South East Coast Ambulance Service NHS Foundation Trust

5. Mrs N complains the Practice did not: • insist her husband Mr N attend hospital on 7 September 2022 • arrange any follow up after this visit • act when Mrs N phoned a few days later.

6. Mrs N said the failure to take the correct action meant there was a missed opportunity to provide care and treatment which would have prevented Mr N’s death in November 2022.

7. Mrs N complains the Community Trust did not: • act as it should in relation to her husband’s pressure ulcers on 19 and 22 September 2022 • put in place a care plan from 12 September to 22 October 2022, to prevent pressure ulcers developing • act or investigate further when Mr N developed a pressure ulcer on 1 October or when Mrs N followed this up with a phone call on 4 October • take appropriate actions in relation to occupational therapy input on 22 September • give appropriate help and advice on 22 September to improve Mr N’s surroundings, in relation to his pressure ulcers • assess or offer appropriate help on 22 September to improve the home environment to meet Mr N’s needs.

8. Mrs N said the failure to take the correct action meant there were missed opportunities to warn of the risk of pressure ulcers, and provide care and treatment which would have prevented Mr N’s death.

9. Mrs N says the Ambulance Trust did not take Mr N to hospital and did not act as it should on 27 September 2022.

10. Mrs N said the failure to take the correct action meant there was a missed opportunity to provide care and treatment which would have prevented Mr N’s death.

11. Mrs N said this has had a profound impact on her emotional and physical health, affected her financially and has prevented her from being able to grieve. It has also made her worried about other vulnerable patients in the community.

12. The outcome she seeks are an apology, acknowledgement of failings, service improvements and financial compensation.

13. Mrs N was a carer for her husband, her son and her mother. Mr N had a diagnosis of diabetes and had diabetic foot problems which were being treated by the community nurses and podiatry service. He also had a history of strokes and Mrs N told us this impacted his communication.

14. Mr N was treated at home by the organisations named in this complaint and refused admission to hospital. He was taken to hospital on 22 October 2022 with pressure ulcers.

15. The Department of Health and Social Care guidance says any category 2 and above pressure ulcer must be reported as a clinical incident according to local clinical governance procedures. The hospitals treating Mr N reported the pressure ulcers and the local authority began an investigation.

16. Mr N sadly died in November. Mrs N raised concerns that the organisations should have done more and this would have prevented her husband’s death.

21. Mrs N explained, through her representative, that when the GP visited Mr N on 7 September they frightened him and so he refused to go to hospital. She thought the GP should have done more to insist Mr N went to hospital, and says the situation was not clearly explained and they were not given enough time to understand. We understand how upsetting it must have been for her to see her husband refusing help.

22. Our GP adviser told us that during the visit on 7 September the GP carried out a comprehensive assessment and a thorough examination. As a result of this assessment the doctor decided Mr N should be admitted to hospital. They told Mr and Mrs N this, sharing with them information about what the implications would be if he decided not to follow this advice. We found this was in line with the GMC guidance Good Medical Practice that says:

‘15: You must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must: a) adequately assess the patient’s conditions, taking account of their history (including the symptoms and psychological, spiritual, social and cultural factors), their views and values; where necessary, examine the patient b) promptly provide or arrange suitable advice, investigations or treatment where necessary c) refer a patient to another practitioner when this serves the patient’s needs.’

23. The GP also told Mr N it was likely his condition would get worse if he did not follow the advice. The GP suggested a referral to social services for home carers. These actions were also in line with the GMC guidance which says:

‘32: You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patients’ language and communication needs.

33: You must be considerate to those close to the patient and be sensitive and responsive in giving them information and support.’

24. Our GP adviser told us it was important that Mr N was given the information he needed, and we found this was in line with the GMC Decision making and consent guidance, which says:

‘11: You must try to make sure the information you share with patients about the options is objective. You should be aware of how your own preferences might influence the advice you give and the language you use. When recommending an option for treatment or care to a patient you must explain your reasons for doing so, and share information about reasonable alternatives, including the option to take no action. You must not put pressure on a patient to accept your advice.’

25. Mr N refused to be admitted to hospital. The GP had assessed that Mr N had capacity to make this decision. Mrs N told us she did not think this was the case and we accept she has a different opinion. It is not possible for us to make a retrospective assessment of capacity from written notes. We can see the actions of the GP in making the assessment were in line with the GMC Decision making and consent guidance that says:

‘81 You must start from the presumption that every adult patient has capacity to make decisions about their treatment and care. You must not assume a patient lacks capacity to make a decision solely because of their age, disability, appearance, behaviour, medical condition (including mental illness), beliefs, their apparent inability to communicate, or because they choose an option that you consider unwise.

82 Assessing capacity is a core clinical skill and doesn't necessarily require specialist input (eg by a psychiatrist). You should be able to draw reasonable conclusions about your patient's capacity during your dialogue with them. You should be alert to signs that patients may lack capacity and must give them all reasonable help and support to make a decision.

83 A person has capacity if they can do all the following: a. understand information relevant to the decision in question b. retain that information c. use the information to make their decision d. communicate a decision.’

26. The records show the GP acted in line with this guidance by ensuring Mr N understood the information they were sharing, and understood the implications of his decision to not follow the advice.

27. Given this circumstance the GP had no option other than to act in the way they did, by giving advice and prescribing antibiotics. This was in line with the GMC guidance Good Medical Practice that says:

‘16: In providing clinical care you must: a prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b provide effective treatments based on the best available evidence.’

28. Our GP adviser told us it is not within the powers of a GP to insist someone be admitted to hospital, and would be contrary to the guidance outlined above about decision making and consent.

29. We have found no failings in the actions of the Practice in relation to the home visit on 7 September.

30. We know Mrs N is concerned about whether the Practice had arranged any follow up after this visit. The records show the Practice did carry out additional actions, with the GP making referrals that same day to the podiatry service, the occupational therapy service and an urgent referral to the district nursing team requesting blood tests.

31. These were all appropriate referrals, in line with the GMC guidance Good Medical Practice guidance, which says: ‘15c you must […] refer a patient to another practitioner when this serves the patient’s needs.’

32. We think it would also have been reasonable and in line with the GMC guidance for the Practice to discuss and document what action to take with the safeguarding lead. The GMC guidance says:

‘25: You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised.

a) If a patient is not receiving basic care to meet their needs, you must immediately tell someone who is in a position to act straight away.’

33. The Practice correctly recognised in its complaint response that there was a missed opportunity to discuss Mr N with the safeguarding lead, given his refusal to accept the advice given, and his apparent neglected self-care. They wrote:

‘We should have a much lower threshold for gaining advice from our senior safeguarding colleagues and encourage a multidisciplinary approach to working towards better outcomes for our patients. In terms of context, we noted from your Husband’s records that he had refused some sort of treatment or input into his care on multiple occasions and it was normal for him to do so; but as his health had deteriorated, this should have been a trigger to raise concerns.’

34. We agree with the Practice response, that it should have explored options with its safeguarding lead. The Practice has since told us the doctors did discuss the concerns during a meeting where the safeguarding lead was present. We think a more formal consideration, with the decision-making documented, would have been in line with the GMC Confidentiality guidance which says: ‘Keep a record of your decisions to disclose, or not to disclose, information.’

35. We do not find that the Practice should have made a safeguarding referral to social services. This is because an immediate referral would not have been in line with the guidance BMA Adult safeguarding – a toolkit 2018, which says:

‘Duty of confidentiality Health professionals owe the same duty of confidentiality to all their patients regardless of age, vulnerability or the presence of disability. A mental disorder, serious physical illness or learning disability should not lead to an assumption that the individual lacks capacity to make decisions relating to the disclosure of confidential information. Competent adults have considerable rights about the extent to which their information is used and shared, and these are protected both by law and by professional and ethical standards. Although there is a presumption that information will be shared between health professionals involved in providing care to a patient, where a competent adult explicitly states that this information should not be shared, this should ordinarily be respected.

Sharing information The multi-agency approach to safeguarding adults nevertheless means that, where it is lawful and ethical to do so, appropriate information should be exchanged between relevant agencies to ensure the right support can be provided. Health professionals can sometimes feel challenged when a competent adult refuses to agree to the sharing of information that would seem to be in their best interests, or that could help mitigate a potential threat. Where a health professional believes that information should be exchanged, they should carefully explain the reasons for this, the likely benefits, and the duty of confidentiality that the various agencies are subject to. The reasons for the refusal should also be sensitively explored and, where appropriate, options that might prove more amenable to the patient offered.’

36. We do not reach the same conclusion Mrs N has, that the failure to take the correct action (in this case discuss issues with the safeguarding lead) meant there was a missed opportunity to provide care and treatment which would have prevented Mr N’s death.

37. This is because we cannot know what the outcome would have been if the GP had carried out a formal documented consultation with the safeguarding lead. It may have led to a safeguarding referral, or it may not. Even if the Practice decided to make a safeguarding referral, we do not know how long it would have taken to arrange a meeting. We cannot conclude this would have made any difference to Mr N’s position, as recorded in the notes by the doctor, ‘he understands the infection may get worse and cause him to die - he would rather die than be admitted to hospital’.

38. We must also be aware of what the GMC guidance Confidentiality: good practice in handling patient information 2017 says:

‘You should, however, usually abide by the patient’s refusal to consent to disclosure, even if their decision leaves them (but no one else) at risk of death or serious harm. You should do your best to give the patient the information and support they need to make decisions in their own interests […]. Adults who initially refuse offers of assistance may change their decision over time.’

39. This means that it would be usual for a practitioner to respect an expressed refusal of help. For these reasons we cannot conclude the outcome would have been any different if the Practice had arranged a documented discussion of the issues with the safeguarding lead.

40. Mrs N told us the Practice did not take the right action when she phoned a few days later. The records show a telephone call between the Practice and Mrs N took place on 12 September.

41. The Practice reviewed the blood tests results and the recent history and provided further antibiotics and pain killing medication. The doctor also took action to chase up the recent referral to the district nurses. We consider this was in line with GMC guidance Good Medical Practice, which says:

‘16: In providing clinical care you must: a) prescribe drugs or treatment, including repeat prescriptions, only when you have adequate knowledge of the patient’s health and are satisfied that the drugs or treatment serve the patient’s needs b) provide effective treatments based on the best available evidence.’

42. For this reason we did not see any failings in relation to the actions the Practice took following the phone call on 12 September.

43. To conclude, the only part of the Practice complaint where we saw a failing was in relation to the Practice not formally carrying our and documenting a discussion of Mr N’s circumstances with its safeguarding lead. We looked at the actions it has taken since then.

44. We have seen that the Practice has already apologised and identified learning from this matter. It has undertaken extensive work to improve its processes, as outlined in its complaint response to Mrs N. It also shared with us additional evidence, including a comprehensive safeguarding handbook and extensive discussion at a quality improvement meeting. It has meetings each morning to allow clinicians to formally discuss any complex patient cases, and these discussions are appropriately recorded.

45. We found these actions to be in line with Ombudsman’s Principles for Remedy. These say when an organisation gets something wrong it should apologise and take action to revise procedures to prevent the same thing happening again.

46. For this reason we do not uphold the complaint against the Practice. This is because we do not uphold a complaint where we can see an organisation has taken sufficient action to remedy the impact of what went wrong.

47. Mrs N told us, through her representative, that she had not realised Mr N had pressure ulcers, and did not know at the time what they were. She said she thinks the Community Trust should have done more to prevent the pressure ulcers and to act on the ulcers when they developed. We looked at all the points she raised about this, and the actions of the Community Trust in relation to this.

48. Our nursing adviser told us that for the period in question the records show the Community Trust offered support to prevent pressure ulcers. The NICE guidance on pressure ulcers says nurses should develop a care plan for:

‘adults who have been assessed as being at high risk of developing a pressure ulcer, taking into account: • the outcome of risk and skin assessment • the need for additional pressure relief at specific at-risk sites • their mobility and ability to reposition themselves • other comorbidities • patient preference.’

49. Our nursing adviser said in line with the NICE guidance, the Community Trust developed and followed a care plan. Unfortunately Mr N’s lack of engagement meant that the Community Trust could not put in place everything it assessed he needed, as detailed in the next paragraph.

