Summary: Mr B complained about the care given to his late mother, Mrs C during a two-week respite stay in one of the Care Provider’s nursing homes. We find the record of significant weight loss should have been investigated at the time and further explanation provided about the medication. The Care Provider has agreed to pay Mr B £250 and improve its procedures for the future.

The complaint

1. Mr B complains that Morris Care Ltd (the Care Provider) provided a poor level of care to his mother, Mrs C for a two-week respite stay in April 2019. Its records indicate she lost 10 kg of weight in two weeks. She was also hungry, dehydrated and in soiled clothing when she returned home.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
3. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

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How I considered this complaint

4. I have considered the complaint and the documents provided by the complainant, made enquiries of the Care Provider and considered the comments and documents from the Care Provider. Mr B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

5. Mrs C was elderly, with dementia and a number of other health conditions. She went into a home run by the Care Provider on 15 April 2019 for two weeks of respite care. Her family provided detailed notes of her routines and requirements and the home carried out a pre-admission assessment. It noted she required help to eat at all meals, the food needed to be pureed and breakfast could take three-quarters of an hour. Her weight was stable at 75.5 kg, with a BMI of 25 and at low risk of malnutrition. The list of her medications and the dosage was also included.
6. The Care Provider says that Mrs C was assisted with all meals and drinks by care staff and no-one raised any concerns about her intake or her presentation or appetite. The records vary in the level of detail: the best records show a carer assisted with all meals and provided details. In all these cases it said she ate and drank everything. The recordings in the second week show that Mrs C was assisted at all meals but give no further details. There are no records of concerns about nutrition or fluid intake. There was one day where no notes were made.
7. The Care Provider in its response to my enquiries accepts there are some missing records, but says staff confirmed these were recording omissions rather than omissions of care.
8. In respect of the medications it said that the home had noted on admission that there was insufficient quantities of two medicines. After liaising with the family Mrs D advised she had arranged for further supplies to be delivered to the home. This did not happen and the medicines ran out on 25 April 2019. The home discovered that the medicines had been delivered to Mrs C’s home address. It picked up a new supply on 26 April 2019 so Mrs C missed out on two doses of two of her medications. It said that staff should have picked up the problem and obtained new supplies sooner. It had addressed this issue within individual staff supervisions.
9. Mrs C’s daughter, Mrs D and Mrs C’s carer picked up Mrs C from the home on 29 April 2019. The home weighed her on discharge and recorded her weight as 65.6kg. The carer said she was not happy with the way Mrs C looked and noted she was not wearing a cardigan or sufficient underclothes. She also remembered that the staff member who weighed her expressed doubt about the scales due to the weight recorded.
10. On 30 June 2019, Mr B complained to the Care Provider about Mrs C’s care. He said that on returning home she had lost 10 kg in weight, was dehydrated, constipated, appeared famished, had insufficient clothing on, was soaked in urine, possibly had an infection and her medication did not correspond to the correct day. Mrs D had called the GP who attended the same day. Mrs C was admitted to hospital on 3 May with the signs of an infection and died on 9 May. He said the poor care at the home had contributed to the rapid decline in her health.
11. The Care Provider responded on 28 July 2019. It said no staff had raised any concerns about Mrs C’s eating, drinking or presentation while at the home. It acknowledged the weight on discharge indicated a 10kg weight loss and accepted this should have prompted staff to reweigh Mrs C to check the accuracy. It apologised for the failure to do this.
12. In respect of dehydration it said no staff had raised any concerns about this but noted one of her medications can result in a dry mouth. It apologised she was soaked in urine but could offer no information on this, beyond questioning whether someone could be dehydrated and soaked in urine. The records indicated regular bowel movements during her stay and said it could not comment on the clothing beyond saying that the home was kept at a very comfortable ambient temperature.
13. It offered an apology and the opportunity of a meeting.
14. On 19 August 2019 Mr B said he was not happy with the response and requested a review. The Care Provider responded on 27 September 2019. It repeated its view on all the issues, including the clinical view that to lose 10 kg of weight in two weeks would be extremely rare given the lack of an underlying condition, the lack of concerns raised and the fact she appeared medically well. The Care Provider had examined the weighing equipment but could find no problems. In conclusion it could find no evidence or reason to account for the weight loss and considered it was most likely to be an inaccurate recording of one of the weights. It apologised once more.
15. Mr B remained unhappy and complained to the Ombudsman.

Analysis

16. I understand how distressing it must have been for Mr B and Mrs D to witness the sudden decline in their mother’s condition and her subsequent death shortly after leaving the Home.
17. I cannot conclude that the care provided by the home contributed to or caused Mrs C’s death. Neither can I conclude that failings by the home caused such dramatic weight loss. The records show that in the main Mrs C ate and drank well throughout her stay and was supported to eat. No concerns were raised about her intake or presentation. However, neither can I dismiss Mrs D’s account (supported by the carer) of Mrs C’s condition when she returned home and the uncertainty this created, given the timing of her deterioration. By the time Mr B complained, it was difficult, on the evidence available to account for the weight loss.
18. The Care Provider has acknowledged such a weight discrepancy should have been checked and investigated at the time. I agree that the failure to do this was fault, which caused Mr B and Mrs D uncertainty at a very distressing time.
19. The Care Provider has also now explained the reason for the gap in providing Mrs C with the correct dose of some medication. This should have been acknowledged and explained in response to the complaint. This added to the family’s uncertainty over Mrs C’s condition.
20. In response to my draft decision Mr B and Mrs D said that the Care Provider’s explanation regarding the medication does not explain why the blister pack returned to them did not show the correct day. They are also unhappy that the Care Provider did not administer the dry mouth cream at all to counteract the effect of one of the medications. I agree that the lack of explanation for these issues is further fault in respect of the medication which has caused distress and uncertainty to the family.

Agreed action

21. I welcome the apologies and the steps taken with staff regarding the medication. But in recognition of the uncertainty and distress caused to Mr B and Mrs D, I asked the Care Provider, within one month of my final decision, to:
• pay them a total of £250; and
• ensure that significant weight discrepancies are investigated immediately.
22. The Care Provider agreed to my recommendations.

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Final decision

23. I consider this is a proportionate way of recognising the injustice caused and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman