Summary: Mrs X complained on behalf of her late sister about care provided to her at a residential care home. Mrs X complained care staff did not correctly administer her sister’s inhalers and delayed seeking medical assistance. Mrs X says she feels this may have contributed to the deterioration in her sister’s health. We found fault by the Care Provider. The Care Provider has agreed to apologise to Mrs X, provide a financial remedy, and make service improvements to prevent a reoccurrence of the fault identified.

The complaint

1. Mrs X complained on behalf of her late sister, Miss Y, about care provided to her by The Abbeyfield Society, (the Care Provider) at one of its residential care homes. Mrs X complained care staff did not correctly administer her sister’s inhalers and delayed seeking medical assistance. Mrs Y says she feels this may have contributed to the deterioration in her sister’s health. She would like the Care Provider to acknowledge what happened and for it to ensure no-one else is similarly affected.

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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. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. 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)

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How I considered this complaint

6. I discussed the complaint with Mrs X and considered the information she provided.
7. I made enquiries to the Care Provider and considered the information it provided.
8. Mrs X and the Care Provider had the opportunity to comment on a draft of this decision. I considered their comments before making a final decision.

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What I found

Relevant legislation

9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 sets out the ‘fundamental standards’ which all care providers should meet in delivering care.
10. Regulation 17 of the 2014 Regulations requires a care provider to keep accurate, complete, and contemporaneous records of care and treatment.

The Care Provider’s medicines management policy

11. The Care Provider’s medicines management policy states a medicine administration record (MAR) must provide an accurate account of the medicines administered to a person by care staff.

The Care Provider’s clinical observations policy

12. The Care Provider’s clinical observations policy aims to ensure care staff are able to identify early signs of a resident being unwell. It also aims to enable care staff to act promptly and appropriately to maintain residents’ safety and improve their health outcomes.
13. The policy says residents’ care plans must clearly detail who care staff should escalate any concerns to.

What happened

14. This chronology includes key events in this case and does not cover everything that happened.
15. In November 2023, Mrs X’s sister, Miss Y, moved into a residential care home managed by The Abbeyfield Society, (the Care Provider).
16. The Care Provider carried out a care needs assessment and produced a care plan for Miss Y. The care plan acknowledged Miss Y’s health conditions, including her diagnosis of vascular dementia.
17. The care plan set out the medication Miss Y should receive and the frequency it should be administered. Miss Y’s regular medication included three separate inhalers. The care plan stated Miss Y should receive the first inhaler, (Inhaler 1), twice a day, the second inhaler, (Inhaler 2), three times a day, and the third inhaler, (Inhaler 3), when required or four-hourly.
18. The care plan said Miss Y did not self-medicate any medication due to her dementia. However, it specified care staff should place Miss Y’s inhalers into a spacer, and that Miss Y liked to do the rest herself. The care plan said Miss Y was able to make day-to-day decisions but acknowledged Mrs X held power of attorney for Miss Y’s health and wellbeing and finances. The care plan stated care staff should report any changes or concerns with Miss Y’s health to a senior staff member.
19. On 10 December 2023, Mrs X called Miss Y on the telephone. Mrs X said she was very concerned about Miss Y’s health during the call as Miss Y was coughing a lot and finding it difficult to breathe and speak.
20. Following the call, Mrs X said she tried several times to call the care home but was unable to get through as the telephone line was engaged. Mrs X said when she did get through, she told the care staff about her concerns and said Miss Y needed to see a doctor straight away.
21. Mrs X said a staff member checked on Miss Y, and subsequently spoke to Mrs X again. Mrs X said the staff member told her Miss Y was ‘fine’.
22. Mrs X said that at about 10am the following morning, Miss Y’s niece visited her at the care home. Mrs X said Miss Y’s niece was extremely worried about Miss Y’s health and asked the care staff to call for an ambulance. Mrs X said an ambulance attended and took Miss Y to hospital.

