CONFI DENTI AL REPORT

l ndependent Revi ew
of
Heal t h Aspect s of compl ai nt recei ved by NHS Wi rral f rom Mr
Leonard Beddows i n regard to Mrs Doreen Beddows
Date of Compl eti on 3' d Febru ary 2013
Terms of Reference
1. Revi ew the care provi ded by El derhol me Care Home to Mrs Doreen Beddows,
speci fi cal l y rel ated to the ti meframe associ ated wi th the compl ai nt made by Mr
Leonard Beddows. Determi ne i f there i s any evi dence to i ndi cate that Mrs
Beddows cl i ni cal care fel l bel ow expected standards at any ti me duri ng the sai d
oer i od.
2. Revi ew the acti ons taken by the Conti nui ng Care Team speci fi cal l y rel ated to the
ti meframe associ ated wi th the compl ai nt made by Mr Leonard Beddows.
Exami ne i f the Conti nui ng Care Team fai l ed, or not, to fol l ow expected standards
i n respect of i ts responsi bi l i ti es and/or duti es rel ated to Conti nui ng Heal thcare
commi ssi oni ng r esponsi bi l i t i es.
I ndependent Revi ewer
Name Desi onat i on Qual i fi cati ons
Mrs Lorrai ne Norfol k Cl i ni cal Lead, NHS
Merseysi de
RGN. BSc. MSc
Pati ent whose case i s bei ng
Name: Mrs Doreen Beddows
PCT Contact for communi cati on:
Ms Janet Hope, Seni or Compl ai nts Offi cer. Qual i ty & Governance.
Tel : 0151 514 2888
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 1 of 19
DOB: 1010311945
Mai n contact for communi cati on and contact detai l s:
Mr Leonar d Beddows
-
husband. Tel . 07742965289
Evi dence
The revi ew consi dered al l the evi dence contai ned wi thi n the records l i sted bel ow
whi ch had been made avai l abl e by NHS Wi rral for the purpose of the revi ew.
NHS Funded Nur si ng Car e Assessment s and Cont i nui ng Heal t hcar e Recor ds,
i ncl udi ng correspondence and database entri es
Care Home records
Input from Mr Beddows
-
meeti ng hel d wi th Mr Beddows, i n the presence of
Mrs Beddows, 18/1 112012.
Backgr ound and Chr onol ogy
2008
Mr Beddows i ni ti al l y rai sed concerns wi th the Matron, Chri sti ne Whi tesi de, at
El derhol me Care Home about the standard of care for hi s wi fe i n Apri l 2008. He
eventual l y wrote to Matron on 16th May 2008 fol l owi ng her i nvi tati on to make an
appoi ntment to meet. A meeti ng was hel d on 20tn May 2008, and the Matron wrote
to Mr Beddows on 22no May 2008 to cl ari fy the outcome of thei r meeti ng. Al l i ssues
rai sed were di scussed. cl ari fi ed and a cl ear
pl an
of acti on was aqreed.
The records i ndi cate that due to changes i n commi ssi oni ng arrangements between
the Local Authori ty and the PCT i t had come to l i ght that the fees bei ng pai d for Mrs
Beddows were i ncorrect, and the home had been noti fi ed that the payments for care
woul d be reduced. The care home was not happy about thi s and wrote to the PCT
accordi ngl y. In a l etter to the PCT, dated 26th June 2008, the Di rector, Mr B Wood,
of El derhol me Nursi ng Home rai ses concern about the reducti on i n fees concerni ng
the care of Mrs Beddows. He states that he has al so i nformed Mr Beddows. The
commi ssi oni ng i ssues hi ghl i ght that a revi ew of care needs i s overdue. On
g' n
October 2008 the PCT recei ved a tel ephone cal l from new Matron at the home,
Heather Ward, who i s seeki ng cl ari ty as to why payments for Mrs Beddows care
have been reduced. A si mi l ar cal l i s al so recei ved from Di rector Mr B Woods on the
same day.
Duri ng a vi si t to the care home on 24th October 2008, Nurse Assessor from the
Conti nui ng Heal th Care Team, Al i son Al dcroft, was approached by Mr Beddows.
She recorded that Mr Beddows i nformed her that he was aware of the fundi ng i ssues
and rai seed hi s concern that the care of hi s wi fe may be affected. The nurse
reassured hi m that the assessment woul d i denti fy al l the care needs. A revi ew of
car e needs was or gani sed and event ual l y t ook pl ace on 1Ot h November 2008. The
outcome of the revi ew cl ari fi ed that Mrs Beddows remai ned el i qi bl e for NHS
Cont i nui nq Heal t hcar e f undi no.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 2 of 19
2009
In May 2009, Mr Beddows was i nvi ted by Matron Heather Ward to attend a meeti ng
to di scuss the care of Mrs Beddows. Present at the meeti ng was GP Dr Meyer and
Assi stant Matron Vi cki Wotton. There i s no cl ear i ndi cati on i n the records about the
i ntended purpose of the meeti ng; however, there are documented mi nutes that have
been agreed by the GP. For the purposes of thi s revi ew onl y the agreed mi nutes by
the GP have been taken i nto account, as i t i s not possi bl e to veri fy the addi ti onal
comments made by Mr Beddows at thi s poi nt.
The detai l of the mi nutes refl ect that the Matron was concerned that Mr Beddows
was havi ng a negati ve i mpact on hi s wi fe' s care and that she had recei ved
compl ai nts from the professi onal s i nvol ved wi th her care. Mr Beddows was
concerned that the purpose for the meeti ng had not been communi cated cl earl y to
hi m as he was l ed to bel i eve that the meeti ng was to di scuss hi s wi fe' s di et. The
mi nutes cl earl y refl ect i naccurate percepti ons of events from the Matron' s part. The
GP was abl e to cl ari fy, for exampl e, that Matrons understandi ng of the conti nence
revi ew was i naccurate. In addi ti on, the records refl ect that there were no compl ai nts
about Mr Beddows from external professi onal s who were i nvol ved i n the care of Mrs
Beddows, and thi s has been confi rmed by the servi ces i nvol ved. Matron rai sed the
concern that Mr Beddows' i nsi sted on 3 peopl e attendi ng to hl s wi fe for transfers
even when he was present. She stated he al so i nsi sted on hourl y checks of hi s wi fe
and the i nterventi ons bei ng recorded. The Matron al so made reference to the l evel
of care for Mrs Beddows i n rel ati on to the number of resi dents i n the home, and i n
compari son to a pati ent i n i ntensi ve care. Matron al so made reference to a
compl ai nt made speci fi cal l y by a member of staff i n the care home about Mr
Beddows.
The meeti ng ended wi th a recommendati on by the GP that al l parti es
' draw
a l i ne'
under the i ssues rai sed and move fonvard. Mr Beddows asked for cl ari ty i n rel ati on
to 3 peopl e bei ng requi red for transfers, the need for hourl y checks of hi s wi fe, and
confi rmati on that hi s wi fe woul d be got out of bed between the hours of 1pm and
2pm Assi stant Matron responded that she coul d not guarantee the ti mi ng but they
woul d stri ve to achi eve thi s.
The care pl an for Mrs Beddows was prescri bed i n her di scharge pl an from
neurol ogi cal servi ces, and has been rei nforced as appropri ate by the previ ous
Matron i n her response to Mr Beddows i n 2008. The care pl an i s di scussed i n more
detai l l ater i n the report. In addi ti on, the revi ewer i s unabl e to cl ari fy i f the compl ai nt
concerni ng the i ndi vi dual member of staff and Mr Beddows was ful l y i nvesti gated by
the Matron. The terms of reference of thi s revi ew have not i ncl uded a revi ew of the
care home' s response to compl ai nts concerni ng Mr Beddows.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 3 of 19
On 30' n June 2009 Matron Heather Ward wri tes to Mr Beddows i n response to
recei pt of the mi nutes from the meeti ng. She states there are
' facets
whi ch we feel
are a total l y i naccurate refecti on of events. However, after our meeti ng wi th Dr
Meyer and hi s di scussi ons wi th you, i t was agreed a
"l i ne
woul d be drawn i n the
sand", and we coul d al l move on from the
past. Therefore, i t i s poi ntl ess i n
respondi ng to the numerous detai l s of your l etter whi ch al l occurred pri or to the
di scussi on wi th Dr Mever' .
The care home conti nued to rai se concerns about payments for the care of a number
of pati ents and wri tes to the PCT i n June 2009. In a l etter dated 23' d Jul y 2OO9 the
Di rector of El derhol me wri tes
' Mr
Beddows conti nues to i nsi st that the protocol l ai d
down by Wal ton Neurol ogi cal Uni t i s executed to the l etter. Furthermore, he i nsi sts
he i s present whenever any procedure i s carri ed out on hi s wi fe and i s at pai ns that
hi s requests are made wi thi n the agreement before hi s wi fe came to us. For
exampl e, i t takes 17, hours wi th hi m present to bath hi s wi fe where he i nsi sts Care
Assi stants and Regi stered Nurses are present on each occasi on. Therefore, i n each
case, I bel i eve El derhol me i s enti tl ed to a reasonabl e i ncrease i n fees beari ng
everythi ng i n mi nd and I trust you wi l l take a personal i nterest i n thi s request' . The
PCT wrote to the care home on 20' n August 2009 and confi rmed the fundi ng
arrangements for the pati ents, i ncl udi ng Mrs Beddows, as correct.
On 1' 1th September 2009 Mr Beddows wrote a l etter of compl ai nt to the Chai rman of
El derhol me Nursi ng Home, Mr Rourke, about the treatment he had recei ved from the
Matron. He stated he remai ned upset by the events earl i er i n the year and fel t hi s
rel ati onshi p wi th the Matron was not sati sfactory and that he was enti tl ed to recei ve
di gni ty, respect and ki ndness from the Matron. He requested an expl anati on to the
events di scussed at the meeti ng i n May wi th parti cul ar reference to the manner i n
whi ch the meeti ng was convened and the atti tude of the Matron. Mr Rourke
responded to thi s l etter on 8th October 2009. He confi rmed that the meeti ng had
been cal l ed because they had recei ved a compl ai nt from a member of staff and al so
.;
because Mr Beddows
' was
conti nuousl y queryi ng and questi oni ng the care of the
' -
professi onal s at the home' . Mr Rourke confi rmed that the care staff woul d attempt to
meet the targets of checki ng Mrs Beddows every hour but stated that someti mes
ot her demands on t he cor r i dor may somet i mes cause a del ay. He went on t o expl ai n
that the home
' recei ves
the same payment for Mrs Beddows as for every other
pati ent on the corri dor and therefore thei r care must be real i sti c and proporti onate' .
Mr Rourke al so stated that he
' doubted
the care for Mrs Beddows woul d be better i n
any other home but you are free to transfer her i f you so wi sh. For the future, I trust
you wi l l desi st from the constant i nterferi ng wi th the professi onal care of your wi fe,
and shoul d you have a poi nt to make or suggesti on then i t shoul d be di rected to the
Matron onl y, and i f thought fi t, Mrs Beddow' s GP.'
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 4 of 19
On 28' n October 2009, Mr Beddows and Matron met i n an attempt to resol ve the on-
goi ng i ssues. There i s no evi dence i n the records to support that the i ssues were
resol ved at thi s ti me.
2010
l n May 2010, Mr Beddows wri tes to the PCT, vi a emai l , fol l owi ng a conversati on wi th
Matron Heather Ward. Mr Beddows states that Matron wanted to di scuss the i ssues
of hourl y checks and subsequent recordi ng on charts. Amongst, Mr Beddows
account of the meeti ng he refers to Matron stati ng that several experi enced medi cal
staff had deci ded that hourl y checks were not necessary. There i s no evi dence to
support thi s al l eged statement by the Matron i n the records. Mr Beddows expresses
concern that the care needs of hi s wi fe bei ng compared to that of other resi dents i n
the home and the fees that are made. He states he has rai sed hi s concern about the
atti tude of the Matron wi th the Care Qual i ty Commi ssi on, but that they have referred
hi m back to the Matron to resol ve. Mr Beddows suggests, i n rel ati on to hi s wi fe, that
' i deal l y
her care pl an shoul d be revi ewed by her consul tant or GP' but askes that i n
the meanti me can the PCT rei nforce that the care ol an must be adhered to. He asks
' can
you tel l me to whom I can l ook to hel p me wi th thi s probl em because I am
reachi ng the end of my sani ty i n what i s a very stressful experi ence anyway' .
In response, Paul i ne Hurst, Physi cal & Sensory Di sabi l i ty Revi ewi ng Offi cer from the
Conti nui ng Care Team wri tes that
' fol l owi ng
the revi ew of Mrs Beddows conti nui ng
heal thcare needs a recommendati on has been made for Consul tant Dr Pi nder to
revi ew Mrs Beddows' . In her response, she states that havi ng fol l owed thi s up wi th
Dr Pi nder' s secretary a referral has yetto be recei ved as of 7th May 2010. She al so
refers to the fact that she understands Mr Beddows conti nues to have di ffi cul ti es
concerni ng hi s wi fe' s care pl an and i t' i mpl ementati on, but states that unfortunatel y
the PCT
' do
not hol d the contracts wi th the care home and therefore have no
i nfl uence over the measuri ng of who gets how much etc.'
Mr Beddows responds further on 27th May 2010 to i nform the PCT, vi a Paul i ne
Hur st , t hat Mat r on has i nf or med hi m t hat hour l y checks wi l l no l onger be
i mpl emented and refers to the home not getti ng extra payments.
As Mr Beddows understood a referral was bei ng made to Dr Pi nder he spoke to the
GP because he thought an updated nursi ng needs assessment coul d be undertaken.
The GP confi rmed that he had not recei ved a referral from the home to contact Dr
Pi nder. Mr Beddows states that GP DR Meyer spoke to Matron the same day and
that Matron rei nforced to hi m that the hourl y checks woul d not be conti nued as the
care
pl an had been wri tten by the previ ous Matron and she di d not have to fol l ow i t.
Mr Beddows al so states that the Matron i nformed Dr Meyer that she had not asked
the GP to refer Mrs Beddows to Dr Pi nder because after further di scussi on wi th other
nurses they fel t a referral to Dr Pi nder was unnecessary as Mrs Beddow' s care
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 5 of 19
needs has not changed. Dr Meyer tol d Mr Beddows that he agreed wi th the Matron.
The revi ewer i s unabl e to establ i sh from the records i f the GP agreed wi th Matron
that a referral was not requi red and/or that Mrs Beddows care needs had not
changed. The records refl ect that Mrs Beddows care needs had not changed and
therefore there i s no i ndi cati on that a change i n care pl an was requi red.
In the same emai l Mr Beddows asks the di rect questi on of the PCT
' are
you sure that
your department has no authori ty to demand a revi ew?' He al so enqui res as to how
can a care home wri te a care
pl an, revi ew i t monthl y and then deci de not to fol l ow i t
wi thout consul tati on. Mr Beddows al so refers to previ ous correspondence at the end
of hi s emai l i n rel ati on to potenti al overchargi ng on hi s part i n rel ati on to the care of
hi s wi fe.
On' l Ot n June 2010 t he Di r ect or of El der hol me wr i t es t o Mr Beddows i n r el at i on t o t he
care fees. He cl ari fi es that the ori gi nal fundi ng for care was transferred from Arrowe
Park to the Pri mary Care Trust i n 2008. From thi s poi nt Mrs Beddows care was
funded through NHS Conti nui ng Heal th Care. Mr Woods i nforms Mr Beddows that i f
he wants addi ti onal care for hi s wi fe then he shoul d
' make
out a case and submi t hi s
fi ndi ngs to the Pri mary Care Trust as the purchasi ng authori ty.' A copy of the l etter
was sent t o Paul i ne Hur st at t he PCT vi a emai l on 13t h June 2010. I n hi s emai l Mr
Beddows referred to the i ssues about hi s wi fe' s care and thei r rel ati onshi p to the
issues about care fees. He reinforced his
_vi,e_w
that all he wished was for the care
-
4
n]a1
j o1 hi s wi fe to be fol l owed. He coul d see no i ndi cati on for i t to be al tered and
stated that he appreci ated the i ssues may be outsi de the remi t of the PCT but di d not
know to whom he coul d approach to assi st to resol ve the i ssues.
Fol l owi ng a conversati on wi th Paul i ne Hurst on 14' n June 2010 Mr Beddows wrote,
vi a emai l , to Paul i ne Hurst wi th i nformati on about hi s wi fe' s care
pl an. He noted
amendments and no menti on of hourl y checki ng. He al so referred to a meeti ng to be
schedul ed, i t i s not cl ear who was to attend the meeti ng. Further to previ ous emai l s
on 28th June 2010, Mr Beddows outl i ned hi s expectati on of the i ssues to be
di scussed at the professi onal s meeti ng to be hel d between the care home and the
PCT. He agai n rei terated that he knew thi s was outsi de the remi t of Paul i ne Hurst to
address, i t i s assumed bv the revi ewer he means PCT when he states thi s.
There i s a copy of a l etter dated l " Jul y 2010 i n the records wri tten by Mr Beddows
to the care home. He asks for cl ari ty as to whether the l etter he recei ved from the
home dated 8' n October i s the home' s ful l response to hi s compl ai nt. He requested a
copy of the home' s compl ai nts procedure and rei terated hi s concerns. There i s no
record of a response from the care home to thi s l etter i n the PCT fi l es.
Mr Beddows wr ot e agai n t o Paul i ne Hur st vi a emai l on 18t n Jul y 2010 wi t h f ur t her
i nformati on for consi derati on i n readi ness for the meeti nq to be hel d on 3oth Jul v
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 6 of 19
The i nformati on rel ates to fi nance and the care
pl an
and i ts i mpl ementati on and
management .
Revi ew Meeti ng 30th Jul y 2010.
Thi s meeti ng was attended by Paul i ne Hurst and Manager Dawn Vasco from
Conti nui ng Heal thcare Team, Heather Ward, Matron and Nurses Rachel Bl ackl ock
from El derhol me Nursi ng Home, and Mr Beddows, Notes were recorded by Sharon
Shackl ady f r om t he PCT.
The mi nut es r ef l ect al l t he ar eas of di scussi on concer ni ng t he car e pl an and
management of Mrs Beddows. There was an agreed outcome and the PCT agreed
to revi ew Mrs Beddows i n 3 months. The Chai rman of El derhol me Nursi ng Home
wrote to Mr Beddows on 6tn August, encl osi ng a copy of the mi nutes of the meeti ng,
and confi rmi ng that once they had recei ved confi rmati on from Mr Beddows that he
was happy wi th the mi nutes they woul d summari se the outcomes and i ncl ude them
i n the care pl an of Mrs Beddows. Mr Beddows repl i ed on 16' n August. The PCT
does not have a copy of thi s response.
On 3Oth November 2O1O a revi ew by the CHC Team was undertaken. Pri or to thi s
vari ous emai l and l etter correspondence was sent to the PCT i n whi ch Mr Beddows
i ndi cated that there remai ned i ssues wi th how hi s wi fe' s care was bei ng managed.
He al so outl i ned concerns i n terms of the rel ati onshi p between care and the care
fees. He al so i denti fi ed the remai ni ng outstandi ng i ssue of compl ai nt wi th regard to
the recommendati on that a referral be made to Dr Pi nder and the subsequent
deci si on not to do so by the Matron. He fel t that thi s i ssue remai ned unexpl ai ned.
There i s no evi dence i n the PCT records i n rel ati on to thi s i ssue at thi s ti me. The
outcome of the revi ew was Mrs Beddows remai ned el i gi bl e for NHS Conti nui ng
Heal t hcar e.
Mr Beddows recei ved a l etter from the Di rector of El derhol me Nursi ng Home, Mr
Woods, on 23' d December 2Ol 0 out l i ni ng t he basi s of a di scussi on hel d i n r el at i on t o
Mrs Beddows. The revi ewer assumes that the di scussi on referred to was that
between Mr Beddows, Mr Bri an Woods, Di rector of El derhol me, and Mr Bri an
Rourke, Chai rman of El derhol me i n December 2010. Mr Woods i ndi cated that hi s
under st andi ng of t he mi nut es f r om t he meet i ng i n Jul y 2010 was t hat t he hour l y
checks coul d be di spensed wi th, and that Mr Beddows agreed to thi s. He suggested
further di scussi on wi th the Matron and the PCT staff shoul d anv further cl ari fi cati on
be r equi r ed.
Mr Beddows wrote to the PCT, vi a Dawn Vasco, on 27' n December 2AA, to ask for
cl ari fi cati on of the outcome of the meeti ng on 3Oth Jul y. Mr Beddows referred to the
i ssues di scussed at the meeti nq i n Jul v 2010.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 7 of 19
He al so orovi ded detai l s of a di scussi on hel d wi th Matron and Mrs Beddows' two
named nurses wi th whom i t was agreed that the care pl an had not been compl eted
as agreed i n the l etter from Mr Rourke, and i nstead of wri ti ng i n the care pl an a chart
woul d be compl eted. He then referred to the revi ew undertaken by the PCT on 3Otn
November 2010 i n whi ch he states he was i nformed that the l evel of i nterventi ons
undertaken by the care home was acceptabl e at 460/o of i denti fi ed need. The
summary chart of i nterventi ons was prepared by Mr Beddows and i s avai l abl e i n the
PCT records. A l etter of response from Paul i ne Hurst, dated 13tn January 2011,
requesti ng consent to source the hospi tal records for Mrs Beddows, was sent out to
enabl e the PCT to respond more ful l y. Mr Beddows di d not recei ve thi s l etter unti l Sth
Apr i l 2011, post mar ked
' 1' t
Apr i l 2011 Ther e i s no evi dence t hat a mor e compl et e
response was sent di rectl y to Mr Beddows at thi s ti me i n the PCT records.
In the meanti me, Mr Beddows wrote to hi s MP, Al i son McGovern. In hi s l etter dated
28th December 2010 he wrote about the December meeti ng wi th the care home
di rector and chai rperson. He tol d of the conversati on about the compl ai nt to the MP,
a meeti ng wi th John Webb i n Bi rkenhead, (the revi ewer i s unaware of who thi s
person i s), and a subsequent unannounced i nspecti on by the Local Authori ty. Mr
Beddows seemed assured i n hi s l etter that the nursi ng home woul d rei nstate the
care pl an i n rel ati on to hourl y checks of hi s wi fe' s needs. However, he di d express
some concern that hi s compl ai nt was not bei ng deal t wi th properl y.
Mr Beddows al so referred to the revi ew
' l ast
autumn' undertaken by the PCT. He
does not provi de a speci fi c date but states he was i mpressed wi th the
professi onal i sm of the nurses and thei r knowl edge of Mrs Beddow' s condi ti on. He
stated that the nurses fel t that the di ffi cul ti es wi th the Matron were rel ated to
di fferences i n personal i ti es. Mr Beddows stated i n hi s l etter that he di d not agree
wi th thi s and gave an exampl e of how the i nconsi stency i n moni tori ng hi s wi fe can
affect her care. Mr Beddows stated he fel t he had exhausted the compl ai nts pol i cy
of the care home, and had recei ved no support from the care Qual i ty Commi ssi on or
the Local Authori ty. Toward the end of hi s l etter Mr Beddows refers accuratel y to the
descri pti ons of previ ous statements made to hi m i n l etters from the nursi ng home.
2011
l n a further l etter to hi s MP, dated 20tn Apri l 2011, Mr Beddows rel ated to the report
fol l owi ng the Soci al Servi ces i nspecti on. He stated he bel i eved the report contai ned
i naccuraci es. He i ndi cated that i n hi s meeti ng wi th the di rector and chai rperson of
El derhol me that they had tol d hi m that they fel t Shei l a Hi l l house from the PCT,
thought Mr Beddows was compl ai ni ng about hi s wi fe' s care. He confi rms he was
compl ai ni ng about t he al l eged l i es t hat t he car e home had made t o t he GP and PCT
that coul d have refl ected on hi s wi fe' s care.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 8 of 19
In a l etter to hi s MP dated 9' n May 2011 Mr Beddows stated that he had onl y made
on di rect compl ai nt to the care home i n September 2011 and that rel ated to the
al l eged behavi our of the Matron toward hi m. Mr Beddows descri bes exampl es of
responses made to hi m by the care home accuratel y. He outl i nes the areas of hi s
concern and hi s di ssati sfacti on wi th the Care Qual i tv Commi ssi on' s and Local
Authori ty' s response to hi s compl ai nt.
