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Care Home- Grandmother put in serious danger by staff incompetence - WWYD

(40 Posts)
notamum3210 Sat 28-Nov-15 22:44:44


There's a long backstory to this one but I'll summarise the key points:
-Grandmother has been in a care home for the last 5 years.
-She is a 'difficult' resident (their words and ours) and as well as being post-stroke she has a lot of co-morbidities and dementia. She does not have mental capacity.
-My mother has power of attorney and a DNAR has been signed. She has also been labelled as not fit for admission to hospital if it can be avoided due to her other health conditions.
-Over the last 18 months there have been serious concerns over her care in the home. 2 incidents of physical abuse which were investigated by social services and the police. The management have been quite poor in how these incidents were handled but social services were excellent. We have been confident in the last 6 months that the abuse-related issues were under control (we were led to believe that it was agency staff responsible). Whilst nobody was caught, she seemed safe and happy.
- she has had a chest infection for the last few weeks. Nothing terrible but it did require antibiotics. She was last seen for a review by the GP who visited the home early on Wednesday who prescribed an oxygen cylinder on demand for as/when she needed it. At the time her oxygen levels weren't too low but she did seem to be short of breath.

Fast forward to this evening:

My mum received a call from the nurse on site at the home at about 5pm saying that she had been monitoring my grandma's oxygen sats every 2 hours since she began her shift early that morning. In that time her oxygen sats had dropped from 88 to mid 70s and at the time when she was calling her oxygen rate was 66. Nurse was calling to let us know and also to inform my mum that the oxygen cylinder that had been My mum is in the medical profession and alarm bells began to ring. She could not believe that oxygen had not been delivered yet and shocked that the nurse had waited this long to call her. Also very shocked that the oxygen order had not been chased up by the home. Mum asked the nurse if there was anywhere they could get oxygen from and she said no. Mum asked the nurse how long somebody with oxygen sats that low would survive and she said 'not very long'. I was horrified hearing all of this.

Mum decided to call the nursing home manager who was off shift but has an emergency on call number. She had no idea about this incident and refused to do anything about it as she was busy and driving at the time. She asked my mum if she wanted her to pull over and pass on the out of hours emergency GP number and mum said yes please. She never called back.

Mum decided to call nhs 111 who said that a call had already been made by the home about my grandma. They had sent out a paramedic with oxygen. Later, mum called the home again and ask to speak to the paramedic who was fantastic but also horrified that a prescription of oxygen had not arrived 2 days after being ordered and that a registered nurse on site had let things get this bad before escalating them. The paramedic agreed to stay and give grandma oxygen for as long as she needed but said it was vital that further supplies were organised as a matter of urgency. He said to mum on the phone 'please take this to the top'.

Flash forward another few hours and the paramedic speaks to mum again saying that he only had 1 hour 1/2 left of oxygen in his cylinder and they needed more desperately for her. Mum is beside herself at this point but finally gets through to the out of hours GP who checks records and says that the correct paperwork for the order of this organised was not completed and so the original order on Wednesday had never been put through! At this stage, they may have managed to arrange some emergency oxygen from the local hospital (which is just across the road!) but we are very worried, angry and distressed.

Obviously my grandma's welfare is paramount but I feel that we really need to complain about the way this was handled as this seems to be a positively dangerous scenario that was brought about by a lot of incompetence. I also don't like the way we have been treated by care home staff. When I tried to call for an update they said they were busy and needed to keep their phone lines free.

Thank you for reading if you've got to the end: my question is what should we do in this situation?

BTW, if relevant it's a Bupa Care Home rather than an independent.

Dothetwist Sat 28-Nov-15 22:55:25

Jesus christ...

You need to be contacting upper upper management and following whistle-blower procedures

thelouise Sat 28-Nov-15 23:01:06

I'd go straight to social services because this needs to be investigated under safeguarding procedures. I'd also contact the CQC but start with social services. (I'm a social worker for older people.)

flowers for you.

thelouise Sat 28-Nov-15 23:04:08

Actually, having read again, I'd contact social services and the CQC first thing in Monday morning. When was their last CQC inspection? Do you know what rating it got?

notamum3210 Sat 28-Nov-15 23:08:05

Sorry I can see that my first post wasn't the clearest - lots of half sentences. I'm a little shaken.

It got a 'requires improvement' score, louise. Thank you for the advice.

Fizrim Sat 28-Nov-15 23:10:39

I'm not surprised you are shaken. Who made the mistake with the oxygen order, the GP or the home?

jacks11 Sat 28-Nov-15 23:10:55

It sounds like you would be justified to make a complaint about the fact that the oxygen recommended by your DGM's GP was not collected by the care home in a timely fashion- given that it was prescribed as the result of an acute event (her chest infection). I think you would also have grounds to ask why the nurse allowed her oxygen saturations to be so low, and for an extended period, before taking any action. That is a poor level of care.

As to how to do that, I imagine the home will have a complaints procedure and I would make a complaint via this in the first instance. If the outcome from this complaint is not satisfactory then take it higher via local SS and if necessary CQC.

Something I am confused about is why your grandmother was not taken to the hospital if she was unwell enough to require oxygen but none is available in the home? I recognise it is possible that part of her anticipatory care plan may be that she should not be admitted to hospital (and I could understand this- they aren't the best places for elderly patients with dementia). However, given that she has sustained hypoxia (low oxygen levels in the blood) and is now dependent on oxygen for the time being, the options are limited as the paramedics really cannot just stay with her "as long as it takes" as she could conceivably need oxygen for many hours, taking an ambulance crew out of action for all that time. Arranging emergency oxygen cylinders can be quite time consuming if certain things are not known (e.g. what type of respiratory failure).

Where I work, if oxygen supply could not be obtained in a reasonable time frame the patient would have to be admitted (on a temporary basis) to hospital or GP bed in the local community hospital as it is just not possible to keep a paramedic with a patient throughout the night. It is simply not feasible.

I hope you get this sorted OP.

HattieA Sat 28-Nov-15 23:11:13

Agree Social Services. Also the county/borough CCG (Clinical Commissioning Group).
Community oxygen can be ordered and delivered within 4 hours. This home has no good excuse for not getting it sorted.

notamum3210 Sat 28-Nov-15 23:11:51

From what my mum has understood, the GP made the mistake but the home should have chased it up.

WhoTheFuckIsSimon Sat 28-Nov-15 23:11:53

I was reading this with my mouth open.

CQC Monday morning!

LaLyra Sat 28-Nov-15 23:12:49

I'd go to senior management, social services and the Care Quality folks as a matter of urgency. I'd also be ringing around other care homes locally to find out who had spaces and pushing for a move because you'll never be able to trust them again.

There is a huge difference between DNAR and negligence and it's disgusting that a nurse wasn't phoning your Mum to say "this is happening, I'm chasing the oxygen urgently..." (assuming she isn't part of the error).

KeepOnMoving1 Sat 28-Nov-15 23:13:51

Omg how stressful for you allsad
Please you need to make a loud noise about this. It's so unacceptable this has happened. How is your grandma now op?

LaLyra Sat 28-Nov-15 23:14:25

If it's the GP's error then it sounds like there's been a big gap that the quality of care your grandmother is entitled to has fallen into. She should reasonably expect the GP to sort it, and she should be able to reasonably expect the people responsible for her care in the home to follow it up.

jacks11 Sat 28-Nov-15 23:18:57

Community oxygen can be ordered and delivered within 4 hours

Yes, in normal hours. On a saturday night is going to be more difficult, especially if paperwork not in place. The out of hours GP should be able to do the paperwork if the original GP made a mistake, but this could take longer as it is a saturday night.

I can understand that things may have been delayed by GP not doing paperwork correctly in the first instance, which should be highlighted to the practice (so they can make sure everyone knows the correct procedure)- but the nursing home should have realised this on Wednesday as they should have been ordering the oxygen ASAP. Then the prescription could have been corrected on Wed/Thursday and Oxygen cylinder provided by Thursday PM.

There isn't an excuse for this, nor any for the trained nurse checking oxygen saturations every 2 hours but doing nothing to correct them when clearly this was a sustained and deteriorating situation.

headexplodesbodyfreezes Sat 28-Nov-15 23:23:29

Paramedics don't turn up with oxygen and settle down for "as long as it takes". A paramedic's role is to provide immediate care. If they attend an elderly patient with a chest infection and an oxygen requirement, who is in a place where oxygen is not available, they will transfer to hospital.


Aeroflotgirl Sat 28-Nov-15 23:37:43

uptheroad if you are in doubt about the op, report.

I wou,d remove gran from the home, make a complaint to SS and QCC. Sounds awful, what with the abuse, neglect of her care.

Aeroflotgirl Sat 28-Nov-15 23:39:08

Sorry Care Quality

notamum3210 Sat 28-Nov-15 23:42:05

uptheroad- I don't know what you're suggesting.

I know that that is the normal role of the paramedic but it was clear that this was an exceptional situation- I hate that this all had to happen as it was a totally avoidable scenario.

Wolpertinger Sat 28-Nov-15 23:47:16

Assuming you are in the UK, the primary error is with the GP in not ordering the oxygen. The home can't 'pick up the order' the GP faxes or emails it to the supplier direct and this clearly hasn't been done. The nursing home don't collect the oxygen concentrator (which is what the GP will have ordered), it's delivered by a supplier.

Nursing home could reasonably expect oxygen concentrator to be arriving whenever as they had nothing to do with it's ordering but when after several days it had failed to materialise it's very poor they were doing nothing to find out what had happened to it.

Only person not at fault appears to be the poor nurse on shift who has spotted your grandma is unwell, monitored her sats, called your mum as per power of attorney and called OOH GP as per her instructions.

Wolpertinger Sat 28-Nov-15 23:48:52

Ooops, re-read - can see GP has asked for a cylinder not a concentrator. However same system applies - they are delivered by a contractor contacted by the GP, not collected by the nursing home.

Shonajay Sat 28-Nov-15 23:50:57

Unbelievably shocking. Just to make you aware, if you complain to a BUPA hospital they won't treat you while the complaint is undergoing, sneaky.

headexplodesbodyfreezes Sat 28-Nov-15 23:59:52

It may seem exceptional to you, but it won't be to a paramedic. Patient with chest infection and low sats is not unusual.

The CQC do not investigate individual complaints. If you wish to do so, you first need to complain to the home. If you are unhappy with their response you then involve the Local Government Ombudsman (even if it is a BUPA home).

Junosmum Sun 29-Nov-15 00:08:00

Contact social services. That is safeguarding and needs to be investigated properly.

jacks11 Sun 29-Nov-15 00:12:05


Agree primary mistake was with GP. However, given that it was prescribed as part of treatment for acute condition- a chest infection (potentially on a background of another respiratory condition)- I would expect the care home to chase up if it had not arrived in a reasonable amount of time.

So, if it had not arrived by Thursday mid-day at the very latest (as GP had been out early Wednesday) I would expect the home to be contacting GP to ask what had caused the delay. Mistakes and delays do happen and that is why a good nursing home with organised staff would actively chase up what had happened to cause a delay in their resident getting access to treatment they need, and to do so promptly.

jacks11 Sun 29-Nov-15 00:22:01

Also agree with Uptheroad, it is odd a paramedic agreeing to stay "as long as needed" in this situation. Wonder if OP has the wrong end of the stick here as I don't think would be feasible for a paramedic to stay on one call all night on a saturday (at least not a call that is an "major incident")- it's a very busy time for the ambulance service. They may agree to stay for a little while to see if things can be sorted out quickly, but I dot think they could possibly agree to stay for an undefined period of time, potentially for many hours.

If the patient cannot be stabilised where they are- i.e. patient is dependent on oxygen to maintain adequate oxygen saturations- and no oxygen is available in the nursing home and cannot be accessed within a short period of time via emergency supply, then they would have few options but to admit to hospital until oxygen supply sorted. The paramedics would not be allowed to just camp out in the nursing home for the entire night to provide oxygen to one patient. That would potentially put other people in danger because they were out of action dealing with something that could be managed in more suitable way.

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