Mrs X’s complaint

23. On 12 December 2023, Mrs X called the care home to make a complaint. Mrs X complained she had been unable to contact the care home by telephone because the care home’s telephone had been left off the hook. Mrs X also complained the care staff did not call for a doctor when she asked them to, and that the care staff had delayed seeking medical assistance the following morning.
24. Miss Y was discharged from hospital on 20 December 2023, and returned to the care home.
25. On 21 December 2023, the Care Provider provided its complaint response, fully upholding Mrs X’s complaint. It apologised that it had taken some time to retrieve the telephone following Mrs X’s call to Miss Y, and that this had led to Mrs X being unable to communicate with the care home.
26. The Care Provider said the senior member of staff on duty on 10 December 2023 spoke to Miss Y following their contact with Mrs X. It said Miss Y told the staff member she was feeling okay and that she did not want to see anyone. The Care Provider said on the morning of 11 December 2023, care staff were aware of the need to call for a doctor. It acknowledged Miss Y’s niece asked staff to request medical assistance when she visited and acknowledged that care staff had delayed calling the doctor. The Care Provider apologised that it did not deal with the request for medical assistance immediately; it said it had discussed this matter with the staff on duty at the time and was taking appropriate action.
27. On the same day, (21 December 2023), the care home called for an ambulance as Miss Y’s health condition had worsened. An ambulance attended and took Miss Y to hospital, where she was readmitted.
28. On 22 December 2023, Mrs X asked the Care Provider to escalate her complaint. She said no-one had checked on Miss Y on the morning of 11 December 2024 until her niece visited and urgently requested an ambulance. Mrs X said at the time Miss Y’s niece requested the ambulance, care staff told her they were in a meeting. Mrs X said Miss Y had pneumonia; she said she felt this infection did not just happen the day before.
29. Mrs X contacted the Care Provider again a few days later; she said she wished to report that sadly, Miss Y had died in hospital.
30. Mrs X said she wanted to add to her complaint and asked if the care staff had properly administered Miss Y’s inhalers.
31. The Care Provider responded on 2 January 2024. It said it had upheld Mrs X’s stage one complaint, and provided additional detail regarding the actions it took on 11 December 2023. It said the night shift care staff completed a handover with the morning shift, which included explaining the need to call a doctor. The Care Provider said it had identified a member of staff had attended to Miss Y early on the morning of 11 December 2023 but had failed to notify a senior team member that Miss Y ‘sounded chesty’. It said it was investigating this matter further under its disciplinary policy. The Care Provider acknowledged it did not call an ambulance until approximately three hours later. It upheld this part of Mrs X’s complaint as it acknowledged a failure to report Miss Y’s presentation to a senior staff member, and a failure to take prompt action.
32. Mrs X asked the Care Provider again on 26 January 2024 if it had properly administered Miss Y’s inhalers. Mrs X said the care staff should have administered each inhaler three times a day.
33. The Care Provider responded on 1 February 2024. It said its records showed it had administered all Miss Y’s medications correctly.
34. The Care Provider provided a further response on 5 February 2024. It said care staff did not administer the inhalers once they had placed them in the accompanying inhaler spacer. It said this was because Miss Y was able to administer the inhalers herself once the care staff had placed them in the spacer, and it was Miss Y’s preference to press the inhalers herself. The Care Provider referred to Miss Y’s medication care plan to confirm this was recorded as an identified need, and that Inhaler 3 was to be administered when required.
35. Mrs X emailed the Care Provider on 7 February 2024 and said Miss Y’s inhalers should have been administered three times a day. Mrs X asked when the frequency for Inhaler 3 changed to ‘when required’.
36. The Care Provider responded on the same day. It said a medication review undertaken by the clinical commissioning group had led to a change of prescription for Miss Y. It said generally, and in most cases, the specific medication contained within Inhaler 3 is used when required.
37. Mrs X remained dissatisfied with the Care Provider’s response and brought her complaint to us.

Analysis – administration of inhalers

38. Mrs X complained the care staff did not correctly administer the inhalers to Miss Y. She says when Miss Y moved into the care home, she explained to the care staff that Miss Y required her inhalers three times a day. Mrs X acknowledges the Care Provider said Inhaler 3 is generally, and in most cases, administered when required. However, she says that when Miss Y first moved to the care home, Mrs X told care staff that Miss Y specifically required all three inhalers three times a day. Mrs X considers the Care Provider did not provide this to Miss Y.
39. In its response to Mrs X, the Care Provider says it administered all Miss Y’s medications correctly. It referred to Miss Y’s care plan which specified care staff should place the inhalers into the spacer, but that Miss Y liked to do the rest herself.
40. I have reviewed Miss Y’s doctor’s records relating to her medication, Miss Y’s care plan and the Care Provider’s medication protocol for Inhaler 3. These documents, including the doctor’s records state Inhaler 3 was prescribed to be administered ‘when required’. As a result, I consider the frequency for administering Inhaler 3, as specified in the care plan, is in line with the doctor’s records provided to the care home.
41. The Care Provider’s medicines management policy says a MAR chart must provide an accurate account of the medicines being administered to a person by care staff. This is in line with Regulation 17 (Good Governance) of the CQC’s fundamental standards.
42. I have reviewed the MAR charts provided in response to our enquiries, including the chart for Inhaler 3. The chart for this medication is not completed and does not show dates or times to indicate when Inhaler 3 was administered to Miss Y.
43. The lack of records relating to the administration of Inhaler 3 means I am unable to determine whether the Care Provider failed to administer it to Miss Y. I acknowledge the Care Provider’s comments in its letter to Mrs X that it did administer all three inhalers correctly; however, the evidence indicates the Care Provider did not record the administration of Inhaler 3. It is noted that the administration of all of Miss Y’s other medications are recorded on the corresponding MAR charts.
44. I acknowledge Inhaler 3 was prescribed to be administered when required rather than at prescribed times like some of Miss Y’s other medication. I also acknowledge the care plan stated Miss Y liked to use her inhalers semi-independently once the care staff had attached the spacers. However, in line with the Care Provider’s medicines management policy and the fundamental standards, the administration of Inhaler 3 should have been recorded.
45. Although the Care Provider says its care staff administered all inhalers correctly, I have seen no evidence to demonstrate they recorded the administration of Inhaler 3 to Miss Y. This is contrary to the Care Provider’s medicines management policy and is therefore fault. The resulting injustice is the uncertainty to Mrs X of whether Miss Y received Inhaler 3 as prescribed.

Delays in seeking medical assistance

46. Mrs X says she asked the care home on the evening of 10 December 2023 to call a doctor as she was very concerned about Miss Y’s condition; Mrs X said Miss Y was coughing so much during their telephone call that she could barely speak.
47. The care home’s care notes from the evening of 10 December 2023 record Miss Y as being ‘unwell, coughing’ and ‘chesty’. The care notes from this time also record that a ‘GP needs to be called’.
48. In response to our enquiries, the Council provided a timeline of events from 10 and 11 December 2023. This states that the night-time senior staff member was aware of Miss Y’s cough, and a doctor was due to be called in the morning of 11 December 2023.
49. The timeline states care staff attended to Miss Y at 6:32am and again at about 7:30am on the morning of 11 December 2023. The timeline states the carer who attended to Miss Y was asked if Miss Y sounded ‘chesty’; the carer confirmed that she did. The carer confirmed they had not referred this matter to the senior staff member on duty. The timeline states the care home called for an ambulance at 10:20am, and Miss Y was subsequently taken to hospital.
50. Mrs X says she asked the care home to call for a doctor at about 4:30pm on 10 December 2023. The care notes do not refer to this, but they do record a request to call for a doctor at about 6:23pm. I have reviewed the Care Provider’s records regarding this matter, including its consideration of the events of 10 and 11 December 2023. As part of this consideration, the Care Provider acknowledged it was unclear if the care staff had called for a doctor; I have seen no evidence to indicate this call was made.
51. Miss Y’s care plan stated staff should report any changes or concerns regarding Miss Y’s health to the senior staff member on duty. The evidence indicates the carer who attended Miss Y on the morning of 11 December 2023 did not do this; the Care Provider acknowledged this in its complaint response and apologised that it did not request medical assistance immediately.
52. Having reviewed the information provided, and as set out above, there is evidence of delay by the Care Provider in seeking medical assistance for Miss Y. This is supported by the Care Provider’s own investigation which identified a delay in responding to Miss Y’s health needs.
53. The apparent failure to call for a doctor is not in line with the required actions identified in the care notes. In addition, the carer’s failure to notify a senior staff member about concerns regarding Miss Y’s condition is not in line with the requirements of Miss Y’s care plan, or the Care Provider’s own clinical observations policy. This is fault. The resulting injustice is the uncertainty to Mrs X regarding the effect of what, if any, this fault had on Miss Y.
54. It is positive the Care Provider itself identified a delay in responding to Mrs X’s request for medical assistance as part of its complaint investigation; it is also positive it apologised to Mrs X and identified several service improvements to avoid similar incidents re-occurring. However, this does not adequately address the injustice caused as a result of the fault identified.
55. Mrs X says she considers the care home’s actions may have contributed to the decline in Miss Y’s health. Where someone has died, we will not normally seek a remedy for injustice caused to that person in the same way as we might for someone who is still living. We would not expect a public or private body to make a payment to someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment in recognition of, for example, the impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from such a payment. However, if we consider the person who has complained to us has been adversely affected by seeing the impact of that poor care on their relative, we may recommend a symbolic payment to them as a remedy for their own distress.

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Agreed action

56. To address the injustice identified, the Care Provider has agreed to take the following action with one month of the final decision;
1. Provide a further apology to Mrs X for the fault identified. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings;
2. Make a symbolic payment of £300 to Mrs X in recognition of the distress and uncertainty identified;
3. Remind staff of the requirement to maintain accurate and contemporaneous records showing all medications administered;
4. Remind staff to ensure all concerns regarding residents are reported to senior staff members in a timely manner. This is in line with the service improvements identified by the Care Provider’s own complaint investigation, and
5. Provide evidence of how the Care Provider has implemented the service improvements as recorded in its post incident review, namely:
1. Providing clear guidance to care staff about residents during handovers.
2. Improving communication with residents’ families regarding obtaining medical assistance.
57. The Care Provider should provide us with evidence it has complied with the above actions.

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Final decision

58. I have found fault by the Care Provider causing an injustice to Mrs X. The Abbeyfield Society has agreed to take the above action to resolve this complaint and I have concluded my investigation on this basis.
59. Under our information sharing agreement, I will share this decision with the Care Quality Commission.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman