An independent provider in the Luton area

7. Mrs R complains that on 20 September 2022, the Care Home: • continued to provide her mother, Mrs P, with food and drink despite her decline in appetite during the day and later in the evening when she had reduced consciousness • failed to properly records concerns about her condition • delayed in calling an ambulance until 10.30pm, after she developed facial drooping around lunch time • failed to communicate her condition with family until 10.47pm

8. Mrs R also complains the Care Home’s complaint response did not reflect the details given by the on-duty nurse and detailed in the Safeguarding Report by the Local Authority.

9. Mrs R says because of the failings her mother developed aspiration pneumonia (fluid in the lungs) which she sadly died from in hospital on 3 October 2022. She says it was distressing to witness her mother in pain and suffering further illness. Mrs R says the family experienced distress, worry and concern for her mother and the family’s bereavement was worsened due to the poor complaint handling and conflicting information in the records.

10. Mrs R is seeking an acknowledgement and apology, service improvements and financial remedy.

11. Mrs P was in her mid-eighties with advanced dementia, Alzheimer’s, epilepsy, DVT (deep vein thrombosis) and osteoarthritis who had been a longterm resident at the Care Home. On 20 September 2022, at 10.42pm paramedics were called to the Care Home for a suspected stroke.

12. Mrs P sadly died from aspiration pneumonia on 3 October 2022.

Events of 20 September 2022

17. Mrs R complains the Care Home failed to take appropriate action when her mother’s physical condition declined on 20 September 2022. We have listened when Mrs R has told us how distressing this experience was. We recognise it would have been upsetting to see a loved one be in pain and discomfort. We understand that Mrs R and her family had unanswered questions about the events that led up to Mrs P being admitted to hospital.

18. We consider that concerns raised by Mrs R are interlinked and should be considered jointly.

19. In its response, the Care Home set out information regarding Mrs P’s health conditions, prior hospital admissions and previous safeguarding concerns which were substantiated for neglect.

20. Regarding the events of 20 September 2022, the Care Home said it had interviewed staff and reviewed the electronic records. It said the records showed on the morning of 20 September 2022 Mrs P was supported with personal care and breakfast. The Care Home said Mrs P was transferred via hoist to her armchair and taken to the lounge where she spent most of the afternoon ‘sat comfortably’. It said at 4.17pm Mrs P was taken to her room and in between meals was offered fluids which she ‘tolerated’.

21. The Care Home said there was no mention of dribbling or stroke symptoms, it said this was confirmed in the electronic shift handover completed by the day nurse at 8.28pm.

22. It went on to say at 10.30pm, a night nurse noticed that Mrs P had not been well, had been sleepy and declined meals. It was noted Mrs P was dribbling when offered fluids. The Care Home said Mrs P’s vitals were checked and were found to be within her baseline. The night nurse called 111 and was advised to call 999.

23. The Care Home said in an interview the night nurse reported the paramedic was abrupt and intimidating on arrival which affected her confidence. The night nurse reported feeling the paramedic was not prepared to listen to her account of events.

24. The Care Home said Mrs P was taken to hospital where she had a CT scan, and it was confirmed she did not suffer a stroke. It noted on 3 October 2022, Mrs P died from aspiration pneumonia.

25. The Care Home said on reflection of the complaint, it had identified areas which it could improve on. This includes: • additional nurse training on recognising and managing patient deterioration • peer reviewing of reports to ensure clarity and prevent confusion • mid-shift briefing between day and night staff to ensure continuity and accuracy.

26. Mrs R complains the staff delayed in calling an ambulance after Mrs P developed a facial droop around midday (12pm). She says she was told this information by the nurse in charge, verbally, on arrival at the Care Home later that evening. She says when she arrived the paramedic who was attending to Mrs P was in a discussion with the nurse in charge and appeared to be upset with the Care Home.

27. Mrs R says she was also verbally told the paramedic would be raising a safeguarding concern. Mrs R also raised a safeguarding concern with Local Authority about the events of 20 September 2022. Local Authority upheld the safeguarding concern on a balance of probabilities after it considered all accounts provided, the records and previous safeguarding concerns that had been substantiated, notably an upheld safeguarding concern 12 months prior where Mrs P had suffered aspiration pneumonia after her swallowing deteriorated.

28. We have balanced the evidence provided by the Care Home against the information provided by Mrs R, the paramedics and the local authority to form our understanding of the events that happened on 20 September.

29. The NMC Code of Conduct (2018) says that nurses must keep clear and accurate records. It continues that records should be completed at the time of the event or as soon as possible afterwards and identify any risks or problems that have arisen for the people they are caring for, so that colleagues who use these records are provided with all the information they need.

30. We would like to note that both our advisers raised concerns on the record keeping within Mrs P’s clinical records noting the records were sparse, inconsistent and limited their ability to comment on the care provided. Adviser A noted the type of system used by the Care Home to record information is limited in the details which can be recorded. Adviser A explained it is likely a tick box activity with only a small section for a user to input information. We consider that whilst the Care Home’s software may be limiting it did not provide a suitable explanation for the poor record keeping.

31. Adviser B explained whilst the Care Home may use a different system the clinical records should be like nursing notes recorded at a hospital, as this is the expected standard.

32. We recognise the system the Care Home uses may be limited in the information it can record and is likely designed for efficiency when staff are doing rounds. However, we do not consider this good enough reason to explain why Care Home records are not in line with expected nursing standards.

33. Adviser B explained there was inconsistency in the records on Mrs P’s ability to swallow food and drink with notes stating Mrs P had eaten and drank with no concerns as well as a note later in the evening that said she had not eaten and drunk well. In addition, we have seen instances where care and service was logged as multiple entries concurrently.

34. We have determined the Care Home records were incomplete and colleagues taking over Mrs P’s nursing care would not have had sufficient information available in the records to safely provide continuing nursing care.

35. The clinical records set out the support staff provided Mrs P throughout the day. Mrs P was dependent on staff for assistance with all aspects of daily living. Adviser A noted, for example, Mrs P was incontinent of bladder and bowel and required regular changes of pads. Mrs P also required assistance with eating and drinking and her fluids were thickened to avoid aspiration. The nature of Mrs P’s preexisting conditions meant she was unable to communicate her needs and therefore her care needs were ‘anticipated in her best interest’.

36. On review of the records, it is unclear what time Mrs P’s condition began to deteriorate. The records indicate Mrs P was documented as ‘content’ throughout the day. The Care Home’s account of events says Mrs P did not show signs of a stroke (a facial droop) until 10.30pm.

37. On 16 January 2024, it reiterated in an email to us that there had been no concerns of a stroke until the night nurse noticed a dribble. Whilst there is no evidence in the records that Mrs P developed a facial droop at midday, we have seen that Mrs P first declined food at around 1pm.

38. Around 8.30pm, a manager at the Care Home checked Mrs P for signs of a stroke. The notes indicate Mrs P reacted normally. Adviser A explained strokes happen because of a blockage of the blood supply to the brain which damages part of the brain and can affect people’s appearance, bodily functions, speech and sight. Adviser A relied on the information provided by British Red Cross which details the ‘FAST’ method when assessing a person for a suspected stroke.

39. FAST stands for face, arm, speech and time. British Red Cross says when assessing a person for a suspected stroke you should look for facial weakness, inability to raise both arms and slurred speech. If a patient meets these criteria, then it is time to call emergency services.

40. At 10.30pm, a nurse reviewed Mrs P and noted she looked unwell, had been sleepier than usual and dribbled when given a yoghurt. This was treated as a medical emergency, and emergency services were called.

41. It is unclear why the Care Home checked Mrs P for signs of a stroke at 8.30pm. Adviser B noted this is unusual and is not consistent with the information recorded in earlier entries that Mrs P ‘was content’.

42. When approached for additional information during our investigation the Care Home provided copies of its investigation and staff interviews which are dated several months after the events complained about.

43. In this interview the manager explained it is routine to check patients for signs of a stroke. Adviser B agreed it is routine to observe elderly patients for any signs of new or worsening health problems. Adviser B relied on NMC Code of Conduct which says staff should pay special attention to preventing ill health and accurately identifying, observing and assessing signs of worsening health in the person receiving care. However, Adviser B explained there is no guidance or agreed upon standard practice which says this should be recorded formally.

44. Adviser B explained it is common practice to look for signs of deterioration during each interaction when providing personal care and assisted support, but this is not typically documented unless there were concerns raised.

45. At 6.54pm, Mrs P was recorded as being content and consuming 550ml of orange juice. The records indicate Mrs P had also had 790ml of orange juice earlier in the day. However, at 8.30pm when she was reviewed by a manager the notes detail Mrs P had been eating pureed meals and drinking level two thickened fluids. It also notes in the same free text box that she had been sleepy today and did not each much food and drank only a little water.

46. We consider this note is conflicting and inconsistent. We consider 8.30pm is when concerns about Mrs P were first documented by the Care Home. We also consider this is indication there had been concerted observations on Mrs P throughout the day as it noted her sleepiness as well as her eating and drinking habits.

47. We have listened when the Care Home has told us it is part of its standard practice to check residents for signs of stroke throughout the day. We have looked at the records the week preceding the events of 20 September 2022 and have seen no indication the Care Home assessed Mrs P for signs of a stroke as standard practice. This is not to say staff were not monitoring Mrs P. We consider it is likely this was done as part of general observations though there is no documentation in the records that supports the Care Home’s explanation this is done regularly.

48. We consider it is also likely Mrs P had deteriorated prior to this assessment at 8.30pm though we are unable to pinpoint when this was based on the records available. We are unable to say if Mrs P had developed a facial droop prior to or at the point of this assessment as there is no contemporaneous evidence to support this.

49. We understand Mrs R was given conflicting information when she later attended the Care Home and witnessed an interaction between the night nurse and the Paramedics.

50. Given the time that had lapsed between the events and the Care Home’s investigation interviews with its staff, we are not satisfied that the accounts provided by staff can be relied on with certainty. We have considered the documents fairly and balanced this against other accounts provided such as the safeguarding report by the Paramedic which was submitted the following day on 21 September 2022. Mrs R also raised a safeguarding report with the Local Authority on 23 September 2022.

51. The reports provided by the paramedic and Mrs R were completed within one to two days after the events and provide similar accounts. We consider the report provided by the Paramedic to be an independent and contemporaneous account. Whilst the report was brief the Paramedic’s report noted they had been informed Mrs P was seen drooling at 10am, experiencing a facial droop at midday, and unable to respond to being fed a yoghurt with covert medication later into the evening.

52. Strokes are a medical emergency and urgent treatment is essential. The sooner a person receives treatment for a stroke, the less damage is likely to happen. When it is suspected someone has had a stroke an ambulance and paramedic assistance should be sought immediately. We recognise Mrs P was taken to a local hospital and provided a brain scan to determine if she had experienced a stroke. It was confirmed at the hospital Mrs P had not suffered a stroke, but her condition was sadly such that she was admitted as an inpatient to the end-of-life ward.

53. While we recognise Mrs P did not suffer a stroke at the Care Home, we consider there were indications Mrs P was not well through the day on 20 September. Adviser B noted when Mrs P began to decline meals, this was a cause for concern. Adviser B explained declining meals is not an emergency but should have prompted the Care Home to contact Mrs P’s GP for a more complete review.

54. Adviser B explained many older people experience a decrease in appetite and a decline in appetite can lead to frailty, falls, hip fracture, pressure ulcers, a poor immune function and a reduction in quality of life.

55. Adviser B explained when a person declines meals, a nurse should consider what the cause might be. This is in line with the NMC Code of Conduct which says nurses must accurately identify, observe and assess for signs of worsening physical health in the people they are looking after, making a timely referral to another healthcare professional when any action, care or treatment is required.

56. Adviser B explained when Mrs P began to show signs of deterioration, which we consider to be declining meals at lunchtime, the Care Home should not have continued to feed Mrs P without taking steps to monitor, review and consider if it was appropriate to take further action such as contacting a GP. There is no evidence in the clinical records this was done.

57. Mrs P declined one meal during the day and later, following a staff handover, had declined dinner. Having taken into consideration the Care Home’s investigation interviews it is possible this information was passed over during a verbal handover but as it is not detailed in the records, we are unable to confirm this. We would expect this to be detailed in the records, in line with NMC standards on record keeping.

58. We have also seen inconsistencies in the notes of the Care Home’s investigation interviews where it says Mrs P’s dribbling was detailed in the handover between day and night staff. The phrasing implies this was a written handover though we have seen no written handover in the records.

59. Despite a decline in health, we understand the Care Home continued to provide Mrs P with thickened fluids. We understand this was raised a cause of concern in the Paramedic report and by the information provided to us by Mrs R. Mrs R believes the Care Home’s continued attempts to provide food and drink caused Mrs P to develop aspiration pneumonia.

60. On review of hospital records we have seen no evidence Mrs P had aspiration pneumonia when she was admitted to hospital. Adviser A referred to the paramedic record which described normal respiratory effort and clear chest examination.

61. Adviser A considered it was more likely Mrs P developed aspiration pneumonia during her hospital admission due to her underlying health conditions.

62. We recognise the distress caused to Mrs R by believing her mother’s deterioration could have been prevented. However, based on the available evidence, we are unable to conclude that the Care Home’s actions caused Mrs P’s aspiration pneumonia.

63. We consider, on balance of probabilities that poor record keeping and the failure to record concerns of Mrs P’s declining condition clearly and contemporaneously also meant the emergency services and family were not involved at an earlier point in the day.

64. We consider this will have resulted in Mrs R experiencing significant distress and worry to see her mother in distress and to not understand the circumstances of how that happened because of the conflicting accounts.

Complaint Handling

65. Mrs R complains the Care Home’s handling of the complaint was poor. She says the final response did not reflect the details given by the on-duty nurse and detailed in the safeguarding report by Local Authority.

66. Mrs R complains the response included incorrect details of the events on 20 September 2022 and incorrectly spelled Mrs P’s name. Mrs R noted it was insulting for the Care Home to refer to Mrs P by her initials throughout its response.

67. We have considered the Care Home’s response and information provided in the complaint file.

68. We can see Mrs R raised a complaint on 31 January 2023. The Care Home stated it would provide a response within 14 days. Mrs R emailed on 20 February 2023 requesting an update. The Care Home responded the same day and advised it was still in the process of investigating the complaint and agreed to provide a response by 28 February 2023.

69. On 27 February 2023, the Care Home emailed Mrs R and explained it would need an additional week to complete the investigation and consider all information, including the recent information provided by Mrs R. It said it would provide a response by 6 March 2023. On 6 March 2023, the Care Home provided a final response.

70. On 9 March 2023, Mrs R contacted the Care Home regarding the final response. She explained she was unhappy with the abbreviation of Mrs P’s name and the discrepancy of details between the Care Home’s final response and the safeguarding report issued by Local Authority. She requested her concerns were escalated to a more senior member of staff.

71. On 10 March 2023, the Care Home said it had escalated her concerns, but the member of staff was on annual leave and would respond on their return. The Care Home provided Mrs R with our details if she remained unsatisfied.

72. On 17 April 2023, the Care Home apologised for the abbreviation used for Mrs P in the final response and explained this was normal practice and not intended to cause upset. The Care Home reiterated there were no discrepancies and that all details in the final response had been ‘double-checked’ against its records.

73. We understand the Care Home is not NHS organisation however, it is an independent provider who provides health care in England under arrangements made with an NHS body and as such it is governed by NHS Complaint Regulations.

74. The NHS Complaint Regulations say an organisation should respond to a complaint in writing within a reasonable period. The reasonable period is defined as six months from the day the complaint was received or if longer, with agreement of an extension with the complainant before the expiry of the six months.

75. We appreciate the frustration Mrs R experienced and recognise she had to chase a response from the Care Home however, we have found no indication of delay as the Care Home was within the timeframe set out in the NHS Complaint Regulations.

76. Mrs R also complains about the content of the Care Home’s final response.

77. We have looked at the Care Home’s response. We consider the abbreviation to be a shortcoming and recognise this would have been insensitive to Mrs R during her bereavement.

78. We have applied our Principles of Good Administration. Our Principles of Good Administration say organisations should be customer focussed. This includes communicating effectively, and using clear language people can understand which is appropriate to them and their circumstances. We would expect organisations to treat complainants with sensitivity, bearing in mind their individual needs, and respond flexibly to the circumstances of the case.

79. We consider the Care Home’s use of initials to be a shortcoming. We consider this was a single incidence where the Care Home’s response fell short of the expected standard but not so far as to be considered a failing. We consider this was put right by the apology Mrs R received on 17 April 2023.

80. Mrs R also says the Care Home’s recollection of the events on 20 September 2022 differ from her own account and the detail in Local Authority’s safeguarding report. Mrs R does not feel the final response provided by the Care Home is an open and accountable response.

81. We consider this concern is linked to the wider issues identified with the Care Home’s record keeping and management of Mrs P’ deterioration.

82. We have determined that the Care Home’s records did not provide a complete account of events. As a result, the complaint response was based on incomplete information and as such we consider this a failing.

1. Mrs R complained about the care and service a Care Home in the Luton Area (the Care Home) provided to her mother, Mrs P, on 20 September 2022. She believes that if the Care Home had acted sooner, it may have changed her mother’s outcome. We were deeply sorry to hear of the circumstances leading to the death of Mrs P. We recognise the profound and lasting impact of losing a loved one.

2. We consider the Care Home did not adequately record concerns about Mrs P’s condition. On the balance of probabilities, we consider that this led to the Care Home continuing to provide her with food and drink despite her declining appetite and failing to contact emergency services or her immediate family in a timely manner. We believe this contributed to significant distress and worsened the bereavement experienced by Mrs R and her family.

3. We consider the Care Home’s response to Mrs R’s complaint was not fully accurate, as it relied on clinical records that were inconsistent and did not meet professional standards. The inadequate complaint handling further worsened the family’s bereavement by leaving them with unanswered questions about Mrs P’ care.

4. Mrs R raised concerns that the continued feeding of her mother contributed to her developing aspiration pneumonia, which was her ultimate cause of death. While we do not underestimate the distress caused to Mrs R and her family, we found no evidence to directly link the Care Home’s actions to her mother’s cause of death.

5. After careful consideration of all available evidence, we partly uphold Mrs R’s complaint. We found failings in record keeping, communication with the family, and the timeliness of escalation to emergency services, as well as shortcomings in complaint handling. These failings worsened a traumatic event and prolonged Mrs R’s bereavement.

6. We are recommending that the Care Home apologise to Mrs R, pay her £600 in recognition of the injustice caused, and implement an action plan to address the failings identified. This should include improving record keeping practices, enhancing communication with families, and ensuring more robust complaint handling processes.

83. We make recommendations in line with our Principles for Remedy which are reflected in the NHS Complaint Standards. These say organisations should identify instances where things have gone wrong, take responsibility for these and find ways to put things right for those involved. They should learn from complaints to improve services.

84. We expect organisations to take action to compensate people appropriately if they cannot return them to the position they would have been in if the poor service had not occurred. In some cases, a financial remedy will be required. To decide on a level of financial remedy, we review similar cases where the person has experienced a similar injustice, along with our severity of injustice scale.

85. We have identified failings in relation to the Care Home’s record keeping, communication with Mrs R and her family, and the timeliness of contacting emergency services. We also found the Care Home’s complaint handling to be inadequate, relying on clinical records that were inconsistent and did not meet expected professional standards.

86. We consider this led to Mrs R and her family significant distress, frustration, and uncertainty. They contributed to a prolonged traumatic event and worsened her bereavement process, as the family was left without clarity about the circumstances leading to Mrs P’s death.

87. With that in mind, we recommend that following this final report the Care Home: • Provides a clear and meaningful apology for the failings we have identified which acknowledges the distress, uncertainty, and frustration these failings caused Mrs R and her family. This should be completed within three months of the date of this report.

• Pays Mrs R £600 in recognition of the avoidable distress, uncertainty, and frustration caused by the failings in record keeping, communication, and complaint handling. The Care Home should make this payment within three months of the date of this report.

• Produces an action plan within three months of the date of this report to address the failings identified, with a focus on record keeping, communication with families, and complaint handling. We would like to see significant focus on training staff to maximise the use of the Care Home’s software for record keeping preventing this situation from happening again.

This action plan should include: • The reasons behind the failings (where possible).

• The learning taken and what steps will be, or have been, taken to prevent recurrence.

• Who is responsible for each action, the timescale for completion, and how progress will be monitored.

88. The Care Home should send us evidence it has completed all of the recommendations we have made. We will check the action plan includes the reason for the failing (where possible), what the Care Home does or will do differently in future, who is responsible for each action, the timescale for completion, and how it will be monitored.