Summary: We found no fault with the end of life care provided to a woman, Mrs C, by the Care Home.

The complaint

1. The complainant, Mrs B, is complaining about the care provided to her mother, Mrs C, when she was resident in Park Farm Lodge Care Home (the Care Home) in June and July 2023. This placement was commissioned by Staffordshire County Council (the Council).
2. Mrs B says the Care Home failed to provide her mother with appropriate end of life care. Mrs B says the Care Home failed to administer Mrs C’s palliative medication and did not attend promptly when she was in distress. In addition, Mrs B says Care Home staff failed to check on Mrs C regularly and that family had to support her instead as there were not enough staff available.
3. Mrs B says these events were extremely distressing for her.

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The Ombudsmen’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. When investigating complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that during an investigation, we will weigh up the available evidence and base our findings on what we think was more likely to have happened. 
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
7. If we are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

8. In making my final decision, I considered information provided by Mrs B and discussed the complaint with her. I also obtained relevant information from the Council and Care Home, including the care records. I took account of relevant guidance and legislation. I invited comments on my draft decision statement from all parties and considered the responses I received.

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What I found

Relevant guidance and legislation

End of life care

9. In 2019, the National Institute for Health and Care Excellence (NICE) issued the clinical guideline ‘End of life care for adults: service delivery [NG142]’. This provides guidance for health and social care professionals on organising and delivering end of life care services. The guideline deals with providing care and support in the final weeks and months of life and the planning for this. It aims to ensure people have access to the care they want and need in all care settings. It also includes advice on services for carers.
10. The NICE guidelines emphasise the importance of keeping a person’s needs under review and making sure these are clearly recorded. They also specify the need for health and social care organisations to work together to coordinate a person’s care.

Background

11. Mrs C had a cancer diagnosis and was considered to be near the end of her life. In 2023, she was living with her sister.
12. Mrs C was admitted to hospital for a period of treatment. She was placed on the palliative care pathway.
13. On 20 May 2023, Mrs C was discharged to a local hospice for management of her symptoms. However, as Mrs C was not considered to be at imminent risk of death, the hospice decided she would need to be discharged. Mrs B and Mrs C disagreed with this decision.
14. In early June, the professionals supporting Mrs C decided she was too frail to return home. An assessment found her complex needs would require a nursing home placement.
15. Mrs C was transferred to the Care Home on 23 June 2023.
16. A nurse from the hospice visited Mrs C at the Care Home on 3 July. She found Mrs C would be eligible for fast track NHS Continuing Healthcare (CHC) funding. This is a package of ongoing care that is arranged and funded by the NHS where a person has been assessed as having a ‘primary health need’.
17. The nurse recommended that the Care Home administer Mrs C’s medications via a syringe driver. This is a small pump used to administer medication through a needle under the skin. This was set up on the same day. The nurse decided Mrs C was too unwell to be moved back to the hospice.
18. On 4 July, a social worker visited Mrs C at the Care Home.
19. On 5 July, the local ICB agreed the fast track CHC funding application.
20. Mrs C died the following day.

My analysis and findings

Palliative medication

21. Mrs B complains that the Care Home failed to administer Mrs C’s palliative medications when she arrived at the placement. As a result, Mrs B says Mrs C was left in unnecessary discomfort.
22. In its complaint response, the Care Home acknowledged it had not been possible to administer Mrs C’s medications on her arrival. It said this was due to an error in Mrs C’s records that recorded she was allergic to some of the medication she had been discharged with. The Care Home said its staff identified that the error had been made by the hospice and that it was resolved following correspondence with relevant clinicians. The Care Home said it also raised a safeguarding alert.
23. On her discharge to the Care Home, Mrs C was accompanied by various discharge documents prepared by the hospice. These included a discharge summary and a Controlled Drug order form (a record of drugs that can be potentially harmful or open to misuse). On both documents it was recorded that Mrs C had allergies to morphine and dihydrocodeine (drugs used to treat severe pain).
24. However, Care Home staff identified that Mrs C had been discharged with both morphine and dihydrocodeine-based medications.
25. The Care Home sought input from an out-of-hours doctor in the first instance. The doctor advised the Care Home to contact a pharmacist for further advice. The pharmacist advised the Care Home not to administer the medication and to instead contact an out-of-hours GP to request alternative pain relief.
26. The Care Home next spoke to an out-of-hours GP. The GP noted that Mrs C had historically been prescribed morphine by her own GP and queried whether this was a mistake. The GP advised the Care Home to contact the hospice to discuss Mrs C’s medications and arrange pain relief.
27. The Care Home’s subsequent correspondence with the hospice revealed that hospice staff had been administering the drugs to Mrs C during her time there. This led to further correspondence between an out-of-hours doctor and the clinical staff at the hospice. This eventually led to confirmation that Mrs C was not allergic to these medications and that they could be safely administered.
28. There is evidence to show that there was a delay in administering pain relief medication to Mrs C on her admission to the placement. The care records show care home staff first identified the problem at around 5.20pm on 23 June. The situation was eventually resolved at around 1.30am on 24 June.
29. However, this delay was not attributable to errors by the Care Home. Rather, it was due to errors in the discharge paperwork provided by the hospice.
30. Indeed, the evidence shows Care Home staff identified the error promptly. They then took appropriate action by seeking clinical input and advice from out-of-hours services to resolve the matter. In addition, the Care Home made a safeguarding referral to the Council the following day. This was in keeping with good practice and the NICE guidelines.
31. In summary, I found no fault by the Council or Care Home in this matter.

