nhs clinical care report

CONFIDENTIAL REPORT

lndependent Review

of

Health Aspects of complaint received by NHS Wirral from MrLeonard Beddows in regard to Mrs Doreen Beddows

Date of Completion 3'd Febru ary 2013

Terms of Reference

1. Review the care provided by Elderholme Care Home to Mrs Doreen Beddows,specifically related to the timeframe associated with the complaint made by MrLeonard Beddows. Determine if there is any evidence to indicate that MrsBeddows clinical care fell below expected standards at any time during the saidoer iod.

2. Review the actions taken by the Continuing Care Team specifically related to thetimeframe associated with the complaint made by Mr Leonard Beddows.Examine if the Continuing Care Team failed, or not, to follow expected standardsin respect of its responsibil i t ies and/or duties related to Continuing Healthcarecommissioning responsibi l i t ies.

Independent ReviewerName Desionat ion Qualif icationsMrs Lorraine Norfolk Cl in i ca l Lead , NHS

MerseysideRGN. BSc. MSc

Patient whose case is beingName: Mrs Doreen Beddows

PCT Contact for communication:Ms Janet Hope, Senior Complaints Officer. Quality & Governance.Tel: 0151 514 2888

NHS Halton and St Helens, Knowsley, Liverpool and Sefton working together of 19

DOB: 1010311945

Main contact for communication and contact details:Mr Leonard Beddows - husband.Tel .07742965289

Evidence

The review considered all the evidence contained within the records l isted belowwhich had been made available by NHS Wirral for the purpose of the review.

NHS Funded Nursing Care Assessments and Cont inuing Healthcare Records,including correspondence and database entriesCare Home recordsInput from Mr Beddows - meeting held with Mr Beddows, in the presence ofMrs Beddows, 18/1 112012.

Background and Chronology

2008Mr Beddows init ially raised concerns with the Matron, Christine Whiteside, atElderholme Care Home about the standard of care for his wife in April 2008. Heeventually wrote to Matron on 16th May 2008 following her invitation to make anappointment to meet. A meeting was held on 20tn May 2008, and the Matron wroteto Mr Beddows on 22no May 2008 to clarify the outcome of their meeting. All issuesraised were discussed. clarif ied and a clear plan of action was aqreed.

The records indicate that due to changes in commissioning arrangements betweenthe Local Authority and the PCT it had come to l ight that the fees being paid for MrsBeddows were incorrect, and the home had been notif ied that the payments for carewould be reduced. The care home was not happy about this and wrote to the PCTaccordingly. In a letter to the PCT, dated 26th June 2008, the Director, Mr B Wood,of Elderholme Nursing Home raises concern about the reduction in fees concerningthe care of Mrs Beddows. He states that he has also informed Mr Beddows. Thecommissioning issues highlight that a review of care needs is overdue. On g'n

October 2008 the PCT received a telephone call from new Matron at the home,Heather Ward, who is seeking clarity as to why payments for Mrs Beddows carehave been reduced. A similar call is also received from Director Mr B Woods on thesame day.

During a visit to the care home on 24th October 2008, Nurse Assessor from theContinuing Health Care Team, Alison Aldcroft, was approached by Mr Beddows.She recorded that Mr Beddows informed her that he was aware of the funding issuesand raiseed his concern that the care of his wife may be affected. The nursereassured him that the assessment would identify all the care needs. A review ofcare needs was organised and eventual ly took place on 1Oth November 2008. Theoutcome of the review clarif ied that Mrs Beddows remained eliqible for NHSCont inuinq Healthcare fundino.


2009In May 2009, Mr Beddows was invited by Matron Heather Ward to attend a meetingto discuss the care of Mrs Beddows. Present at the meeting was GP Dr Meyer andAssistant Matron Vicki Wotton. There is no clear indication in the records about theintended purpose of the meeting; however, there are documented minutes that havebeen agreed by the GP. For the purposes of this review only the agreed minutes bythe GP have been taken into account, as it is not possible to verify the additionalcomments made by Mr Beddows at this point.

The detail of the minutes reflect that the Matron was concerned that Mr Beddowswas having a negative impact on his wife's care and that she had receivedcomplaints from the professionals involved with her care. Mr Beddows wasconcerned that the purpose for the meeting had not been communicated clearly tohim as he was led to believe that the meeting was to discuss his wife's diet. Theminutes clearly reflect inaccurate perceptions of events from the Matron's part. TheGP was able to clarify, for example, that Matrons understanding of the continencereview was inaccurate. In addition, the records reflect that there were no complaintsabout Mr Beddows from external professionals who were involved in the care of MrsBeddows, and this has been confirmed by the services involved. Matron raised theconcern that Mr Beddows' insisted on 3 people attending to hls wife for transferseven when he was present. She stated he also insisted on hourly checks of his wifeand the interventions being recorded. The Matron also made reference to the levelof care for Mrs Beddows in relation to the number of residents in the home, and incomparison to a patient in intensive care. Matron also made reference to acomplaint made specifically by a member of staff in the care home about MrBeddows.

The meeting ended with a recommendation by the GP that all parties 'draw a l ine'under the issues raised and move fonvard. Mr Beddows asked for clarity in relationto 3 people being required for transfers, the need for hourly checks of his wife, andconfirmation that his wife would be got out of bed between the hours of 1pm and2pm Assistant Matron responded that she could not guarantee the timing but theywould strive to achieve this.

The care plan for Mrs Beddows was prescribed in her discharge plan fromneurological services, and has been reinforced as appropriate by the previousMatron in her response to Mr Beddows in 2008. The care plan is discussed in moredetail later in the report. In addition, the reviewer is unable to clarify if the complaintconcerning the individual member of staff and Mr Beddows was fully investigated bythe Matron. The terms of reference of this review have not included a review of thecare home's response to complaints concerning Mr Beddows.


On 30'n June 2009 Matron Heather Ward writes to Mr Beddows in response toreceipt of the minutes from the meeting. She states there are 'facets which we feelare a totally inaccurate refection of events. However, after our meeting with DrMeyer and his discussions with you, it was agreed a "l ine would be drawn in thesand", and we could all move on from the past. Therefore, it is pointless inresponding to the numerous details of your letter which all occurred prior to thediscussion with Dr Mever'.

The care home continued to raise concerns about payments for the care of a numberof patients and writes to the PCT in June 2009. In a letter dated 23'd July 2OO9 theDirector of Elderholme writes 'Mr Beddows continues to insist that the protocol laiddown by Walton Neurological Unit is executed to the letter. Furthermore, he insistshe is present whenever any procedure is carried out on his wife and is at pains thathis requests are made within the agreement before his wife came to us. Forexample, it takes 17, hours with him present to bath his wife where he insists CareAssistants and Registered Nurses are present on each occasion. Therefore, in eachcase, I believe Elderholme is entit led to a reasonable increase in fees bearingeverything in mind and I trust you wil l take a personal interest in this request'. ThePCT wrote to the care home on 20'n August 2009 and confirmed the fundingarrangements for the patients, including Mrs Beddows, as correct.

On 1'1th September 2009 Mr Beddows wrote a letter of complaint to the Chairman ofElderholme Nursing Home, Mr Rourke, about the treatment he had received from theMatron. He stated he remained upset by the events earlier in the year and felt hisrelationship with the Matron was not satisfactory and that he was entit led to receivedignity, respect and kindness from the Matron. He requested an explanation to theevents discussed at the meeting in May with particular reference to the manner inwhich the meeting was convened and the attitude of the Matron. Mr Rourkeresponded to this letter on 8th October 2009. He confirmed that the meeting hadbeen called because they had received a complaint from a member of staff and also

.; because Mr Beddows 'was continuously querying and questioning the care of the'- professionals at the home'. Mr Rourke confirmed that the care staff would attempt to

meet the targets of checking Mrs Beddows every hour but stated that sometimesother demands on the corr idor may sometimes cause a delay. He went on to explainthat the home 'receives the same payment for Mrs Beddows as for every otherpatient on the corridor and therefore their care must be realistic and proportionate'.Mr Rourke also stated that he 'doubted the care for Mrs Beddows would be better inany other home but you are free to transfer her if you so wish. For the future, I trustyou wil l desist from the constant interfering with the professional care of your wife,and should you have a point to make or suggestion then it should be directed to theMatron only, and if thought fit, Mrs Beddow's GP.'


On 28'n October 2009, Mr Beddows and Matron met in an attempt to resolve the on-going issues. There is no evidence in the records to support that the issues wereresolved at this time.

2010ln May 2010, Mr Beddows writes to the PCT, via email, following a conversation withMatron Heather Ward. Mr Beddows states that Matron wanted to discuss the issuesof hourly checks and subsequent recording on charts. Amongst, Mr Beddowsaccount of the meeting he refers to Matron stating that several experienced medicalstaff had decided that hourly checks were not necessary. There is no evidence tosupport this alleged statement by the Matron in the records. Mr Beddows expressesconcern that the care needs of his wife being compared to that of other residents inthe home and the fees that are made. He states he has raised his concern about theattitude of the Matron with the Care Quality Commission, but that they have referredhim back to the Matron to resolve. Mr Beddows suggests, in relation to his wife, that' ideally her care plan should be reviewed by her consultant or GP' but askes that inthe meantime can the PCT reinforce that the care olan must be adhered to. He asks'can you tell me to whom I can look to help me with this problem because I amreaching the end of my sanity in what is a very stressful experience anyway'.

In response, Pauline Hurst, Physical & Sensory Disabil ity Reviewing Officer from theContinuing Care Team writes that 'following the review of Mrs Beddows continuinghealthcare needs a recommendation has been made for Consultant Dr Pinder toreview Mrs Beddows'. In her response, she states that having followed this up withDr Pinder's secretary a referral has yetto be received as of 7th May 2010. She alsorefers to the fact that she understands Mr Beddows continues to have diff icultiesconcerning his wife's care plan and it ' implementation, but states that unfortunatelythe PCT 'do not hold the contracts with the care home and therefore have noinfluence over the measuring of who gets how much etc.'

Mr Beddows responds further on 27th May 2010 to inform the PCT, via PaulineHurst , that Matron has informed him that hour ly checks wi l l no longer beimplemented and refers to the home not getting extra payments.

As Mr Beddows understood a referral was being made to Dr Pinder he spoke to theGP because he thought an updated nursing needs assessment could be undertaken.The GP confirmed that he had not received a referral from the home to contact DrPinder. Mr Beddows states that GP DR Meyer spoke to Matron the same day andthat Matron reinforced to him that the hourly checks would not be continued as thecare plan had been written by the previous Matron and she did not have to follow it.Mr Beddows also states that the Matron informed Dr Meyer that she had not askedthe GP to refer Mrs Beddows to Dr Pinder because after further discussion with othernurses they felt a referral to Dr Pinder was unnecessary as Mrs Beddow's care


needs has not changed. Dr Meyer told Mr Beddows that he agreed with the Matron.The reviewer is unable to establish from the records if the GP agreed with Matronthat a referral was not required and/or that Mrs Beddows care needs had notchanged. The records reflect that Mrs Beddows care needs had not changed andtherefore there is no indication that a change in care plan was required.

In the same email Mr Beddows asks the direct question of the PCT 'are you sure thatyour department has no authority to demand a review?' He also enquires as to howcan a care home write a care plan, review it monthly and then decide not to follow itwithout consultation. Mr Beddows also refers to previous correspondence at the endof his email in relation to potential overcharging on his part in relation to the care ofhis wife.

On' lOtn June 2010 the Director of Elderholme wri tes to Mr Beddows in relat ion to thecare fees. He clarif ies that the original funding for care was transferred from ArrowePark to the Primary Care Trust in 2008. From this point Mrs Beddows care wasfunded through NHS Continuing Health Care. Mr Woods informs Mr Beddows that ifhe wants additional care for his wife then he should 'make out a case and submit hisfindings to the Primary Care Trust as the purchasing authority. ' A copy of the letterwas sent to Paul ine Hurst at the PCT via emai l on 13th June 2010. In his emai l MrBeddows referred to the issues about his wife's care and their relationship to theissues about care fees. He reinforced his _vi,e_w that all he wished was for the care - 4n]a1 jo1 his wife to be followed. He could see no indication for it to be altered andstated that he appreciated the issues may be outside the remit of the PCT but did notknow to whom he could approach to assist to resolve the issues.

Following a conversation with Pauline Hurst on 14'n June 2010 Mr Beddows wrote,via email, to Pauline Hurst with information about his wife's care plan. He notedamendments and no mention of hourly checking. He also referred to a meeting to bescheduled, it is not clear who was to attend the meeting. Further to previous emailson 28th June 2010, Mr Beddows outl ined his expectation of the issues to bediscussed at the professionals meeting to be held between the care home and thePCT. He again reiterated that he knew this was outside the remit of Pauline Hurst toaddress, it is assumed bv the reviewer he means PCT when he states this.

There is a copy of a letter dated l" July 2010 in the records written by Mr Beddowsto the care home. He asks for clarity as to whether the letter he received from thehome dated 8'n October is the home's full response to his complaint. He requested acopy of the home's complaints procedure and reiterated his concerns. There is norecord of a response from the care home to this letter in the PCT fi les.

Mr Beddows wrote again to Paul ine Hurst v ia emai l on 18tn July 2010 with fur therinformation for consideration in readiness for the meetinq to be held on 3oth Julv


The information relates to finance and the care plan and its implementation andmanagement.

Review Meeting 30th July 2010.

This meeting was attended by Pauline Hurst and Manager Dawn Vasco fromContinuing Healthcare Team, Heather Ward, Matron and Nurses Rachel Blacklockfrom Elderholme Nursing Home, and Mr Beddows, Notes were recorded by SharonShacklady from the PCT.

The minutes ref lect a l l the areas of d iscussion concerning the care plan andmanagement of Mrs Beddows. There was an agreed outcome and the PCT agreedto review Mrs Beddows in 3 months. The Chairman of Elderholme Nursing Homewrote to Mr Beddows on 6tn August, enclosing a copy of the minutes of the meeting,and confirming that once they had received confirmation from Mr Beddows that hewas happy with the minutes they would summarise the outcomes and include themin the care plan of Mrs Beddows. Mr Beddows replied on 16'n August. The PCTdoes not have a copy of this response.

On 3Oth November 2O1O a review by the CHC Team was undertaken. Prior to thisvarious email and letter correspondence was sent to the PCT in which Mr Beddowsindicated that there remained issues with how his wife's care was being managed.He also outl ined concerns in terms of the relationship between care and the carefees. He also identif ied the remaining outstanding issue of complaint with regard tothe recommendation that a referral be made to Dr Pinder and the subsequentdecision not to do so by the Matron. He felt that this issue remained unexplained.There is no evidence in the PCT records in relation to this issue at this time. Theoutcome of the review was Mrs Beddows remained eligible for NHS ContinuingHealthcare.

Mr Beddows received a letter from the Director of Elderholme Nursing Home, MrWoods, on 23'd December2Ol0 out l in ing the basis of a discussion held in relat ion toMrs Beddows. The reviewer assumes that the discussion referred to was thatbetween Mr Beddows, Mr Brian Woods, Director of Elderholme, and Mr BrianRourke, Chairman of Elderholme in December 2010. Mr Woods indicated that hisunderstanding of the minutes f rom the meet ing in July 2010 was that the hour lychecks could be dispensed with, and that Mr Beddows agreed to this. He suggestedfurther discussion with the Matron and the PCT staff should anv further clarif icationbe required.

Mr Beddows wrote to the PCT, via Dawn Vasco, on 27'n December 2AA, to ask forclarif ication of the outcome of the meeting on 3Oth July. Mr Beddows referred to theissues discussed at the meetinq in Julv 2010.


He also orovided details of a discussion held with Matron and Mrs Beddows' twonamed nurses with whom it was agreed that the care plan had not been completedas agreed in the letter from Mr Rourke, and instead of writ ing in the care plan a chartwould be completed. He then referred to the review undertaken by the PCT on 3OtnNovember 2010 in which he states he was informed that the level of interventionsundertaken by the care home was acceptable at 460/o of identif ied need. Thesummary chart of interventions was prepared by Mr Beddows and is available in thePCT records. A letter of response from Pauline Hurst, dated 13tn January 2011,requesting consent to source the hospital records for Mrs Beddows, was sent out toenable the PCT to respond more fully. Mr Beddows did not receive this letter unti l SthApri l 2011, postmarked '1 ' t Apr i l 2011 There is no evidence that a more completeresponse was sent directly to Mr Beddows at this time in the PCT records.

In the meantime, Mr Beddows wrote to his MP, Alison McGovern. In his letter dated28th December 2010 he wrote about the December meeting with the care homedirector and chairperson. He told of the conversation about the complaint to the MP,a meeting with John Webb in Birkenhead, (the reviewer is unaware of who thisperson is), and a subsequent unannounced inspection by the Local Authority. MrBeddows seemed assured in his letter that the nursing home would reinstate thecare plan in relation to hourly checks of his wife's needs. However, he did expresssome concern that his complaint was not being dealt with properly.

Mr Beddows also referred to the review 'last autumn' undertaken by the PCT. Hedoes not provide a specific date but states he was impressed with theprofessionalism of the nurses and their knowledge of Mrs Beddow's condition. Hestated that the nurses felt that the diff iculties with the Matron were related todifferences in personalit ies. Mr Beddows stated in his letter that he did not agreewith this and gave an example of how the inconsistency in monitoring his wife canaffect her care. Mr Beddows stated he felt he had exhausted the complaints policyof the care home, and had received no support from the care Quality Commission orthe Local Authority. Toward the end of his letter Mr Beddows refers accurately to thedescriptions of previous statements made to him in letters from the nursing home.

2011ln a further letter to his MP, dated 20tn April 2011, Mr Beddows related to the reportfollowing the Social Services inspection. He stated he believed the report containedinaccuracies. He indicated that in his meeting with the director and chairperson ofElderholme that they had told him that they felt Sheila Hil lhouse from the PCT,thought Mr Beddows was complaining about his wife's care. He confirms he wascomplaining about the al leged l ies that the care home had made to the GP and PCTthat could have reflected on his wife's care.


In a letter to his MP dated 9'n May 2011 Mr Beddows stated that he had only madeon direct complaint to the care home in September 2011 and that related to thealleged behaviour of the Matron toward him. Mr Beddows describes examples ofresponses made to him by the care home accurately. He outl ines the areas of hisconcern and his dissatisfaction with the Care Qualitv Commission's and LocalAuthority's response to his complaint.

On 16th May 2011 the PCT is asked to provide a response to MP Alison McGovern inrelation to the issues outl ined in Mr Beddow's letter. A letter of response dated 11thJuly 2011 stated that information has been gathered from Mrs Beddows GP and alsothe relevant Heads of Service in NHS Wirral and Wirral Community NHS Trust. Theletter outl ined the instructions given by the Dietetic Service in relation to a call fromthe care home. The RGN at the home had contacted the service as she wasconcerned that the fluid intake was too high in relation to fluid output. Informationwas also provided in relation to the continence service and its response to issuesrelated to the supra-pubic catheter. Both services clarif ied that they did not makeany complaints about Mr Beddows. Dr Meyer provided a response that stated hewas happy with the care the home was providing to Mrs Beddows. He also indicated'great respect' for Mr Beddows in overseeing his wife's care and remarked that MrBeddow's concern to do the very best for his wife was commendable. Confirmation

, was also provided in relation to reviews undertaken by the CHC Team and that nofcomplaints had been received in relation to the medical care given to Mrs Beddows.

However, the confirmation that there was no record of a recommendation made torefer Mrs Beddows to Dr Pinder was inaccurate. There is evidence that this wasi".iro-.id-on-bdt6i6;ursfrttiome-noLs and PCT records electronically and in thecase fi le. In fact, this recommendation delayed the case being prepared for panel asPauline Hurst wished to have the information from the outcome of this referral tocomplete her presentation.

On 2nd September Mr Beddows wrote to Mr Khan, CHC Manager. He providedinformation in relation to the recommendation to refer Mrs Beddows to Dr Pinder byNurse Pauline Hurst. Mr Beddows also provided information in relation to thetimeline of events relating to correspondence with the care home and the PCT. Heasks Mr Khan to request the care home to reinstate the hourly checks of his wife andto inform the care home that this is a requirement within the fees being paid for hiswife's care.

On 26th September Mr Beddows wrote to Mr Khan via email asking for a response tohis earlier letter by 2nd October 2011. In his response dated 27th September 201'1,Mr Khan wrote that the PCT are happy that Mrs Beddows is appropriately placed atElderholme and acknowledges the point of tension about how the care is delivered.


He stated that it would be inappropriate to direct how the care is given by the homeand informed Mr Beddows that the matter did need to be dealt with by himself andthe home.

ln November 2011the PCT received a letter from Lawson Stebbings, Chief ExecutiveOfficer, Elderholme Nursing Home informing them of formal notice given to MrsBeddows cit ing her husband's conduct as the reason for this. A strategy meetingwas held and the PCT met with Mr Beddows, along with Local Authority Colleagueson 18th November 2011. On 23'd November 2011 the PCT received an emai l f romthe MP Alison McGovern's office to inform them that Mr Beddows does not feel he isgetting support from the PCT.

On 25th November 2011 Mr Beddows solicitor wrote to Elderhome to request awithdrawal of the eviction notice and stating that they wil l seek Court of Protectionand decision by a High Court Judge. A request for a written decision is made by 28tnNovember 2011. A response is made by Elderholme Nursing Home the same daystating the eviction notice is irrevocable. Mr Stebbings states that ' in the l ight of anindependent advocate being appointed for Mrs Beddows and the involvement ofWirral Social Services the demands of the solicitor are unnecessary and prematureas are the suggested recourse to the courts.'

Mr Khan, PCT, spoke to GP Dr Meyer on 28th November 2011 in relation to MrsBeddows and the potential move to another care home. Dr Meyer felt that MrsBeddows would become distressed by a move. Dr Meyer explained that whilst MrsBeddows was diagnosed as being in a Persistive Vegetative State she did respondto touch, was fami l iar wi th her surroundings, and did respond to s imple quest ions byblinking her eyes. Although Dr Meyer felt it would not be in her best interests tomove, she was medically f it to move. Mrs Beddows transferred to Vale CourtNursing Home on 6th December 2011.

On 8tn December 2011 Mr Beddows wrote to the PCT. He referred to the previousletters to his wife's MP. Mr Beddows confirmed that he has only made onecomplaint to the care home since 2009 about the Matron allegedly giving the GPfalse information and being aggressive in nature toward him. He stated that he feelshis complaint has never been fully investigated and the replies from the home havenot been satisfactory. He made a request for the matter to be investigated further bysomeone with medical exoer ience.

2012On 10th April 2012 PCT wrote to Mr Rourke at Elderholme Nursing Home, NeilRyder, Director of Corporate Affalrs, NHS Commissioning Support Service, and MrDave Jones, Complaints Manager at the Directorate of Social Services (DASS)


requesting an investigation and response to outl ined concerns by 22nd May 2012.On 18th June 2012 the PCT and DASS provided a joint response to Mr Beddows.The letter informed Mr Beddows that they would be wil l ing to commission an externalcomplaints investigation officer to examine the issues relating to Mrs Beddow's'eviction' from Elderholme and the subsequent safeguarding referral. A joint apologywas given to Mr Beddows in acknowledgement that the service he received had notmet his expectations and caused upset and inconvenience to Mr Beddows.

There is no evidence in the records that Elderholme Nursing Home have made aresoonse to the letter from the PCT

Terms of reference and Findinqs

TOR 1: Review the care provided by Elderholme Care Home to Mrs DoreenBeddows, specifically related to the timeframe associated with the complaintmade by Mr Leonard Beddows. Determine if there is any evidence to indicatethat Mrs Beddows clinical care fell below expected standards at any timedur ing the said per iod.

BackqroundMrs Doreen Beddows was transferred to the Walton Centre in June 1999 for acutemanagement having suffered a catastrophic intra-cerebral haemorrhage. Sheundenvent craniotomy and evacuation of the haematoma the same day as hercollapse. Her best post-operative neurological status was flexing to pain. Herrecovery was complicated by several chest infections. She was admitted toElderholme Nursing Home in October 2000 following discharge from Wirral Neuro-Rehabi l i tat ion Uni t .

At this time Mrs Beddows was described as being in a vegetative state and althoughshe experienced some spontaneous eye opening there was no evidence ofpurposeful response to stimuli. She had a supra-pubic catheter and PercutaneousEndoscopic Gastrostomy (PEG) feeding tube in place. She was diagnosed withepilepsy and suffered seizures. Her care needs were clearly identif ied at this timeand management of care was prescribed by Specialist Registrar and Ward Manager.

Mrs Beddows required splints and passive exercises for her l imbs to prevent thedevelopment of contractures. She required the administration of multiplemedications and feeds; and monitoring of symptoms by a registered nurse. She hada tendency to bi te her lower l ip and required oral hygiene. Reposi t ioning was acrit ical element to her care as sne experienced vomiting it snefiafEpiSfrr,eO tooquickiy afGi a feed and problems with breathing due to poor neck posture. Sherequired 3 e for all repositioning to ensure effective head control. Her optimum+,-->-t im€-ih-a wheelchair was 4 to 5 hours. She also experienced excessive salivation

NHS Halton and St Helens, Knowsley, Liverpool and Sefton working together of t9

She required careful monitoring of her bladder, bowels and skin integrity, andrequired the use of anti-embolism compression stockings on a daily basis.

She was identif ied as requiring hourly monitoring !q!.".. B-ain, signs of catheter'OypftStnj-and

signs of OetadneO PfC tufFnyalGlfreO nurse. She required thesupevisiQ1 ol_a gyqlifue_Q lurse during all transfers between bed and chair, andd u ri n g he r we_ekl y s gQ1p11o_l p"_!h

Analvsis of evidence

Mrs Beddows care needs have been well documented as remaining unchangedthroughout the whole of the review period. She requires regular monitoring by ar e g i s t e r e d n u r S e a n d r e v i e w s f r o m t h e G P , d i m , p r c n u r s e ,and Community Matron. In relat ion to:

Cognition: Mrs Beddows is unable to demonstrate any orientation to herenvironment. She displays no awareness of very basic understanding. GP hasassessed her as having some familiarity of her surroundings, responding to touchand able to blink in acknowledgement of extremely simple questions only.

Psychological & Emotional needs: Has occasional episodes of distress whichrespond to reassurance. These episodes can relate to episodes of anxiety inrelation to coughing and attempts to clearing her ain,ray.

Communicat ion: Mrs Beddows is unable io rel iably communicate even withmaximum support .

Mobil ity: Mrs Beddows is completely immobile and requires a hoist and theassistance of 3 people for all transfers, and 2 people for all care interventions.Positioning of head and neck support is crucial to maintain airway. She requiresspecialist equipment to support posture and to bathe. She requires repositioning 3to 4 hourly, and passive exercises to prevent contractures.

Nutrit ion - food and drink: Mrs Beddows is nil by mouth and required PEG feed foral l nutr i t ional intake. She requires monitor ing f rom a diet ic ian regular ly. Fluidbalance requires monitor ing dai ly. She requires oral hygiene dai ly. She is at r isk ofmalnutr i t ion and requires weighing and BMI calculated regular ly,

Continence: Mrs Beddows has a supra-pubic catheter and requires regular bladderwashouts and management from continence services. Her catheter is problematicand is changed regularly. Her bowels are managed with enemas prescribed by herGP who advises on a regular basis.

Skin Integr i ty: PEG si te requires dai ly c leansing and monitor ing. She requiresrepositioning 2 to 3 hourly to maintain skin integrity. Tolerance for sttt ing in a chair is4 to 5 hours. She is at h iqh r isk of skin breakdown due to immobi l i tv .


Breathing: Mrs Beddows is prone to chest infections. She needs support to clearher upper respiratory tract through correct positioning of head and neck.

Drug Therapies, medication & Symptom Control: Mrs Beddows is prescribedmult ip le medicat ions in addi t ion to PEG Feeds as fo l lows:

. Oxybutynin 2.Smgs twice daily (for urinary symptoms)

. Ascorbic Acid 500mgs twice daily (vitamin c)o Domperidone 1mg three times daily (anti-emetic). Senna 1Smgs at n ight ( for const ipat ion). Baclofen Smgs twice daily (muscle relaxant)o Carbamazapine 200mgs three times daily (anticonvulsant and mood

stabil iser). Paracetamol soluble 1g four t imes a day (analgesia)

In addition, she has a Latex allergy and requires all medication to be administeredvia her PEG. Over the review period Mrs Beddows has been prescribed antibioticsas follows:

. 2 0 0 8 - 5 c o u r s e s

. 2 0 0 9 - 2 c o u r s e so 2010-4courses ,o 2011 -2courses ,

nasal cream and eye ointmenteve ointment

Mrs Beddows has complex needs. Her posture is crucial to maintaining her arrwayand combined with monitor ing her for s igns of pain, epi lepsy, and potent ia l problemswith her PEG and catheter, and frequent monitoring of her skin integrity. The nature,intensity, complexity and unpredictabil ity of her care needs mean that she requiresregular monitoring every hour.

Altered State of Consciousness: Mrs Beddows has a diagnosis of epilepsy andhas a history of seizures. She is prescribed medication.

Care RecordsThe care plans reflect all the care needs for Mrs Beddows. Care plans are reviewedregularly and updated. However, there are some anomalies. Over the yearsrepositioning charts and fluid balance charts have been completed. There issignificant inconsistency as to where fluid balance and repositioning have beenrecorded. On occasion fluid balance has been captured on repositioning charts andvice versa. In addition it is clear that there is inconsistency in recording of f luidoutput, particularly in relation to measurement. Often urine output is noted but theamount is not recorded. In 2006 new charts are introduced. In 2010 newpersonalised charts are introduced that only records input. Throughout the wholereview period the daily inputs and outputs are not totalled. Weight, BMl, bloodpressure and pulse were recorded consistently throughout the period.


Overall, the timescales for interventions vary considerably. Whilst care plans aresigned none of the daily intervention charts are signed on a regular basis, often thereis only one set of in i t ia ls.

The charts identify that there is a lack of intervention for repositioning between thehours of 5/6 am and 9/10 am on a daily basis and inconsistency between the hoursof 2l3pm and 6pm. Checking Mrs Beddows is more consistently recorded thanrepositioning. The latter may be related to visits and trips out with Mr Beddows, butthis is not clear from the records as timescales for these trips out are not identif ied.There is also a lack of evidence to identify how skin integrity is managed when MrsBeddows is sitt ing in her chair. The use of both care charts, repositioning charts andfluid balance charts has resulted in information being recorded in any one of threeplaces.

Conclusion

It is the requirement of the care home and its care staff to keep contemporaneousand accurate records for each patient. Whilst the_care plans for Mrs Beddowsreflected all of her care needs and were regularly reviewed and updated, the dailycharts did not reflect that the care had been consis-te-n,tLy m-a.naged. TnEre is-=--a-=-- - - . -evidence that tI-ere were times when checkinq Mrs Beddows was undertaken andrecorded more consistently than repositioning. lnformation was recorded in differentplaces at different t imes. Daily records and summaries of interventions were notdetai led. Whi lst the dai ly summaries were s igned, the dai ly charts were notconsistently signed, often they were init ialled, and often by only one person. [ ' t j t uopinion of the reviewer that due to the lack of consistent record keeping clinical carewas compromised and fell below expected standards.

TOR 2: Review the actions taken by the Continuing Care Team specificallyrelated to the timeframe associated with the complaint made by Mr LeonardBeddows. Examine if the Continuing Care Team failed, or not, to followexpected standards in respect of its responsibil i t ies and/or duties related toCont inuing Healthcare commissioning responsibi l i t ies.

Backqround

As Mrs Beddows is in receipt of NHS Continuing Healthcare funding she receivesregular reviews undertaken by the CHC Team, In l ine with the requirements of theNational Framework for NHS Continuing healthcare the reviews take place annually.There is no evidence to suggest that the reviews have not been undertakenappropriately. As the care needs of Mrs Beddows have remained unchanged, shehas remained eligible throughorlt the review period.


ln May 2010, Mr Beddows wrote to the PCT, via email, following a conversation withMatron Heather Ward. Mr Beddows stated that Matron wanted to discuss the issuesof hourly checks and subsequent recording on charts.

Mr Beddows expressed concern that the care needs of his wife were beingcompared to that of other residents in the home and the fees that are made. Hestated he had raised his concern about the attitude of the Matron with the CareQuality Commission, but that they had referred him back to the Matron to resolve.Mr Beddows suggested, in relation to his wife, that ' ideally her care plan should bereviewed by her consultant or GP' but asked that in the meantime can the PCTreinforce that the care plan must be adhered to. He asked 'can you tell me to whomI can look to to help me with this problem because I am reaching the end of mysanity in what is a very stressful experience anyway'.

In response, Pauline Hurst, Physical & Sensory Disabil ity Reviewing Officer from theContinuing Care Team wrote that 'following the review of Mrs Beddows continuinghealthcare needs a recommendation had been made for Consultant Dr Pinder toreview Mrs Beddows'. In her response, she stated that having followed this up withDr Pinder's secretary a referral had yet to be received. She also referred to the factthat she understood Mr Beddows continued to have diff iculties concerning his wife'scare plan and it ' implementation, but stated that unfortunately the PCT 'do not holdthe contracts with the care home and therefore have no influence over themeasuring of who gets how much etc.'

It was incorrect to state that the PCT cannot influence the management of care incare homes. As responsible commissioner for the care of Mrs Beddows the PCTshould act in her best interests, providing support for any issues between the carehome, pat ient and their fami ly to resolve any issues. As responsible commissionerthe PCT can assess, and review, the standard of care and support the care home toimprove the care provision to individual patients. In addition, the opportunity todiscuss Matron's concerns about the care plan was missed. Mr Beddows clearlyindicated that he needed to support to address the issues. lt is not clear from therecords if senior management were informed of the situation by the nurse so thatsupport could be offered.

Mr Beddows responded further on 27th May 2010 to inform the PCT, via PaulineHurst, that Matron had informed him that hourly checks would no longer beimplemented and referred to the home not getting extra payments. As Mr Beddowsunderstood a referral was being made to Dr Pinder he spoke to the GP because hethought an updated nursing needs assessment could be undertaken. The GPconfirmed that he had not received a referral from the home to contact Dr Pinder. MrBeddows stated that GP DR Meyer spoke to Matron the same day and that Matronreinforced to him that the hourly checks would not be continued as the care plan hadbeen written by the previous Matron and she did not have to follow it.


Mr Beddows also stated that the Matron informed Dr Meyer that she had not askedthe GP to refer Mrs Beddows to Dr Pinder because after further discussion with othernurses they felt a referral to Dr Pinder was unnecessary as Mrs Beddow's careneeds has not changed. Dr Meyer told Mr Beddows that he agreed with the Matron.

The reviewer is unable to establish from the records if the GP agreed with Matronthat a referral was not required and/or that Mrs Beddows care needs had notchanged. The records reflect that Matron agreed Mrs Beddows care needs had notchanged and therefore there is no indication that a change in care plan was required.Her rationale to GP Dr Meyer appears contradictory to her statement about MrsBeddows needs, and the need to alter the care plan. ln the same email Mr Beddowsasked the direct question of the PCT 'are you sure that your department has noauthority to demand a review?' He also enquired as to how can a care home write acare plan, review it monthly and then decide not to follow it without consultation. MrBeddows also referred to orevious correspondence at the end of his email in relationto potential overcharging on his part in relation to the care of his wife.

There is a lack of clarity as to why GP supported the decision of the Matron. TheCHC Team should have addressed this so that there was clear understanding inorder to reassure Mr Beddows. lt was a reasonable request to request a review ofMrs Beddows needs to understand if the care plan needed to change, and MrBeddows was happy for this to happen. lt was also important that unti l a reviewestablished that a change in the care plan was required that the existing care planshould remain unchanged. Otherwise, how could the PCT be assured that all r iskswere being managed appropriately and care needs being met. The reviewer alsonotes that Mr Beddows, not for the first t ime, has informed the PCT of his concernsin relation to care fees.

Review Meeting 3Oth July 2010.

This meeting was attended by Pauline Hurst and Manager Dawn Vasco fromContinuing Healthcare Team, Heather Ward, Matron and Nurse Rachel Blacklockfrom Elderholme Nursing Home, and Mr Beddows. Notes were recorded by SharonShacklady from the PCT.

The minutes reflect all the areas of discussion concerning the care plan andmanagement of Mrs Beddows. lt is noted that the reassurance given to Mr Beddowsthat 3 staff always carry out transfers when he is not present was received well. Theminutes of the meeting record the nurse in attendance as saying 'changing MrsBeddows position early morning between 6am and 9am would depend on whichcarer was on duty, as Mrs Beddows would be left t i l l last if a male carer was on duty'.Whilst Nurse Hurst stated that Mr Beddows required reassurance that his wife waschecked, she did not take the opportunity to state that the care needs of patients donot f it around the staffing levels, it should be the other way round.


Nurse Hurst also stated that just because care was not documented it did not meanit had not happened. She fai led, as did her col league, to understand that how couldassurance be given that care had been provided if i t wasn't documented. NurseHurst went on to state that Mr Beddows had no problem with the level of care given,he just wanted to be assured that the care plan was followed. Nurse Hurst failed tounderstand that the level of care is dictated by the care plan.

The minutes also reflected the Matron's concern about providing hourly checks forMrs Beddows being documented. Matron stated that the care plan said 'checks notdocument checks. Will not document but wil l always check hourly. She stated thatthis was putting staff on l ine, puts too much onus on them'. Matron was not asked toexplain this further, however, the PCT nurse suggested that am and pm interventionswere collated and then recorded. Mr Beddows said he would be happy with this.However, it is unclear how information that is not recorded can be collated. Matronstated that qualif ied nurses wil l be the ones documenting, taking information fromcarers. Nurse Blacklock, from the care home, stated that 'staff are only human,mistakes wil l be made'. Matron stated that 'these are legal documents. Staff areworried if they put things on forms, and a chart is not completed hourly, then theyfeel they would be l iable in a court of law.' The CHC nurses did not respond to thesecomments and reinforce the need to provide contemporaneous nursing records.There was an agreed outcome and the PCT agreed to review Mrs Beddows in 3months.

On 30th November 2010 a review by the CHC Team was undertaken, Prior to thisvarious email and letter correspondence had been sent to the PCT in which MrBeddows indicated that there remained issues with how his wife's care was beingmanaged. He also outl ined concerns in terms of the relationship between care andthe care fees. He also identif ied the remaining outstanding issue of complaint withregard to the recommendation that a referral be made to Dr Pinder and thesubsequent decision not to do so by the Matron. He felt that this issue remainedunexplained. There is no evidence in the PCT records in relat ion to th is issue at th istime. The outcome of the review was Mrs Beddows remained eligible for NHSConti nuing Healthcare.

Record Keeping

It was noted that the PCT records were not robust, particularly from the perspectiveof the database. lt is not clear if responses were made to all the letters and emailsfrom Mr Beddows. Where responses were made the timescales were inconsistent.For example, the response, dated January 2011, to Mr Beddows letter of December2010, did not reach Mr Beddows unti l April. There is no recorded explanation of whythis happened.


Conclusion

Mr Beddows first contacted the CHC Team in May 2010. The Review meeting didnot take place unt i l July 3oth 2010. l t is unclear why i t took so long to arrange thismeeting. The CHC Team should have met earlier with a view to resolving the issuesbetween Mr Beddows and the care home. There are concerns noted earlier inrelation to statements made at the meeting that were inaccurate and inappropriateby both the care home staff and the CHC Team.

The issue concerning the recommendation of a referral to Dr Pinder for review hasnever been investigated. The rationale offered by the Matron to the GP contradictsher statement that the care needs of Mrs Beddows have not changed, thus negatingthe need for a referral. lt has not been established with whom this decision wasagreed.

The CHC team records were not robust and it was evident that the team had !a'(

responded to all emails and letters sent by Mr Beddows. There was evidence thatthere were delays in communicating with Mr Beddows by the CHC Team and thePCT generally. There are no documented reasons for the delays.

Lastly, the CHC Team and PCT have failed to respond to the need to investigate therelationship between the issues related to care fees and the care plan for MrsBeddows The PCT should have strived to separate the two issues in order tomaintain c lar i ty, in l ine wi th i ts responsibi l i t ies in relat ion to the Nat ional Frameworkfor NHS Cont inuing Healthcare.

Overal l Summary and Conclusions

Having considered all the evidence and after consideration of the terms of referencein relation to the review, it is the opinion of the reviewer that due to the lack ofconsistent record keeping clinical care for Mrs Beddows, at Elderholme NursingHome, was compromised and fell below expected standards. Furthermore, theContinuing Care Team, failed to follow expected standards in respect of itsresponsibi l i t ies and dut ies under i ts Cont inuing Healthcare (commissioning)resoonsibi l i t ies in relat ion to Mrs Beddows.

Recommendat ions1. An acknowledgement from the PCT that the care plan for Mrs Beddows

should not be altered without a formal review of her care needs, by theappropriate professionals, and only where a formal review be indicatedbecause there is a change in need identif ied.

2. A review of the care home records at Elderholme to ensure the daily recordsare being completed in l ine with the identif ied care plans of patients.

3. A review of the record keeping of the CHC Team and entries on the database.


4. Training and Development in relat ion to commissioning responsibi l i t ies of the

PCT andior CHC Team and the PCTs responsibi l i t ies concerning the Nat ional

Framework for NHS Continuing Healthcare.5. An investigation into the response of Elderholme Nursing Home to Mr

Beddows' complaint . This should include a review of the Home's complaintpoi lcy.

6. A review of the payments made by Mrs Beddows in relation to her care. lt is

c lear that Mrs Beddows care needs have not changed since discharge from

Wirral Neuro-Rehabil itation Unit. lt is not clear that all care costs have beenmet by the NHS.

This report wil l be scrutinised by NHS Wirral in order to ensure compliance with the

terms of reference of the review.

Lorraine NorfolkCl in ical Lead, NHS Funded CareNHS Merseyside

3'o February 2013


nhs clinical care report

Documents

mr beddows meeting

mrleonard beddows

informed mr beddows

atelderholme care home

standard of care

matron wroteto mr beddows

mrs beddows carehave

mr leonard beddows husband