Decision Date: 24th March 2020
Mrs X complained on behalf of her mother, Mrs Y.
Mrs Y had been living at a residential home run by the care provider for over two years.
At the end of December 2018 the care provider noticed Mrs Y seemed unwell, and called for a GP to visit. She was prescribed antibiotics, and later that day staff called Mrs X to inform her of what had happened.
The next day Mrs Y’s condition had significantly deteriorated; she had become very hot and struggled to breathe. Staff called an ambulance at 16.35, which arrived at 16.50. Notes from the care provider stated that Mrs Y was unresponsive when the ambulance crew arrived, so they took her to hospital where she was admitted.
At 16.47 staff called Mrs X and told her that Mrs Y was unresponsive and that they had called for an ambulance. They told her she should go straight to the hospital resuscitation ward.
However, Mrs X said that when she passed the home at 17.10, the ambulance was only just leaving, so she followed it to the hospital.
Mrs X was told at the hospital that Mrs Y was severely dehydrated. Sadly, she died a few days later.
There was no evidence that either the ambulance crew or hospital staff raised safeguarding concerns about Mrs Y’s condition.
The day after Mrs Y was admitted to hospital, Mrs X went to collect a few of her belongings from the home. Mrs X told the LGO that she asked to see Mrs Y’s file, took some photos, but after a few minutes the manager was called away, so took the file back and asked Mrs X to leave.
The care manager, on the other hand, said that she had had a lengthy discussion with Mrs X, and after a resident had become unwell, had to leave, but left the documentation with Mrs X. When she had returned, Mrs X had given the file back to another member of staff and left. She believed that this had resolved all issues Mrs X may have had, so did not contact her further.
Mrs X subsequently asked for copies of the records for the three days leading up to Mrs Y’s admission to hospital. She eventually reviewed them around May 2019. When she received them however, she found discrepancies between the copies and the photographs she had made.
During the LGO’s investigation, it found that there was more than one version of the care chart for the afternoon Mrs Y was admitted to hospital.
- The original version said staff called 999 at 3.35pm, the other says 4.35pm.
- The original version described Mrs Y as “sleepy” between 4:30 and 5pm and noted a 5pm check. The second version does not include the 5pm check and described Mrs Y as “quite chatty and responsive up until 4:30pm”.
- It also included a note that Mrs X was called, which was not on the original.
- The care chart from the previous day showed more hourly checks but did not note the reason for why the checks were increased.
What was found
The LGO stated that the care provider acted properly by calling the GP and appeared to be offering her fluids regularly as planned.
However, it stated that “the amended documentation is concerning and puts in question all the records for Mrs Y. I cannot be confident that the Care Provider’s records are accurate. This is a potential breach of regulations 17 and 20. I will therefore share a copy of this decision with the CQC.”
It concluded that on the balance of probabilities the care provider did not adequately care for Mrs Y, at least for the last few days that were in question.
As records were amended after Mrs X visited and asked to look at them, the LGO stated that this was inappropriate, and that it would have caused Mrs X undue stress and anxiety.
The LGO recommended that the care provider apologise, and ensure that all staff were aware of the need to maintain accurate and complete records for each resident, and understand the serious implications of falsifying records.
Points for the public and care homes, families, councils, and service users.
This is not a case where the care home was being accused of causing a death or a deterioration, but there was a question over what it should have done and how it had engaged with outside help. That is how duplicated records were revealed – no wonder the LGO referred the care home to the CQC.
We anticipate more of this sort of complaint post lockdown as relatives who have lost loved ones try to get to the bottom of whether their relatives were made the subject of DNAR notices, and whether properly or not; whether they were taken to hospital promptly or at all, and if not, why not. We are not saying that people were not looked after properly; we can well imagine circumstances in which going to hospital would not have been the kind thing to push for. But we were and are still gravely concerned as to the way in which the priority of saving the NHS from exceeding its capacity may have operated on the minds of professionals at that time – especially when visiting was being controlled and not even best interests assessors or advocates were being brought in to tell anyone whether what was being said was legally correct or not.
It is all that the LGSCO can really do in the circumstances, it being too later to organise a safeguarding adults’ investigation into what had happened.
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The full Local Government Ombudsman report of Hestoncourt Limited’s actions can be found here