Shropshire care provider pays compensation to family of dementia patient left 'famished'

The same provider, Morris Care, has also been ordered to review its approach to preventing falls-related injuries, following a separate case in which provisions were not made for a resident assessed as being at high risk of falls.

The Local Government and Social Care Ombudsman found Morris Care to be at fault in both cases and upheld complaints made by the families of the two women.

Details of the incidents, which happened in August 2019 and December 2017 respectively, have now been revealed following the conclusion of the investigations.

In the first case, a woman, named only as Mrs C in the ombudsman’s report, was recorded as having lost 10kg in weight following a two-week respite stay at one of the company’s homes. Mrs C, an elderly woman with dementia and other health conditions, was not re-weighed to check the discrepancy.

She had also missed doses of her medication as the care home had noticed not enough had been provided but failed to collect more before it ran out.

Mrs C was collected by her daughter and carer, who were concerned about her presentation and later complained that she, “was dehydrated, constipated, appeared famished, had insufficient clothing on, was soaked in urine, possibly had an infection and her medication did not correspond to the correct day”.

She was admitted to hospital with signs of an infection and died 10 days later.

The report said: “I cannot conclude that the care provided by the home contributed to or caused Mrs C’s death. Neither can I conclude that failings by the home caused such dramatic weight loss.

“The records show that in the main Mrs C ate and drank well throughout her stay and was supported to eat. No concerns were raised about her intake or presentation.

“However, neither can I dismiss her daughter’s account, supported by the carer, of Mrs C’s condition when she returned home and the uncertainty this created, given the timing of her deterioration.

“The care provider has acknowledged such a weight discrepancy should have been checked and investigated at the time. I agree that the failure to do this was fault, which caused the family uncertainty at a very distressing time.”

The ombudsman ordered Morris Care to pay £250 compensation to the family and “ensure that significant weight discrepancies are investigated immediately”.

In the second case, a woman named as Mrs X moved into Stretton Hall nursing home in All Stretton and was assessed as being at high risk of falls. The ombudsman’s report said the home judged bed rails “would place Mrs X at greater risk because she could move independently in bed and would be able to attempt to climb over them”.

She was checked regularly throughout the day and night, being found on the floor on one occasion and with her feed out of bed on another.

A month after she moved into the home, Mrs X was found on the floor again and hoisted back into bed. She had a cut to her forehead and the carer carried out standard checks of pulse, oxygen levels and blood pressure.

Mrs X then began showing signs of a seizure and an ambulance was called. She died in hospital three days later.

The report concluded: “There is no evidence the care provider failed properly to assess Mrs X at the pre-admission or when she arrived at the home. Her needs and risks were well documented. The use of bed rails was considered appropriately, and the care provider decided they were not appropriate. That decision was in line with the extant guidance.

“However, there is no evidence to explain why either a safety mat or other provision, such as a low bed, were not put in place. Although they would not have prevented Mrs X from falling, they may have lessened any consequent injury.

“There is no evidence that Mrs X sustained actual injury other than a skin tear from the fall itself on 6 December. The event which prompted her hospital admission was a seizure.

“Nevertheless, her family suffered the distress of not knowing whether other actions might have prevented a fall.”

The ombudsman ordered Morris Care to pay the family £500 and review its procedures for measures to prevent injury from falls.

A Morris Care spokeswoman said the cases had been “fully investigated and sorted to the satisfaction of the ombudsman”.