Case Studies

Please be aware the account told in this case study is very distressing. As a responsible organisation all documentation and reports to date in this case have been viewed by Care Campaign for the Vulnerable. We are fully supporting the family

''My 92 year old Mother lived independently in her own home until 10 March 2019. She was happy, content and had good cognition. Mum was an avid birdwatcher and would sit most days watching the antics of the birds in her garden. She was outside putting food onto the bird table when she fell over, broke her left hip and suffered a heart attack. Her neighbour called me and my husband and I rushed to her home just as the ambulance arrived. She was taken to A&E and the next day to a ward where she spent eight weeks. Due to the condition of her heart, doctors were reluctant to operate on her hip which remained un-united requiring her to be nursed in bed.

Because of my Mother’s fluctuating health, the hospital viewed her as a ’bed blocker’. The hospital was desperate to get her discharged into a Nursing Home as soon as possible. As her daughter and primary carer for 23 years with full LPOA and EPOA, I know that she was very upset by this as she wanted to go home. I had many discussions with the doctors as I didn’t feel that she well enough to be discharged, sadly all to no avail. In fact, I overheard the Charge Nurse on the ward say something like ‘let’s get her out before something else happens’. The alarm bells started ringing for me early on. It was decided that Mum may be eligible for NHS Continuing Health Care so a Checklist was conducted at the hospital where she scored highly. During this time, the family were under constant and considerable pressure to agree to a nursing home placement, even though we were only offered two Nursing Homes to view. We received constant telephone calls from the hospital discharge team and the Clinical Commissioning Group (CCG). On one occasion as many as five calls in one day. We found this totally unnecessary as it put a lot stress on the family at such a difficult time.

''My mother told me she was suicidal...''

Photo published with permission of family

One morning, I received a telephone call out of the blue from the Manager of a Nursing Home to say that they had been asked by the CCG to accept Mum. She called me as she felt it was only right that I was made aware. However, it was made quite clear that I had no choice in the matter. I visited the Nursing Home the next day and agreed on the placement as the room they offered was on the ground floor and looked out onto a nice garden.

Mum was discharged to the Nursing Home on the 1 May 2019 on a 28 day Placement without Prejudice basis. I visited my Mother the next day and was shocked to find her eating her lunch in a dirty top and wearing nothing else but a continence pad. There was food over the bed covers. To me this was a very worrying sign and I was really annoyed. My mother was always dressed clean and tidy and would never have worn soiled clothing. She had difficulty expressing herself and was very confused. I remember that she looked quite frail and tired. This was to be the start of my concerns over the quality of nursing care my mother would receive during her short time at the Nursing Home. In the coming weeks, I often found her lying in bed talking to herself and completely uncovered with the sheets balled up.

My Mother also had other health issues such as Diabetes, Atrial Fibrillation, Gout and Osteoarthritis to name but a few. More importantly Mum had a long history of anxiety and depression stretching back over 40 years. As time went on, I was becoming increasingly worried that she was showing signs of depression. At times it seemed she was hallucinating and she spoke as if her mum and dad were still alive. She began to refuse her medication at times and became fussy over food, something that she would never normally have done. She had difficulty in swallowing her food and she couldn’t hold her cutlery because she had gout in her fingers. I asked for help for her at mealtimes when I wasn’t there which was met with a mixed response. Mum became very drawn, gaunt and looked thin and in fact in the 12 weeks she was at the Nursing Home she lost 6.2kg. I felt Mum was in a difficult situation as I realised that the care she was receiving wasn’t what I had expected from a Nursing Home. I really thought I had made a big mistake in agreeing to the placement but then I was given no choice.

''My mother told me she was being handled roughly during personal care.''

My mother wanted to receive personal care from female staff only. This I reiterated in her Care Plan. However despite this, male carers were used regularly with the excuse that there was a lack of staff. Mum used to get really upset by it and I was left to constantly remind the staff to use female carers only. They either said no one was available or that they were too busy.

In the first few days, I was told that the staff had hoisted Mum onto the commode. I had already told the Nursing Home not to attempt this as it was far too painful for her, something we knew from her stay in the hospital. Mum complained of the pain so staff said she would have to wear pads instead. This caused another problem with identifying UTI’s as staff often told us that it was difficult to get a sample to test as she was wearing pads. No surprise then when they told me that she was suspected of having a UTI within days of arriving. Mum also had the most dreadful, sore, painful and sometimes bleeding genital moisture lesions and a grade 2 sacral pressure sore. We have photographic evidence of when her incontinence pad was ripped up and thrown on the floor, left for hours for me to have to clean up when I visited. At the core of this, is her right to be treated with dignityand respect. My Mother was never afforded this right.

My Mother was being roughly handled and she told me so many times. I even started to doubt whether she was telling me the truth but then I started to notice the odd bruise on her right arm and her right leg (the un-injured leg). I noticed that these bruises increased in number over the weeks. When I asked the Nursing Home about them I was told it is because she is on Warfarin. I wasn’t convinced. On one occasion, I decided to stay in Mum’s room when the staff gave her personal care despite the staff using excuses as to why I should leave. I personally witnessed my Mother being grabbed by her wrist and her lower leg and dragged over onto her broken hip without any care or consideration.

'' She cried out in pain asking the staff to go gently. This would explain the grip marks and serious bruising to her arms and lower un-injured leg.''

I visited my mother every day as she was isolated, left alone in her room without any social interaction from staff or residents. The staff told me they were too busy to chat to her and would glance in on her as they were passing her room. To be honest, I was really worried about her and I started to become increasingly concerned about her welfare and care. For example, I noticed that the call bell was often left out of reach, placed on the cradle on the wall behind her bed or, when it was available, Mum told me it took ages for staff to respond. Relatives of other service users at the home would alert us to the fact that they heard my Mother shouting and banging her table to attract attention. I spoke to her allocated nurse who placed a notice on the wall stating to put the call bell within reach. We have photographs where the call bell was repeatedly left on the wall next to the notice!

Another worry was that her water jug was often left empty, out of reach and one occasion I even found it in the draw of her bedside cabinet. We mentioned this to the care staff time and time again but it simply made no difference. There was no acknowledgement of the problem by the staff. During her time at the Nursing Home, she had several bouts of urinary tract infections probably because she wasn’t able to drink enough fluids. Over the next few weeks, my mother became increasingly depressed and upset and would cry when I visited. She kept saying she wanted to go home and that she was so fed up. She started to cuddle up to the net curtains which were by her bedside which alarmed me. When staff did come into the room to check her, I noticed that my mother did not engage with them but looked away towards the wall. During the first few weeks, she was occasionally dressed in other people’s clothes. When I complained about this I was told that the Home was in the process of sorting her name tags out.

'

My Mother was subjected to four bare walls day in and day out. Her TV was often left on with the sound turned down and or the remote left out of reach. Even the CD player we bought for her was mysteriously broken within a matter of days. She was only ever put out into her chair five times in the three months she was there. Mum told me she didn’t want to sit out in her chair as she found it too painful. I wasn’t surprised when I found out that her pain management was simply paracetamol(something I later demanded to be changed to Oramorph). On 23 May, the duty Nurse told me that she needs one to one supervision in her chair as she was at a high risk of falls but it couldn’t be provided. So the Nursing Homes’ answer to this problem was to tell me to let them know when I was to visit and they would put her in her chair for me to supervise. I explained I couldn’t possibly be tied down to this kind of arrangement. So the Home didn’t bother to put her out in her chair at all but simply left her lying in bed. The family’s concerns over her isolation were completely ignored. My mother was becoming increasingly depressed and said that she didn’t want to be ‘here’ anymore.

We have also included the photo of the unexplained wound on her injured leg. Bear in mind that the wound was caused on 29 June and remained covered until we took the photo on 24 July. The CPN told us that it would have been deep when it was caused. The GP had no knowledge and commented in his notes that Mum may have fallen out of bed but nobody has told us how this happened to this day. The CQC was only informed on 15 August. So much for submitting the notification without delay.

I have serious doubt over whether there was proper and safe management of my Mother’s medication and in particular, her warfarin. On 3 June 2019 at 18:30, I received a call from my Mother’s GP Surgery to say that her INR level was well above 8 and that she needed to be taken to A&E immediately but the surgery couldn’t contact the Nursing Home. I telephoned the Home and eventually spoke to the duty nurse, who told me she didn’t know what to do as the family’s wishes were not to send her to hospital unnecessarily yet the GP said she must go. I didn’t hesitate. I told her if the GP said she needed to go, she goes. I met my Mother at A&E. She was given a 5mg vitamin K injection. She was placed in the Clinical Decision Unit overnight for observation. In all the years that I supervised my Mums warfarin at home, I had never known her INR level to go above 3.7. I have recorded in our contemporaneous notes, that on one visit I found a blue warfarin tablet in the back of her mouth. I remember from my notes, that on 6 July 2019, I was asked if I could go and pick up some cream for her moisture lesions prescribed by the out of hours GP because she was in so much pain. I collected it from the local chemist because the staff didn’t have the time to get it and it would otherwise have taken days. On Friday 28 June, my Mother told me that the dietician had been to visit her because of her weight loss. Mum told me she was so fed up she that felt suicidal. I was shocked to hear this, she had never said such a thing to me before. I was so concerned I asked Mum to repeat this to the Duty Nurse in front of me which she did. I told the Nurse I wanted it recorded in my Mothers records. I have never seen this mentioned anywhere.

On Saturday 29 June, at 18:20 the duty nurse called me at home. She told me that Mum had tried to get out of bed and in doing so had got the call bell wire caught around her left leg which had caused a wound. I was obviously concerned but I was assured Mum was settled and fine and that a visit to the Nursing Home was unnecessary. The Nurse went on to tell me that she had removed the call bell so in future Mum would have to shout for help instead. I was taken aback by this and it didn’t sink in at the time as my mind was in turmoil.

I visited Mum the following day and found her without a call bell. She had a large dressing on her lower broken leg which was soaked in blood and fluids and was leaking onto the sheets. Mum was really pleased to see me. I had a conversation with her allocated nurse who assured me that they were looking after the wound and were changing the dressing regularly. Nothing was mentioned about the incident the previous evening. They continued to dress her wound for over four weeks.

In the following days a relative of another resident pulled me to one side and told me that he often hears my Mother shouting for help or banging on the table. A friend visited mum and she was disgusted that mum was left without any means to call the staff and told meso in no uncertain terms. I agreed with her but what could I do. I didn’t want to make a fuss which may have come back onto my Mother. I was in a very difficult situation trying to keep the equilibrium.

A meeting to decide who would be paying for Mums care was scheduled for 19 July 2019. Together with us at the meeting would be two Nurses from the CCG, a Social Worker and a Nurse representing the Nursing Home. The family had the services of an advocate to represent us as the process is very complicated. On the previous afternoon of 18 July, our advocate went to the Nursing Home to look at the records they kept of my Mothers care. It appeared that many records were missing from the ones that she would have expected to see. In particular, our advocate asked the Nursing Home to produce Behaviour Charts as there were none offered. Not even one explaining the June incident where she hurt her leg.

On the day of the meeting, we arrived early to find our advocate had already arrived. She told my husband and I to come into the meeting room and take a seat as she had something serious to show us. She then presented me with three behaviour charts, two of which covered the incident on 29 June 2019. What I read was truly shocking. I quote, ‘Carers heard a bang as if something had fallen – on getting to her room, her table was sideways on the floor and she was found with the call bell cable/wire around her neck which was knotted.’ Another area of the chart states, ‘The cable was removed/unknotted with the help of 8 staff which included the nurse.’ I was speechless. I showed it to my husband as it was clear that we had been deliberately misled by the account given to me by the nurse on the telephone in June.

We now had a very serious safeguarding issue on our hands because nobody could account for how the serious wound on my Mother’s broken leg had been caused. I now felt everything that had been going on had now fallen into place. We also discovered that the GP had not been informed, no risk assessments were undertaken and more importantly, her room had not been made safe. Following this disclosure and despite our objections and upset, we were forced to go ahead with the meeting which we did for fear of losing any of her funding. Afterwards, our advocate told us that it was the worst Assessment meeting she had ever taken part in her 25 years. As we now know the only action taken on the day of the incident was to remove her call bell. We also know that the staff including the duty nurse did not treat or acknowledge that my Mother had attempted suicide, something that other medical professionals from outside the Nursing Home made comment on later. This deception sealed our opinion that we now had absolutely no confidence or trust in the Nursing Home.

'' I truly believe that the treatment my Mother suffered during her residency at the Nursing Home significantly contributed to her feeling of fear and anguish, her persistent low mood which probably led to her attempted suicide.''

We, the family raised the safeguarding issue ourselves and subsequently called the Police. An investigation was undertaken by the CCG who was responsible for placing her in the Nursing Home. However, her poor care continued. Having spoken to my Mother about all of this, she asked me to move her from the home as she didn’t want to stay there. She was frightened over possible reprisals, as were the family. On the same day, I spoke to the GP who agreed with me that she should be moved as soon as possible. This was further reinforced by the Social Worker who made the unannounced visit on 22 July, the Community Psychiatric Nurse during her visit on 24 July and the Consultant Psychiatrist during her visit on 25 July. Despite being assured by the CCG that they were looking for alternative placement, the family subsequently learnt that the CCG had absolutely no intention of moving her and failed to inform the family of their decision. I was absolutely furious and appalled when I found out.

