Decision Date: 7th November 2019
Mr P complained on behalf of his late mother, Mrs D. She had bladder cancer, heart failure and kidney failure, Parkinson’s Disease and other conditions.
Mr P complained about the care provided by the Royal Borough of Greenwich (the Council), Oxleas NHS Foundation Trust (Oxleas), Kings College Hospital NHS Foundation Trust (Kings), and Bexley Clinical Commissioning Group (the CCG). He complained that:
- After Mrs D was discharged from hospital in April 2016 she did not receive adequate care and support to change her stoma bag.
- When Mrs D was discharged from hospital in December 2016 the district nurses failed to visit every day as planned
- When asked to take over care on 22 December, the district nurses failed to do so care, leaving her without care for a few days.
Mrs D had a stoma bag since early 2016.
She originally said did not need help from district nurses to help her manage the stoma care because she could do it herself with support from her sister. A specialist stoma nurse visited to give her advice. She also had support from carers employed by the council with her stoma care.
A few months after the bag was fitted, Oxleas noted that carers from the Council were changing the stoma bag, while the Council noted that the district nurses were visiting Mrs D to help with stoma care. There was no information as to why Mrs D could no longer manage with help from her sister.
On 13 May, the Council completed a social care assessment which arranged for a care agency (Blue Ocean) to help empty and attach Mrs D’s bag. The contracts made no specific reference, (that was a commissioning failure).
On 19 May, Mrs D told a district nurse (nurse K) from Oxleas that a carer had refused to change her leaking stoma bag as they had no training in stoma care. The nurse changed the bag, explained to Blue Ocean that it was their responsibility and arranged to show a carer how to do it. Numerous appointments were arranged, but there was no evidence that the training ever took place.
There were many difficulties surrounding stoma-related care; nurses said carers should change the bag, whilst Blue Ocean said it was the nurses’ job. The Council also gave contradictory information; at first a social worker said the district nurses should change the bag, and then the Council wrote to Mr P to clarify that in fact the carers should manage routine stoma care. This inconsistency resulted in Mrs D frequently being covered in urine because of the bag leaking.
Nursing visits 12th-22nd December
After a stay in hospital in December 2016, discharge arrangements were made for Mrs D. A doctor completed funding paperwork for the CCG (presumably a Nursing or Health Needs assessment done in conjunction with a social care assessment because there is no suggestion that she was regarded as eligible for CHC). This said the that the heart failure nurse would visit intermittently and that district nurses should visit Mrs D and deal with pain management. The hospital made a referral to Oxleas and someone there ordained that nurses would visit daily.
After the first visit, the day after Mrs D was discharged (12th December), the nurse noted Mrs D’s carers were managing her personal care, and that the district nurses should visit once a week only for palliative care.
Mr P sent an email expressing concerns about the district nurses *what about them? Just this coming once a week? The hospital discharge nurse agreed it would be appropriate for the nurses to check in weekly. Oxleas said it would reassess Mrs D’s needs. This reassessment (16th December) again said district nurses would check in daily. After this reassessment, nurses adhered to daily visits until the 22nd December.
No nursing visits after 22nd December
On 21 December, an Oxleas health care assistant visited Mrs D. Also that day, the district nurses decided to reduce their visits to Mrs D visits to three times a week. They did not record why they decided this or whether Mrs D and her family knew about the change.
On the morning of 22 December, the care agency called the CCG to say it would stop providing care to Mrs D that evening. The CCG emailed Oxleas and asked that the district nurses assist Mrs D with her personal care.
Mr P complained to the Council about the care agency cancelling its care; however the LGO explained why it did not address this in its report: the agency said it planned to stop its service on 16 December because of tobacco smoke in the house. Mr P refuted this, but there were conflicting accounts of events which an investigation by the Ombudsmen would not resolve.
On the morning of 23 December, a health care assistant from Oxleas visited Mrs D. The district nurses recorded that they tried to phone in the evening but there was no answer and they left a message. During Oxleas’ investigation a staff member gave a statement that Mrs D and her sisters had agreed that the next visit would be 26 December, but there was no mention of this in the records.
The only district nursing record on 24 December was a note at 21:06 which said the nurses could not contact Mrs D.
On 25 December, Mrs D went to hospital and sadly died on 28 December of pneumonia, which antibiotics failed to resolve.
What was found
- The Council was at fault as it failed to include the need stoma support on her care plan, and failed to ensure she was supported with this by trained carers. This contributed to Mrs D experiencing distress and embarrassment from leaking stoma bags, and also caused the family distress.
- Oxleas was at fault for not continuing to assist Mrs D with stoma care until it had made sure she had care from trained and competent carers with this. This contributed to Mrs D’s experiencing distress and embarrassment from leaking stoma bags, and also caused the family distress.
- Oxleas was at fault for not following the recommended discharge plan from 12 – 15 December. This did not cause injustice to Mrs D but caused Mr P unnecessary anxiety and distress.
- Oxleas was at fault because nurses did not visit Mrs D from 22 – 25 December. This left Mrs D without access to personal care, and caused distress to her family.
As it identified in May that Mrs D needed support to manage her stoma care, the Council should have included on the care plan that Blue Ocean’s carers needed to support Mrs D with this, and ensured they were competent to do so.
If it had, the confusion about whose role it was and consequent difficulties for Mrs D and her family could have been largely avoided. The Council wrongly believed changing the bag was a nursing need. Though stoma care is generally a personal care need rather than a nursing need (the LGO had taken advice from a clinical advisor but no authority for the proposition with regard to the legal framework is cited) nurses should identify any gaps in care delivery when completing discharge assessments. They should ensure people are safe and should take responsibility for delegating tasks to others.
The LGO was not satisfied that Oxleas made sure the carers were adequately trained. It became apparent that some of them could not competently manage the stoma care.
The LGO stated that in its conflict with Blue Ocean over which of them should change the bag, Oxleas appeared to have lost sight of Mrs D’s need to receive competent support consistently. Leaks from the bag caused damage to mattresses and carpets, and Mrs D was frequently left sitting in urine all night. It was therefore unsurprising to the LGO that the family became distressed and frustrated.
All in all, the LGO found it more likely than not, that Mrs D could not manage her stoma care without help. Therefore, the failure of the Council and Oxleas to ensure she consistently received competent care and support with her stoma care caused Mrs D to experience distress and embarrassment due to leaks from the stoma bag. In turn, this caused distress to her family.
Nursing visits between 12th and 22nd December
After Mrs D’s discharge of 12 December, Oxleas should have followed the instructions on the discharge plan, which included visiting Mrs D daily and monitoring her weight and blood pressure.
Nurse K said district nurses always complete their own assessment of nursing needs when someone is discharged from hospital, and she concluded Mrs D did not need daily visits.
The LGO stated that although district nurses could and should complete their own assessments, they should follow recommended discharge plans unless they have established, in liaison with other professions as appropriate, that the recommendations are no longer required.
Nurse K’s record of her visit of 13 December said a GP was present. Oxleas’ investigation report incorrectly said this was Mrs D’s GP. In actual fact it was a trainee GP from a different GP practice. Therefore, this was not someone who could make decisions about Mrs D’s care.
Therefore, departing from the discharge plan was fault. There was no evidence it caused any harm to Mrs D, but it caused unnecessary anxiety and stress to Mr P.
Visits after 22nd December
The district nurses should have continued to visit Mrs D each day from 22 December. They should not have stopped visiting without properly establishing through assessment and care planning that Mrs D did not need support.
There were several entries in Oxleas’ records which said staff could not contact Mrs D by phone so left a voicemail. Mrs D had been living at her sister’s house for months, and this information was stored on Oxleas’ records. It appeared the staff on duty in the evenings were calling the wrong phone number, even though they had the right number. Staff should also have contacted her next of kin when they could not get in touch with her.
In consequence of these failures, Mrs D was left without care from 22 to 25 December. This caused distress to her family.
The LGO recommended that the Council and Oxleas each pay Mr P and his brother £250 in recognition of its failings, and apologise.
Points for the public, service users, families, councils and CCGs working (or trying to work) in integrated delivery schemes
We cannot BELIEVE the contents of this report, in terms of the system failure that it represents, regarding letting people slip between the gaps in the system. It is evidence of obvious negligence (possibly actionable negligence, if it had caused foreseeable harm, and not just institutional neglect of which to be ashamed) set out in the report, in our view. The investigator however concluded that Mrs D’s death would not have been prevented even if the district nurses had visited each day.
When a person has a complex care package based on health and social care conditions, or might need one with two strands in it, it is absolutely essential that the liable authorities co-operate and understand that each is working under a legal framework.
That framework does not say that stoma care is personal care, but it doesn’t say it isn’t. The law is that unless it’s clear that it’s NOT care, or clearly agreed locally that it’s for the local health service to provide, then social services needs to take responsibility for it. Historically, the care of the stoma itself has always been a district nursing responsibility.
That which is in the care plan is supposed to be in a contract. It is no good if the contract is so anodyne and standardised that it doesn’t descend to the detail of what’s required. At the very least it must mention the council’s care plan and the care plan must be specific as to inputs to be lawful, and valid and transparent.
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The full Local Government Ombudsman report of Essex Royal Borough of Greenwich’s actions can be found here