Report Date


Case Against

Swansea Council



Case Reference Number



Upheld in whole or in part

Mrs A complained about the care and treatment that Mrs X received at the Care Home between February and March 2017. Mrs X was unable to make decisions about her treatment and care arrangements. Mrs A complained that the Care Home failed to treat Mrs X’s chest and urine infections, failed to notify the immediate family she was seriously ill until it considered she was going to die, misdiagnosed her, withheld treatment, food and fluid, actively encouraged the family to let her die and failed to notify social services of the aforementioned.

The investigation found that it was appropriate for the Care Home to rely on the diagnosis and treatment plan formulated by the GP. Appropriate attempts were made by the nursing staff to administer treatment in accordance with the instruction of the GP and any omissions were a consequence of safety concerns. Timely contact was made with the immediate family, appropriate updates were given and their concerns were relayed to the GP. The Care Home did not withhold food and fluid however due to the lack of documentary evidence, the investigation could not determine whether the amounts offered were appropriate to meet her dietary needs and so this aspect of the complaint was partially upheld. There was no evidence to suggest that the Care Home staff “actively encouraged” the immediate family to let Mrs X die; rather an accurate and frank description of the clinical situation and advice was given. There was no contractual obligation for the Care Home to keep social services updated unless there were safeguarding concerns.

The Care Home agreed to provide Mrs A with an apology for the failings identified. It also agreed to undertake an audit and any action necessary in response to the audit findings to ensure compliance with the completion of approved electronic fluid and food charts.

Mrs A complained about the primary care service provided to Mrs X by the GP Practice. In particular, the appropriateness of the assessments and investigations undertaken, the diagnoses made and the treatment plan devised between 1 March and 3 March. Mrs A also complained about the communication around Mrs X’s acute condition, the decision not to admit her to hospital for the administration of intravenous fluids and antibiotics, the decision that she was not for resuscitation in the event of a cardiac arrest (”DNACPR”) and the consultation held prior to that decision being made.

The investigations found that the assessments, investigations, diagnoses and treatment plan (including the decision not to admit Mrs X to hospital) were all appropriate. It is usual practice for staff within care homes to liaise with relatives about the clinical status of residents unless there are questions that the family need addressing. The GP provided the family with a timely and accurate update of Mrs X’s condition. Although, clinically, the rational for the enactment of a DNACPR was appropriate, the GP did not comply with the requirements of the Mental Capacity Act or the General Medical Council Guidance on Consent and the views of the appropriate people were not sought; this aspect of the complaint was therefore upheld.

The GP Practice agreed to provide Mrs A with an apology for the failings identified and provide the GP (who had since left the GP Practice) with a copy of the report, drawing his attention to the failings and recommendations. The GP Practice agreed that all clinicians involved in the complaint would reflect upon the matters raised in relation to the DNACPR decision making process and ensure that they are fully appraised of the updated national guidance and policies.
Mrs A also complained about the actions of the Council. Mrs A said that the Council did not follow the relevant policy and procedure when it undertook a Protection of Vulnerable Adults (“POVA”) investigation, and that it should have taken the family’s concerns regarding the care and treatment of Mrs X into consideration when making a best interest decision about Mrs X’s long-term placement.

The investigation found several, serious failings in the manner that the POVA investigation was undertaken. It found that it was reasonable that the family’s unsubstantiated concerns were not considered as part of the best interest decision.

The Council agreed to provide Mrs A with an apology for the failings identified. Prior to the finalisation of the investigation, the Council provided evidence of its training schedule for staff leading the Safeguarding Process (formally POVA).