Ms B complained that her mother, Mrs A, died because of an inappropriate transfer between a care home and a nursing home. Ms B said that the decision to move Mrs A was made without due consideration and that she was moved too far away from her family. This caused Mrs A distress and meant that she was alone when she died.
What happened
Mrs A went into the care home in early 2012 after her health worsened following a stroke. The local authority began working with the care home on issues about the quality of care in summer 2012. In spring 2013, after receiving an alert from the Care Quality Commission, local authority officers reviewed Mrs A's care plans at the care home and found they did not reflect her needs. The officers also found other issues with the care home. The local authority told the Clinical Commissioning Group's (CCG) continuing healthcare team about what it had found.
The local authority asked Ms B if she had any concerns about her mother's care. Ms B had none and was happy about Mrs A's care. Later in spring 2013, a community nurse found that Mrs A was sore at the base of her spine and could no longer bear weight. The nurse felt the care home could no longer meet Mrs A's needs, and the CCG agreed to visit and assess her. A local authority officer and a continuing healthcare assessor visited Mrs A and decided she needed a nursing home placement to meet her needs. They arranged overnight nursing from another team and nursing home staff. Ms B was happy with this.
Eventually the local authority and CCG agreed to move Mrs A to a nursing home very soon. They were aware that Mrs A would be isolated by a move and that this would be distressing, but they felt that the move was in her best interests. Ms B was unhappy about the move, which took place by ambulance.
Mrs A remained unwell and died several days after arriving at the nursing home.
What we found
We found maladministration in that the CCG did not formally assess Mrs A in the care home before any issues were raised. However, we did not find any fault in the CCG's decision to move Mrs A to the nursing home. We did not find fault with the way in which the local authority investigated the alert that was raised about Mrs A's care.
Putting it right
The CCG apologised for the distress caused when it did not assess Mrs A between early 2012 and spring 2013. It agreed to produce an action plan to show how it would learn from this.
West Hampshire CCG
Hampshire
Not applicable
Apology