Summary: Mrs S complained about the care provided to her husband by Runwood Care Homes. We found the Care Home at fault. The Care Home has agreed to apologise to Mrs S and make improvements to avoid a repeat of the fault identified.

The complaint

1. Mrs S complains about the standard of care the care home provided to her late husband (Mr S). She says the care home failed to provide an appropriate level of care and believes this led to the deterioration of his health and subsequent death.
2. She specifies:
1. Mr S developed cellulitis but was not appropriately tended to;
2. Mr S developed a Urinary Tract Infection (UTI) and was not taken to hospital;
3. She visited Mr S and was told he was asleep, but it was obvious to her he was unconscious;
4. The hospital said Mr S was severely dehydrated, and was suffering with malnutrition and sepsis;
5. Mr S had not been given his Parkinson’s medication for a few days;
6. Mr S suffered pressure sores as the care home did not provide sufficient care.
3. Mrs S is seeking an apology and service improvements to ensure the issues are not repeated.

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The Ombudsman’s role and powers

4. 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)
5. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
6. When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.

7. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
8. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

9. I have considered information provided by the care home and Mrs S, alongside the relevant law and guidance.
10. Mrs S and the Council have had an opportunity to comment on a draft decision before this final decision is made.

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What I found

What happened

11. Mr S moved into the care home in March 2023.
12. Over the following two weeks, Mr S’s health deteriorated significantly. He developed suspected cellulitis, a urine infection and was taken to hospital.
13. The hospital said Mr S was severely dehydrated, malnourished and had sepsis.
14. Mr S passed away in hospital, a week later.

Analysis and findings

Mr S developed cellulitis but was not appropriately tended to.

15. The care notes show that Mr S fell twice on 12 March. The home had an out of hours doctor check Mr S that day. The doctor notes that Mr S’s legs were swollen and prescribed medicine for possible cellulitis.
16. The care notes kept by the care home show how often the carers checked on Mr S, his meals, and all of the details of his day. The home says it kept a separate record of medication administered but has been unable to provide a copy.
17. I am satisfied the care home monitored Mr S closely and sought medical attention when it felt this was needed.
18. We cannot conclude, even on the balance of probabilities, that the home did not administer the medicine, but we cannot say it did. The home should make and maintain an accurate record of all medicine administered. Failure to do so is a fault.
19. The care home says the record of medicine administered must have been sent to the hospital with Mr S, as it has not been found at the home. If the home had maintained a record, it would be able to provide a copy to this office even if it had sent a copy to the hospital. Not having a record at the home is a failure to maintain a record. This is fault.
20. While I cannot conclude that this means the medicine was not administered, it does mean the home cannot provide Mrs S with assurance that it was. The injustice here is the uncertainty caused to Mrs S.

Mr S developed a urine infection but was not taken to hospital.

21. The care notes show that carers noticed that Mr S was unsteady on his feet and that there was a strong odour when they administered personal care.
22. The care notes show the home called 111 for advice and were told to encourage more fluids and call back if there were any changes. The care home spoke with the 111 General Practitioner (GP) who prescribed antibiotics.
23. The notes show the prescription was collected by the home and a medication administration record (MAR) was written and put in place to begin the next day.
24. The home spoke with Mrs S and explained what had happened, the advice obtained from 111 and that they would start antibiotics the following day.
25. The care notes show that staff were encouraging Mr S to eat and to drink before and after this date. I can see Mr S’s fluid intake was monitored and staff were reminded to keep encouraging his intake daily.
26. The care home cannot make medical decisions itself. Where there are concerns, it is required to obtain medical advice and follow that advice. The GP’s advice was not to take Mr S to hospital, so I cannot criticise the home for not doing this. There is therefore no fault in this regard.

Mrs S visited Mr S and was told he was asleep, but it was obvious to her that he was unconscious.

27. The care notes show that Mrs S was at the home when Mr S was taken to hospital. There is no record of the home telling Mrs S that Mr S was asleep. The home has apologised for any miscommunication here.
28. The care notes from that day note Mr S was sleepy.
29. It is not possible, even on the balance of probabilities, to know when Mr S became unconscious and whether he had been unconscious for long enough for it to be unreasonable of the home not to have realised. On this basis, the home is not at fault here.

The hospital said Mr S was severely dehydrated and was suffering with malnutrition and sepsis.

30. The care notes show Mr S’s fluid intake was being closely monitored by the home following the GP’s advice when they suspected he may have a UTI.
31. The carers were offering several drinks frequently throughout the day. When Mr S refused a drink, the home would offer an alternative. Although Mr S refused to eat or drink several times, the home continued to offer him at least a little, often to ensure he ate and drank as much as he could manage.
32. The care home took medical advice and followed it. The notes show there was a daily reminder to encourage as many fluids as possible and this was adhered to by the carers. This is therefore not a fault.

Mr S had not been given his Parkinson’s medication for a few days.

33. Ms S says the hospital confirmed Mr S had not taken his Parkinson’s medication for a few days. This contributed to stiffness in his body.
34. Mr S’s care plan clarifies that he required help from a trained member of staff to ensure he took his medication daily. Failure to follow this is a fault.
35. The care home suspect its medical records were sent to the hospital with Mr S. The hospital’s reference to the missed medication would suggest that this is what has happened.
36. We are unable to remedy an injustice to Mr S as he is deceased. However, the care home’s failure to ensure that medication was administered correctly has caused an injustice to Mrs S.
37. Mrs S said in her complaint that she believes the home did not provide her husband with the care he needed. She says she believes this caused his dramatic deterioration and subsequent death.
38. We cannot say the home caused Mr S’s death or the other health issues he was suffering when he went to hospital. We can however, conclude that Mr S did not receive the care he ought to have.
39. Mrs S is now in a position where she lives with a belief, or at least an uncertainty, that the care home caused Mr S to die sooner than he would have. This is a significant impact on her in addition to dealing with the fact of her husband’s death.

Mr S suffered pressure sores as the care home did not provide sufficient care.

40. The care home says carers had noted that Mr S had some pressure sores and it sought advice from district nurses. The home says district nurses advised he should be turned every two hours.
41. The care notes do not reference the pressure sores, or the advice received.
42. The care notes show that the carers were repositioning Mr S when he was in bed in the days leading up to his hospitalisation.
43. Although Mr S was repositioned, this was not done every two hours. As the home has said this is what was advised, failure to comply with the advice is fault.

Remedy

44. I can only look at the injustice caused to Mrs S as there is no way to remedy any injustice to Mr S. I have considered the distress she has been caused by knowing her husband was not cared for in his last weeks, and her belief that the care home caused him to die sooner than he might have. It is not possible to know whether this is in fact the case, but it is clear Mrs S has been left with this belief. The remedy I have recommended cannot make up for how Mrs S feels. Payments we recommend for distress are symbolic and recognise that care homes’ actions caused injustice.
45. By failing to administer his Parkinson’s medicine correctly and failing to follow medical advice in relation to bed sores, the care home failed to provide the care it was paid to provide. This is not to say the home did not provide any care, and this is reflected in my remedy recommendation.

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Agreed action

46. Within one month of the decision, the care home will:

• Apologise to Mrs S in accordance with our guidance on apologies;
• Make a payment of £500 to Mrs S.
• Refund 10% of the fees paid for Mr S’s stay at the home in recognition of the care which was paid for but he did not receive.

47. Within three months of the decision, the care home should:

• Review its processes in regard to keeping and maintaining medical records;
• Review its processes in regard to ensuring that care plans are accurate, up to date and followed strictly;
• Review its processes in regard to dealing with a resident whose food and drink intake is decreasing;
• Train all staff in relation to all of the above.

48. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

49. We found the care home has caused an injustice through the faults identified.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman