Summary: There is no evidence the care provider failed to seek medical attention promptly or give a good standard of care to the late Mr X. The care provider acknowledges it did not always communicate with the family as it might have done but I am satisfied its apology and retraining was sufficient.

The complaint

1. Ms A (as I shall call her) complains about the care and treatment of her late father Mr X in the Marlborough House care home. In particular she complains that staff were unable to care for his complex needs, failed to supervise him while he was eating despite his swallowing difficulties and did not call for medical help promptly enough when he fell ill. She complains that some possessions went missing.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers and decide whether their actions have caused injustice, or could have caused injustice, to the person complaining. I have used the term fault to describe this. (Local Government Act 1974, sections 34B and 34C)

Back to top

How I considered this complaint

3. I considered the information provided by Ms A and by the care provider. I spoke to Ms A. Both Ms A and the care provider had the opportunity to comment on a draft of this statement and I considered their comments before I reached a final decision.

Back to top

What I found

Relevant law and guidance

4. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards that registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards.
5. Regulation 12 says that care and treatment must be provided in a safe way, including when patients are transferred between services.
6. Regulation 14 says the nutritional and hydration needs of service users must be met. That includes, if necessary, support for the service user to eat and drink.

What happened

7. Mr X had a stroke. He required nursing care and moved to Marlborough House in September 2023. He was described as ‘high dependency’.
8. Mr X’s care plan on admission said he required assistance with all personal care needs. In terms of eating and drinking, at the point of discharge from hospital to the nursing home he was assessed by the hospital team as requiring ‘easy to chew’ foods which were cut up small. His care plan also said he “might need assistance with meals at times”.
9. As Mr X began coughing when drinking normal fluids, his GP recommended level 1 thickened fluids (defined as ‘slightly thick’) and made a referral to the SALT (Speech and Language Therapy Team) in November 2023. The care plan contains the recommendations received by letter in December from the Team:

Level 2 Thickened fluids

Drink from an open cup – no spout or straws

Normal diet – cut food into small bite-sized pieces

Ensure slow pace, verbally prompt and assist when required

1:1 supervision for all eating and drinking

Small mouthfuls: ensure he has swallowed completely before taking another spoonful

Fully upright and alert for all eating and drinking

The letter from the SALT team said Mr X had ‘mild oropharyngeal dysphagia’ and his risk of aspiration was increased due to a fast-feeding pace, but the risk was reduced with thickened fluids and the detailed strategies in place.

10. In December Ms A emailed the care home manager concerned about her father’s weight loss. She said she had been told the family would be sent weekly weight and blood sugar results but that had not happened. The care home records show that the requested results were sent but Ms A continued to express concern. The deputy manager agreed to contact the dietitian in view of her concerns. The dietitian agreed to provide some pre-made milkshakes for Mr X.

The hospital admission

11. On 29 February 2024 Mr X’s condition deteriorated. The care home records for the morning show that he was offered breakfast as usual, ate half a bowl of porridge and drank half a cup of thickened tea at 09.07. The carer informed the nurse on duty that Mr X had only eaten half his breakfast which was unusual for him and was “coughing and lethargic”.
12. The records show the nurse carried out observations and noted that Mr X had a raised temperature, low blood pressure, raised pulse, and low oxygen sats. The nurse telephoned the GP who called back 20 minutes later and said Mr X appeared to have hypoxia and tachycardia and advised the nurse to call for an ambulance. The nurse had also checked with Mrs X that she was content for Mr X to go to hospital if necessary. An ambulance was called and arrived about two hours later.
13. The care home records show Ms A telephoned later that day. She said she was unhappy as Mr X was on a drip and was being treated for dehydration and an infection. Ms A says the ambulance crew was told something different from the care home records.
14. Sadly Mr X died on 4 March in hospital.

The complaint

15. Ms A complained to the care home on 8 March. She said her family had raised concerns about Mr X’s condition for a few days before he was hospitalised. She said he appeared to have vomited once during a visit on 26 February and the carer said she would ‘keep an eye on him’; on another occasion he had pushed his sheets off as he felt hot; she was concerned that different information had been given to the ambulance crew and the GP. She also complained that family had been unaware Mr X had sometimes refused food and said they would have asked for bigger portions to be provided. She raised concerns about the advice given by the SALT team and said in her opinion Mr X should have been given different levels of food and drink from those recommended. She said “SALT and the Dietitian were as much at fault on this as you at the home for his care”.
16. The care home manager responded. She said in response to Ms A’s doubts about Mr X eating and drinking on the morning of his hospital admission, the notes clearly stated what had been offered and consumed. She said it was inappropriate for her to comment on the professional advice of the SALT team and the dietitian. She said no concerns had been raised by staff about Mr X’s condition in the days before 29 February.
17. Ms A was dissatisfied with the response and complained again. After a further local response she complained again to the care provider. She was concerned the care home had waited to speak to the GP before calling an ambulance. She said this had delayed Mr X’s hospital admission. She also raised other concerns about matters over the previous months; Mr X not joining in activities in the home; staff not always assisting with eating and drinking; the diet being given as recommended by the SALT team and dietitian when the family had requested a more pureed diet. She also complained that the care home had charged for some fees after Mr X’s death. She complained about the loss of some items.
18. The regional manager responded. She replied to Ms A’s individual points of concern. In response to an allegation about poor records of food and fluids she said there were only 3 missed entries since Mr X’s admission to the home. She said the nurse had acted properly by contacting the GP and acting on his advice. She said staff had a duty to abide by the advice given by the dietitian and the SALT team. She said the terms and conditions provided for a charge for seven days after discharge. She added that some training had been put into place as a result of an acknowledged lapse in communication with the family. She apologised that the items which Ms A said had gone missing had not been traced.
19. Ms A complained to the Ombudsman. She said the care home staff had failed to provide the proper care and treatment required for someone with complex needs and the effect on her family had been considerable. She said she did not believe staff had always supervised her father’s eating, she on one occasion she had visited and found he had been left alone to eat a sandwich, and in any event in her view he should have been on a pureed diet as he was in hospital.
20. The care home manager says Mr X “was supervised with all meals throughout his stay with us, unless a family member was present and happy to assume that role”. She says at no point was there any clinical indication that Mr X required pureed foods as Ms A later suggested he should have had. She points out that Mr X had been seen by three different registered nurses in the five days prior to his hospital admission and no one had raised any concerns about his condition during that time.
21. Mr X lost some weight after his admission to the home and his weight then fluctuated over the next months. The care home records show that on the MUST charts (malnutrition universal screening tool) he scored 1; the manager indicates that a score of 2 would have been required to raise further concerns with the dietitian. The records describe in detail what Mr X ate or refused.
22. In respect of the morning Mr X became unwell, the manager says “His Care and Nursing notes do not indicate any untoward concerns raised by either the Registered Nurses or Care staff from the 25/02/34 – 28/02/24.

(Mr X’s) fluid intake is recorded as having averaged 1321 ml over the 5 days, with an intake of 480 ml prior to admission to hospital on 29/02/24.

His dietary intake was unremarkable, and it is documented what he ate prior to becoming unwell.”

The care records for the three days before the hospital admission show that Mr X was eating and drinking normally.

23. The nurse who attended Mr X on the morning of his hospital admission says he telephoned the GP surgery and requested a visit, as he says that was “the first line of action for non-emergency medical incidents”. He says there were no signs of any escalation in Mr X’s condition. He says that Mr X was sitting up in bed to await the ambulance, was “alert and orientated”, and was offered some fluids which he took.
24. Ms A says her father was extremely ill when he arrived at the hospital, and was diagnosed with sepsis. She says she knows there were occasions when he was not supervised when he ate.

Analysis

25. There is no evidence that the care provider failed to give safe care to Mr X. Appropriate referrals were made to the dietitian, the GP and the SALT team.
26. The care provider sought attention promptly when Mr X fell ill on the morning of 29 February. There was no indication he was a medical emergency and it was reasonable for the nurse to call the GP for medical advice at that point. I have not seen any indication that caused a delay which adversely affected Mr X.
27. The care provider kept detailed records of the food and fluid offered to and consumed by Mr X. There is no evidence of a lack of supervision while he ate (except when his family was with him) although I recognise Ms A’s concern that she believed her father was sometimes left unsupervised to eat.

Back to top

Final decision

28. I have completed this investigation. There is no evidence that the actions of the care provider caused injustice to Mr X’s family.

Investigator’s decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman