Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately manage her mother’s skin integrity, leading to the development of a grade 4 pressure sore, and failed to inform the family that Mrs B had developed this level of sore. Similarly, Mrs A raised concerns that the Care Home did not recognise that her mother was at the end of her life and provide appropriate nursing care, or provide clear communication with the family on this matter. Mrs A also complained that the Health Board, which had funded Mrs B’s stay at the Care Home, had failed to provide appropriate oversight of her mother’s condition while she was a resident. In addition, Mrs A raised concerns about the Health Board’s handling of her complaint. Lastly, the investigation considered Mrs A’s complaint that her mother’s GP Surgery failed to carry out appropriate consultations with Mrs B in July 2021 (which included the prescription of primidone) and so had been unaware of her deteriorating condition.
The Ombudsman found that there was a lack of clear direction in managing Mrs B’s pressure areas at the Care Home and that it was not clear whether the referral to the Tissue Viability Team had been made in a timely way. Although the Ombudsman could not conclude that the later development of Mrs B’s grade 4 pressure sore was avoidable, there were lost opportunities to maximise the effectiveness of Mrs B’s pressure area care. Furthermore, the Ombudsman found that it did not appear that staff at the Care Home had recognised the grade of pressure sore, and so by extension did not fully inform Mrs B’s family of the severity of it. As a result, the Ombudsman upheld these aspects of Mrs A’s complaint. The Ombudsman also found that whilst staff recognised that Mrs B was possibly nearing the end of her life, her deterioration had not been comprehensively recorded within the care plans and there was a lack of detail in the advanced care planning for final days. Although the investigation found that staff had made Mrs A aware of the possibility that her mother was nearing the end of her life, there was also evidence of avoidable “mixed messages” to Mrs B’s family. The Ombudsman also upheld these aspects of Mrs A’s complaint.
The Ombudsman did not consider that the Health Board failed to provide oversight of Mrs B’s condition in the final weeks of her life, as it had not been made aware of her rapid deterioration. However, there were some deficiencies in more general follow-up with the Care Home. To that limited extent, the Ombudsman upheld this aspect of Mrs A’s complaint. The Ombudsman did not uphold Mrs A’s complaint about complaint handling.
Lastly, with regard to the complaint against the GP Surgery, the Ombudsman found that 3 of the consultations carried out by Mrs B’s GP in July 2021 were not within the range of appropriate clinical practice. In particular, the Ombudsman found that the GP failed to make an entry to document his rationale for the prescription of primidone to Mrs B or to demonstrate that an adequate clinical assessment had taken place. The Ombudsman concluded that the prescription was an unreasonable one to make, given the risk of interactions with Mrs B’s other medications and the possible side effects, and one which had potentially serious consequences, the uncertainty of which was a significant injustice to Mrs B’s family. The Ombudsman also found that the GP failed to recognise that Mrs B was possibly reaching the end of her life in late July, and that inappropriate reassurance had been given to Mrs A. As a result, the Ombudsman upheld the complaint.
The Ombudsman recommended that the Care Home apologise to Mrs A for the failings identified by the investigation and to share the report with staff to reflect on its findings. The Ombudsman also recommended that the Care Home provided evidence of the recent training that had been provided to staff relating to end of life care and its implementation plan to roll this training out to other staff in the Care Home. Similarly, the Ombudsman recommended that the Health Board and GP Surgery also apologise to Mrs A. In terms of the latter, the Ombudsman recommended that the GP discussed this case at their next appraisal and provide evidence of the discussion with their appraiser, while the Health Board was asked to ensure that appropriate follow-up takes place in situations where appointments are postponed or if discrepancies are identified.
Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately manage her mother’s skin integrity, leading to the development of a grade 4 pressure sore, and failed to inform the family that Mrs B had developed this level of sore. Similarly, Mrs A raised concerns that the Care Home did not recognise that her mother was at the end of her life and provide appropriate nursing care, or provide clear communication with the family on this matter. Mrs A also complained that the Health Board, which had funded Mrs B’s stay at the Care Home, had failed to provide appropriate oversight of her mother’s condition while she was a resident. In addition, Mrs A raised concerns about the Health Board’s handling of her complaint. Lastly, the investigation considered Mrs A’s complaint that her mother’s GP Surgery failed to carry out appropriate consultations with Mrs B in July 2021 (which included the prescription of primidone) and so had been unaware of her deteriorating condition.
The Ombudsman found that there was a lack of clear direction in managing Mrs B’s pressure areas at the Care Home and that it was not clear whether the referral to the Tissue Viability Team had been made in a timely way. Although the Ombudsman could not conclude that the later development of Mrs B’s grade 4 pressure sore was avoidable, there were lost opportunities to maximise the effectiveness of Mrs B’s pressure area care. Furthermore, the Ombudsman found that it did not appear that staff at the Care Home had recognised the grade of pressure sore, and so by extension did not fully inform Mrs B’s family of the severity of it. As a result, the Ombudsman upheld these aspects of Mrs A’s complaint. The Ombudsman also found that whilst staff recognised that Mrs B was possibly nearing the end of her life, her deterioration had not been comprehensively recorded within the care plans and there was a lack of detail in the advanced care planning for final days. Although the investigation found that staff had made Mrs A aware of the possibility that her mother was nearing the end of her life, there was also evidence of avoidable “mixed messages” to Mrs B’s family. The Ombudsman also upheld these aspects of Mrs A’s complaint.
The Ombudsman did not consider that the Health Board failed to provide oversight of Mrs B’s condition in the final weeks of her life, as it had not been made aware of her rapid deterioration. However, there were some deficiencies in more general follow-up with the Care Home. To that limited extent, the Ombudsman upheld this aspect of Mrs A’s complaint. The Ombudsman did not uphold Mrs A’s complaint about complaint handling.
Lastly, with regard to the complaint against the GP Surgery, the Ombudsman found that 3 of the consultations carried out by Mrs B’s GP in July 2021 were not within the range of appropriate clinical practice. In particular, the Ombudsman found that the GP failed to make an entry to document his rationale for the prescription of primidone to Mrs B or to demonstrate that an adequate clinical assessment had taken place. The Ombudsman concluded that the prescription was an unreasonable one to make, given the risk of interactions with Mrs B’s other medications and the possible side effects, and one which had potentially serious consequences, the uncertainty of which was a significant injustice to Mrs B’s family. The Ombudsman also found that the GP failed to recognise that Mrs B was possibly reaching the end of her life in late July, and that inappropriate reassurance had been given to Mrs A. As a result, the Ombudsman upheld the complaint.
The Ombudsman recommended that the Care Home apologise to Mrs A for the failings identified by the investigation and to share the report with staff to reflect on its findings. The Ombudsman also recommended that the Care Home provided evidence of the recent training that had been provided to staff relating to end of life care and its implementation plan to roll this training out to other staff in the Care Home. Similarly, the Ombudsman recommended that the Health Board and GP Surgery also apologise to Mrs A. In terms of the latter, the Ombudsman recommended that the GP discussed this case at their next appraisal and provide evidence of the discussion with their appraiser, while the Health Board was asked to ensure that appropriate follow-up takes place in situations where appointments are postponed or if discrepancies are identified.