Response times

32. Mrs B complains that Care Home staff failed to respond promptly to Mrs C’s call buzzer when she was in distress. She said this led Mrs C to attempt to get out of bed while attached to a syringe driver (a pump designed to administer medication under the skin at set intervals). Mrs B said this placed Mrs C at increased risk of falls.
33. The Care Home said it reviewed the nurse call response times throughout her admission. Based on the call activation record, the Care Home said most calls had been responded to within an acceptable level of time. The Care Home added that no concerns had been raised directly with nurses at that time.
34. As part of its response to my enquiries, the Care Home provided me with a copy of Mrs C’s call activation record for the duration of her placement. The Care Home explained that it was experiencing some technical difficulties with its call alarm system at that time that meant the system sometimes failed to reset after a call had been attended by a member of staff. This means some of the entries in the log do not accurately reflect the response times.
35. Nevertheless, when compared against the care notes, it is sometimes possible to determine whether care staff attended to Mrs C during these periods.
36. There is evidence in the call records to show Mrs C sometimes tried to get out of bed when agitated. Two examples of this were documented by care staff on 5 July.
37. I also accept, on balance of probabilities, that there would have been some occasions on which staff took longer to respond than should have been the case, particularly during busy periods or at night. I acknowledge any such delays would have been concerning for Mrs C’s family at what was already a very difficult time.
38. However, taken as a whole, the records show care staff generally responded in a timely manner to Mrs C’s call alarm. In the absence of any further evidence, I found no fault on this point.

Family assistance

39. Mrs B complains the family was told Mrs C’s blood pressure was too low for her to get out of bed to use the toilet. Despite this, Mrs B says Mrs C was placed in a room where Mrs C’s family were left to assist her. She says the family were left for extended periods of time without support.
40. The Care Home did not comment specifically on the complaint that the family had been required to assist Mrs C to the toilet. However, the Care Home said families often stayed for extended periods with loved ones and apologised if Mrs B felt the family had been left unattended.
41. When Mrs C was transferred to the Care Home in June 2023, staff produced a care plan for her. This set out Mrs C’s needs in several different areas and the level of support required to meet those needs. The care plan recorded that Mrs C was continent but required the assistance of one member of staff to assist her to the toilet.
42. The care records suggest care staff were supporting Mrs C to use the toilet during the early part of her placement. However, Mrs C was sometimes noted to be drowsy. This was exacerbated by Mrs C’s strong pain relief medication. The Care Home arranged for Mrs C to be seen by a GP on 30 June for a review of her medication.
43. I found no evidence in the care records to suggest specific concerns about Mrs C’s blood pressure. However, by 1 July, the care records show Mrs C was too frail to be assisted to the toilet and was largely being nursed in bed with incontinence pads. The evidence shows staff checked and changed the pads regularly.
44. Mrs C was approaching the end of her life. This meant Care Home staff were required to balance her care needs with the need to give the family space and privacy to spend time together. In addition, the family members occasionally asked staff not to provide care interventions (such as repositioning Mrs C in bed). This meant there were times when the family was left alone with Mrs C and was required to provide some support.
45. Nevertheless, I found no evidence in the records to suggest the family were unhappy with the care the Care Home was providing at that time. Indeed, the care records show staff were responsive when the family raised concerns about Mrs C, such as when she became restless or agitated.
46. I accept Mrs B’s recollections of what took place do not always match what is recorded in the care records. In the absence of any further independent evidence to assist me, I am unable to comment further. However, I am satisfied the available evidence shows the Care Home provided Mrs C with appropriate care in this area. I found no fault on this point.

Regular checks

47. Mrs B complains that Mrs C required regular checks due to her medication but that this did not happen. She says there were insufficient staff available at the Care Home to provide proper palliative care.
48. The Care Home said staff had tried to give the family as much time together as possible. However, it said staff continued to deliver and document care. With regards to specific syringe driver checks, the Care Home said care records showed all checks had been completed as required.
49. The care records show that, by 3 July, Mrs C’s condition had deteriorated. She was no longer able to take her medication orally. The hospice nurse who visited Mrs C that day recommended the use of s syringe driver to administer medication. The Care Home arranged for this to be set this up on the same day.
50. Care Home staff had to carry out regular four-hourly checks to ensure the syringe driver was functioning properly.
51. The syringe driver record provided by the Care Home shows that, between 3 and 5 July staff completed the necessary checks. This is also reflected in the care notes, which contain regular entries relating to the monitoring and maintenance of the syringe driver.
52. It is understandable that Mrs B and her family found this period very distressing and were keen to ensure Mrs C received the care she required. However, as I have explained above, I am satisfied Care Home staff were attempting to support Mrs C, while allowing time and space for her to be with her family.
53. I found no evidence of fault by the Council or Care Home with regards to this aspect of Mrs C’s care.

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Final decision

54. I found no fault by the Council or Care Home with regards to the care provided to Mrs C. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman