NHS 111 arranged for a GP to visit, in case she needed end‑of-life medication. Woodland Grove spoke to Mr Y about the possibility his wife was approaching the end of her life, as she was not eating or drinking. However, the GP decided Mrs Y was not in immediate need of end-of-life medication (she was settled and her observations were good).
25. Mr Y visited his wife on 19 December and tried to encourage her to eat but she could not.
26. On 20 December Woodland Grove received some positive test results for COVID‑19. A GP prescribed end-of-life medication for Mrs Y. Her family visited. The Manager told them they would have to visit one at a time for no more than an hour, but agreed two could visit at a time. Mrs Y went up with a sister and stayed for 15 minutes, so her father could stay for 45 minutes, but he was allowed to stay much longer than that.
27. Mr Y visited his wife on 21 December between 11.00 and 13.00. Woodland Grove called Mr Y around 15.45 to say his wife was unlikely to live much longer so the family should visit immediately. Initially Woodland Grove would not let them in at the same time. Mrs X stayed until 22.30. Mr Y stayed with his wife until 06.30 the next day.
28. Mr Y returned at 14.00 on 22 December. Mrs Y’s condition had declined so he contacted Mrs X. Mrs X says no one was expecting them when they arrived. They were again told they would have to visit one at a time, which Mrs X queried. Woodland Grove then agreed they could visit two at a time. Mrs X went up first to join Mr X. She then waited outside with a sister. Another sister who was with Mr and Mrs Y called to say she did not have long left so they should ask to come up again so they could all be with her. She says they were left waiting for nearly 10 minutes, before the Manager came to speak to them. The Manager proposed allowing three people at a time, with someone rotating every 30 minutes. However, after an argument, the Manager agreed all four of them could be with Mrs Y. The Manager says she did this to de-escalate a situation which was getting out of hand.
29. Mrs X has provided a recording of conversations with staff at Woodland Grove asking for the family to be allowed to visit Mrs Y together. Mrs X accused staff of ignoring her attempts to attract their attention, which they denied. The Manager said she would check on Mrs Y before making a decision.
30. She has also provided a video clip which shows the Manager speaking to other staff in the entrance lobby before smiling and waving at Mrs X and coming to the door. She said three people could visit at a time. When Mrs X questioned this, the Manager said four would be too many people in the room. The clip then ends.
31. Mrs Y’s family was with her when she died on 22 December.

Did the care provider’s actions cause injustice?

32. Oakland Primecare decided not to follow the Government’s guidance of 1 December because of doubts over the reliability of lateral flow tests. That was not fault as the Government left decisions to individual care providers. It was a decision Oakland Primecare was entitled to take and not one I can criticise.
33. Oakland Primecare was at fault for applying too narrow a definition of end-of-life care. It linked this to the prescription of end-of-life medication, which happens at the very end of life. But the Government guidance made it clear end-of-life care should not be limited to the “very end of life”. When Mrs Y started refusing food in December, because she found it difficult to swallow, it should have been apparent she was approaching the end of her life. Woodland Grove should then have reviewed Mrs Y’s visiting arrangements and confirmed them with her family. This could have avoided much of the distress caused by the inconsistent and irrational approach to visits in the days leading up to Mrs Y’s death. It made little sense for three people to visit with one person rotating every 30 minutes, as this would have unnecessarily increased the number of people passing through the home at a time when there were cases of COVID-19.
34. This fault caused injustice to Mr and Mrs Y, as they were unable to spend as much time together as should have been the case. It also caused injustice to Mrs X and her sister who were caused avoidable distress. It is no longer possible to remedy the injustice to Mrs Y because she has died.

Back to top

Recommended action

35. I recommend Oakland Primecare:
• within four weeks:
1. writes to Mrs Y’s family apologising for the failure to make suitable arrangements for visiting her and the distress this caused;
2. pays Mr Y £400 for the avoidable distress caused; and
3. pays Mrs X and her sister £200 each for the avoidable distress they have been caused;
• within eight weeks:
1. takes action to ensure staff identify people who are approaching the end of their lives before they are at the very end of their lives and put appropriate plans in place.
36. Under the terms of our Memorandum of Understanding and information sharing protocol with the Care Quality Commission, I will send it a copy of this statement.

Back to top

Final decision

37. I have completed my investigation on the basis that Oakland Primecare’s actions have caused injustice to Mrs Y’s family and that it will take the action I have recommended.

Back to top

Investigator's decision on behalf of the Ombudsman