During the unannounced visit made by the Local Authority social worker on 22 July in response to the safeguarding, it so happened that my husband and I were visiting my Mother. Thank goodness that this was one of Mums good days as she was able to explain to the social worker that she was being roughly treated and that she feared reprisals for being labelled a troublemaker. The social worker also noted that on one of the hottest days in July that year she had no means of hydration in her room. She also noted that Mum told her that she didn’t like it at the Nursing Home or the male carers performing personal care. On leaving the Nursing Home we bumped into the social worker on her way out. She told us that she had serious concerns about what she had discovered and the lack of proper records.

The Nursing Home did not ensure that they undertook appropriate timed checks for her safety and to reduce isolation even though they had been instructed to by the consultant Psychiatrist. 15-minute checks were requested but the home could only manage every 30-45 minutes (as recorded on her records) using the excuse of a lack of staff. Even after the visit and recommendations by the Consultant, I found my Mother using metal cutlery as opposed to plastic and the bed remote control cord was left back on the side of her bedrail within easy reach. A pen was left within reach of her bedside cabinet. All contrary to her risk assessment. On Sunday 28 July 2019, one of my final visits to Mum before she passed away, I noticed that she had dropped tea in her bed. She was struggling to prop herself up as the staff had left her lying flat which she didn’t like as it affected her breathing. The bed control which had a long curly lead was still clipped on the side of the bed. Mums breathing seemed laboured and she told me that she didn’t have the strength anymore. I told the nurses that I wanted an ambulance called if Mum had difficulty breathing and became distressed.

On Wednesday 31 July 2019, I visited my Mother her breathing was laboured with periods where she seemed not to be breathing. She didn’t know I was even in the room. I went straight out of the room to call the nurse in and asked for an ambulance to be called immediately. The ambulance arrived within minutes and the paramedics asked the nurse if the end of life meds were written up. She said that they were and she was admonished for not administering them earlier as my mother was in the final stages of life. They were administered straightaway. The paramedics stayed in the room for an hour to make sure Mum had no reaction to the medication and then waited outside whilst writing up their notes. They were wonderful at such a difficult time. I was left distraught at how my Mother had been left so long in such a distressing way. On Saturday 3 August my Mother passed away in the Nursing Home. The last two weeks of her life were filled with fear over the way she was being treated. I and the family were so worried for her safety that we visited at least once and sometimes twice a day. What a terrible way to spend the last days of your life trapped in a place and unable to escape.

My Mother had complex needs and in my opinion, should never have left the hospital let alone been referred to this particular Nursing Home. According to the Care Quality Commission (CQC), this Nursing Home is not a service that specialised in supporting people with enduring mental ill-health. As such, the staff were not trained to identify or respond to serious incidences of mental ill-health. Bearing this in mind, I do ask myself why did the CCG refer her to this Nursing Home and/or why did the Nursing Home agree to accept her knowing her mental health history. I wonder, was it because she could have been a self-funder?

'' A Safeguarding Vulnerable Adults Review meeting was held on the 27 August 2019, Chaired by the Head of Adult Social Services where it was agreed by all attendees that harm had occurred.''

This has had a massive impact on me knowing that my mother was abused and neglected in her final weeks. I have been left traumatised and utterly bereft wondering whether I could have done more. I am still trying to come to terms with what has happened. To this day, I have trouble sleeping, waking in the early hours and ruminating over the whole dreadful affair. There has been no offer of any form of support or counselling. With some exceptions, many of the staff at the Nursing Home appeared completely dehumanised when providing care and were lacking kindness or compassion. I would go further to say that in my and the family’s opinion the Nursing Home and the CCG is egregious in every respect. As I have stated at the beginning of my Mothers story, the family had full LPOA and EPOA. In our particular experience the Hospital, CCG and Nursing Home completely ignored and rode roughshod over us when it suited them and regardless of our rights. To date there has been no acceptance of any responsibility or accountability on the part of any individual or department over the way that my Mother and the family have been treated. At every point, I found that doors are slammed closed. The family have been treated in a totally uncompassionate and disrespectful way and without any conscience whatsoever.

Writing this and recalling the events and contemporaneous notes fills me with such sorrow and fills my eyes with tears over the treatment my mother endured. Our fight continues for justice and accountability for my Mother.''

Care Campaign for the Vulnerable is fully supporting this family. We have seen all investigation reports and is still ongoing. If you are interested in this case study please contact ccftv.cares@gmail.com