50. The records show he declined the moving and handling equipment, pressure relieving equipment and suggestions for carers. These were all included in the care plan as needed to prevent pressure ulcers. Mr N’s lack of engagement also meant that his pressure areas could not be checked, because he could not stand independently.

51. On 19 September the community nursing team shared the care and treatment of Mr N’s foot ulcers with the podiatry team. The attending team followed the care plan, removing dressings and cleaning his feet and legs with tap water and antibacterial moisturiser. The records show the Community Trust was aware Mr N was taking a course of antibiotics for his wounds.

52. The sore areas on Mr N’s legs and feet had previously been photographed. This allowed the nurse to objectively assess if the ulcers were improving or deteriorating. This was in line with the IMI guidance on wound management photography.

53. Poor mobility impacts on wound healing, and the nurse asked Mr N if they could refer him to occupational therapy, which he accepted. He declined referral to social care for carers.

54. The care and treatment the Community Trust gave was in line with the NICE guidance in paragraph 48. Working with other teams and considering referrals was also in line with the NMC Code, which says ‘work with colleagues to preserve the safety of those receiving care, share information to identify and reduce risk’

55. The records show that on 22 September Mr N had cellulitis (a bacterial skin infection that causes swelling and pain) and very poor mobility. He had declined admission to hospital. The nurse carried out and documented a review of his care needs and social situation. Our nursing adviser told us this was important as nutrition, mobility, hygiene and continence can all impact on wound healing.

56. The records outlined the living situation, which was not good for someone with Mr N’s needs, and increased the risk of pressure ulcers. He was eating and drinking well and was using bottles and a commode to go to the toilet. He lived with his wife, son, mother-in-law and dogs and his room was cluttered with little room to move. He had poor mobility and was reliant on his family to transfer from his chair. He continued to refuse carers, and he smoked within his home. He had mental capacity and could therefore voice his preferences and wishes.

57. The records show the nurse gave wound care in line with Mr N’s care plan and scheduled visits were on a two-weekly basis. Nurses were unable to assess Mr N’s pressure areas because he declined moving and handling equipment and they could not therefore move him to check sacral areas. The risks of refusing care were clearly outlined to Mr N.

58. Our nursing adviser told us the care and treatment given followed the guidance and standards outlined in paragraphs 48 and 54. It was also important that the Community Trust respected Mr N’s right to make his own decisions, as outlined in the NICE guidance on Patient experience in adult NHS services, that says:

‘1.3.6: Accept that the patient may have different views from healthcare professionals about the balance of risks, benefits and consequences of treatments.

1.3.7: Accept that the patient has the right to decide not to have a treatment, even if you do not agree with their decision, as long as they have the capacity to make an informed decision (see recommendation 1.2.13) and have been given and understand the information needed to do this.’

59. Our nursing adviser also referred to the NICE guidance on decision-making and mental capacity, which explains that a practitioner must assume someone is able to make their own decisions, unless there is evidence to show that they lack capacity. The said in this case there was no evidence of this.

60. We considered the issues Mrs N raised, that the Community Trust did not provide appropriate advice on improving Mr N’s surroundings and the home environment. She told us the Community Trust staff, including the nurse and the occupational therapist (OT), did not give the help they should.

61. The records show the nurse and the OT spoke at length with Mr and Mrs N on 22 September and explained what needed to happen for Mr N to get the support he needed.

62. It was noted that Mr N declined some interventions and equipment aimed at preventing pressure ulcers. Mr N declined to address the clutter in his property to enable the use of moving and handling equipment. Carers were also declined, and respite care whilst the property was decluttered was also declined.

63. Mr N also refused pressure redistribution equipment, which can reduce or redistribute pressure, and chose to sleep in a reclining chair despite the advice given.

64. Our nursing adviser told us all help and support offered was in line with recommendations of the NICE guidance on pressure ulcers.

65. The records show clearly that the nurse and the OT did all they could to make Mr and Mrs N aware of what they needed to do to allow the team to provide the help that was needed. They document:

‘- Risk of injury to Mr N or a member of his family while practicing unsafe moving and handling techniques with no equipment.

- Mr N is at significant risk to his health as he sits and sleeps on the same chair with no pressure relieving properties.

- He is at high risk of pressure damage to his sacral area, he may already have damage but [community nurses] haven't been able to assess this because of the moving and handling problems.

Despite the risks being outlined and explained to Mr N and his wife they aren't willing change the situation. [occupational therapy] don't feel there much that can be offered.’

66. Mrs N was concerned that the Community Trust did not act on 1 October, when it identified a pressure ulcer, or when she followed up with a phone call on 4 October.

67. The records show that on 1 October the Community Trust carried out a wound assessment that included a holistic assessment of Mr N. This outlined the contributory factors to wound development and healing, including Mr N’s poor mobility, chronic diseases (diabetes and vascular disease) and his smoking. The wound was described, measured and photographed. This was in line with the care plan as outlined in paragraph 48.

68. The nurse tried to visit again on 3 October, but there was no answer and so the Community Trust could not give the planned follow up care and treatment.

69. Mrs N phoned on 4 October and the nurses discussed why the pressure ulcer had developed. They again repeated the need for moving and handling equipment:

‘Over the weekend [nurse] went into find Necrotic area to [Mr N’s] Right heel I have explained that this will likely results from direct pressure as he sits all day and night in his office chair, which has already been highlighted is not appropriate but he does not agree to changing his chair or to be referred for some[thing] more suitable.

I brought up again the possibility of considering either a referral for rehab or for respite so that the environment at home can be made suitable for a hoist or other moving and handling equipment, again [Mrs N] says [Mr N] refuses to consider this.’

70. Our adviser said the nurses acted in line with guidance, as they repeated the previously offered equipment, care and respite to help prevent pressure ulcers and to enable assessment of pressure areas. This was in line with the standards of proficiency for registered nurses, which says:

‘2.8 provide information and explanation to people, families and carers and respond to questions about their treatment and care and possible ways of preventing ill health to enhance understanding.’

71. To conclude, the nurse gave care and treatment in line with guidance. The OT and the nurse visiting made all efforts to encourage the family to accept help with their environment, but all offers of help were declined. They provided Mrs N with the number for adult services, should she agree to help or equipment in future. The note concludes that Mr N was ‘determined he and his family could manage as they were. Wife in agreement.’

72. We have not seen any failings in relation to the issues outlined in the complaint about the Community Trust.

73. Mrs N told us the Ambulance Trust should have taken Mr N to hospital on 27 September. She told us she had asked the paramedic to take her husband to hospital as they were leaving and they would not come back to do this.

74. We looked at what happened to see if it was in line with what the guidance, outlined in the Joint Royal Colleges Ambulance Liaison Committee, Clinical Guidelines (the Guidelines) said should happen.

75. The call that led to the ambulance attending said that Mr N had had a fall. The records show the family told the crew he had slipped when being transferred from bed, Mrs N had lowered him to the floor, and he had been unable to get up.

76. The records show there was no evidence Mr N had been injured when he slipped to the floor. Our paramedic adviser told us this meant there was nothing relating to the fall to show he needed to go to hospital.

77. The Guidelines do not explicitly say which patients should or should not be taken to hospital. They give general circumstances of when a patient should be taken to hospital. These reasons include the patient having a life‑threatening condition, any conditions requiring hospital only interventions, vital signs not being at a safe level, or an unclear diagnosis with potential for deterioration. Our paramedic adviser told us Mr N did not meet any of these categories.

78. It is clear from the information in the records that the crew considered the correct decision for Mr N would be to take him into hospital for a further health assessment. This was based on his overall condition, his long-term mobility issues, the described recent history of a diabetic foot infection and his home situation. The records show the crew tried to persuade Mr N to go to hospital, but he refused.

79. For this reason the decision that Mr N would not go to hospital was his own, and not that of the ambulance crew.

80. We looked at the issue of whether Mr N had the capacity to make and communicate this decision. The Mental Capacity Act (MCA) 2005 says:

• Assume a person has capacity unless proven otherwise • Support the person to make their own decision • Unwise decisions do not equal lack of capacity • If they lack capacity, act in their best interests.

81. The MCA says you should assume a person has the capacity to make a decision themselves, unless it is proven otherwise. Capacity is assessed at the time the person makes that individual decision. The NHS website information on the MCA outlines that just because someone doesn’t have capacity to make some decisions, this does not mean they lack the capacity to make all decisions.

82. In line with this the MCA says that to be able to make a decision about healthcare a patient must be able to:

• understand the information relevant to the decision • retain that information for long enough to make the decision • use or weigh up that information as part of the process of making the decision • communicate their decision in any way.

83. We can see that the crew carried out an assessment in line with what the MCA says should happen, and found Mr N had the capacity to make this decision. While the medical notes do not record how Mr N communicated this, there are references within the records of him responding to questions and communicating his situation and how he was feeling.

84. We can see that the documentation the crew completed was not filled in as well as it could have been. The section of the form for ‘consent and capacity’ is not fully completed, as it does not give details of why the crew concluded Mr N had capacity. However, this information is outlined elsewhere in the form and the ‘outcome notes’ give an explanation of the reasons Mr N had capacity to make this decision.

85. On balance, the actions of the Ambulance Trust (in not recording the information about capacity on the template in the expected section of the form), did not fall so far below the expected standard as to be considered a failing. The required information was recorded elsewhere, as outlined above in paragraph 84.

86. For these reasons we found there was sufficient evidence to show the Ambulance Trust acted in line with the MCA and the Guidelines in allowing Mr N to make his own decision.

87. We can see Mrs N signed the form to show she agreed with this approach. The records show the crew was at the property for almost two hours, which suggests they made considerable efforts to try and persuade Mr N and did not rush the process. Mrs N told us she does not believe what is written in the records is an accurate account of what happened. We have not seen any evidence to question the accuracy of the records.

88. Mrs N has a clear recollection of speaking to the crew once they had left the property. Her representative told us she had asked them to return and check on Mr N as she had nearly persuaded him to go.

89. We cannot take a position about exactly what was said, when there is no clear independent evidence. It would not be reasonable of us to find failings after the crew had already spent a long time trying to persuade Mr N. There is no evidence to suggest that re-entering the property would have presented any different situation or led to a different outcome.

90. As outlined in paragraph 77, the Guidelines do not explicitly say which patients should or should not be taken to hospital. They instead give guidance on what should happen to assess whether this is needed. This includes:

• ‘immediate identification and treatment of life‑threating conditions • taking a detailed history, examining the patient in line with the suspected injury or cause of symptoms, and checking vital signs.’

91. We can see this happened. The crew carried out the correct action by doing the assessment in line with the Guidelines, and trying to persuade Mr N to attend hospital for a fuller assessment of any additional health needs.

92. The crew continued to be concerned for Mr N once they had left the scene. They undertook the correct action by making a vulnerable person referral to social services to try and get help with Mr N’s increasing care needs and issues of self-neglect. This was in line with the Care Act 2014 which requires ambulance services to co‑operate, report concerns, and work in partnership as part of the safeguarding system. This demonstrates the crew was trying to get the support the family needed.

93. We did not see any failings in the actions of the Ambulance Trust. Additionally we can see it has taken action to ensure that learning is taken from this sad case. The training materials the Ambulance Trust completed following the complaint, and has shared with us, show a good example of learning from a challenging situation, in the spirit of continuous improvement.

94. We recognise how deeply Mrs N was affected by what happened and we thank her for sharing details with us. We hope she will be reassured by our careful consideration of the issues.

1. We did not find failings on the part of the Practice in relation to the care and treatment provided to Mr N. We did see that there was more it should have done to discuss and document Mr N’s situation with the safeguarding lead (the person at the Practice who takes responsibility for ensuring people are protected from harm).

2. We did not see evidence that this led to the impact Mrs N identified. The Practice has already recognised this and made service improvements. For these reasons we do not uphold the complaint about the Practice.

3. We have not identified failings on the part of the Community Trust or the Ambulance Trust, and so we do not uphold the complaints about these organisations.

4. We were sorry to hear about the circumstances that led to Mrs N bringing this complaint. We understand the experience has caused her much distress and we hope this report explains our careful consideration.