On 16th May 2011 the PCT i s asked to provi de a response to MP Al i son McGovern i n
rel ati on to the i ssues outl i ned i n Mr Beddow' s l etter. A l etter of response dated 11th
Jul y 2011 stated that i nformati on has been gathered from Mrs Beddows GP and al so
the rel evant Heads of Servi ce i n NHS Wi rral and Wi rral Communi ty NHS Trust. The
l etter outl i ned the i nstructi ons gi ven by the Di eteti c Servi ce i n rel ati on to a cal l from
the care home. The RGN at the home had contacted the servi ce as she was
concerned that the fl ui d i ntake was too hi gh i n rel ati on to fl ui d output. Informati on
was al so
provi ded
i n rel ati on to the conti nence servi ce and i ts response to i ssues
rel ated to the supra-pubi c catheter. Both servi ces cl ari fi ed that they di d not make
any compl ai nts about Mr Beddows. Dr Meyer provi ded a response that stated he
was happy wi th the care the home was provi di ng to Mrs Beddows. He al so i ndi cated
' great
respect' for Mr Beddows i n overseei ng hi s wi fe' s care and remarked that Mr
Beddow' s concern to do the very best for hi s wi fe was commendabl e. Confi rmati on
,
was al so provi ded i n rel ati on to revi ews undertaken by the CHC Team and that no
fcompl ai nts
had been recei ved i n rel ati on to the medi cal care gi ven to Mrs Beddows.
However, the confi rmati on that there was no record of a recommendati on made to
refer Mrs Beddows to Dr Pi nder was i naccurate. There i s evi dence that thi s was
i".iro-.id-on-bdt6i6;ursfrttiome-noLs and PCT records electronically and in the
case fi l e. In fact, thi s recommendati on del ayed the case bei ng prepared for panel as
Paul i ne Hurst wi shed to have the i nformati on from the outcome of thi s referral to
compl ete her presentati on.
On 2nd September Mr Beddows wrote to Mr Khan, CHC Manager. He provi ded
i nformati on i n rel ati on to the recommendati on to refer Mrs Beddows to Dr Pi nder by
Nurse Paul i ne Hurst. Mr Beddows al so
provi ded
i nformati on i n rel ati on to the
ti mel i ne of events rel ati ng to correspondence wi th the care home and the PCT. He
asks Mr Khan to request the care home to rei nstate the hourl y checks of hi s wi fe and
to i nform the care home that thi s i s a requi rement wi thi n the fees bei ng pai d for hi s
wi fe' s care.
On 26th September Mr Beddows wrote to Mr Khan vi a emai l aski ng for a response to
hi s earl i er l etter by 2nd October 2011. In hi s response dated 27th September 201' 1,
Mr Khan wrote that the PCT are happy that Mrs Beddows i s appropri atel y pl aced at
El derhol me and acknowl edges the poi nt of tensi on about how the care i s del i vered.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 9 of 19
He stated that i t woul d be i nappropri ate to di rect how the care i s gi ven by the home
and i nformed Mr Beddows that the matter di d need to be deal t wi th by hi msel f and
the home.
l n November 2011the PCT recei ved a l etter from Lawson Stebbi ngs, Chi ef Executi ve
Offi cer, El derhol me Nursi ng Home i nformi ng them of formal noti ce gi ven to Mrs
Beddows ci ti ng her husband' s conduct as the reason for thi s. A strategy meeti ng
was hel d and the PCT met wi th Mr Beddows, al ong wi th Local Authori ty Col l eagues
on 18t h November 2011. On 23' d November 2011 t he PCT r ecei ved an emai l f r om
the MP Al i son McGovern' s offi ce to i nform them that Mr Beddows does not feel he i s
getti ng support from the PCT.
On 25th November 2011 Mr Beddows sol i ci tor wrote to El derhome to request a
wi thdrawal of the evi cti on noti ce and stati ng that they wi l l seek Court of Protecti on
and deci si on by a Hi gh Court Judge. A request for a wri tten deci si on i s made by 28tn
November 2011. A r esponse i s made by El der hol me Nur si ng Home t he same day
stati ng the evi cti on noti ce i s i rrevocabl e. Mr Stebbi ngs states that
' i n
the l i ght of an
i ndependent advocate bei ng appoi nted for Mrs Beddows and the i nvol vement of
Wi rral Soci al Servi ces the demands of the sol i ci tor are unnecessary and premature
as are the suggested recourse to the courts.'
Mr Khan, PCT, spoke to GP Dr Meyer on 28th November 2011 i n rel ati on to Mrs
Beddows and the potenti al move to another care home. Dr Meyer fel t that Mrs
Beddows woul d become di stressed by a move. Dr Meyer expl ai ned that whi l st Mrs
Beddows was di agnosed as bei ng i n a Persi sti ve Vegetati ve State she di d respond
t o t ouch, was f ami l i ar wi t h her sur r oundi ngs, and di d r espond t o si mpl e quest i ons by
bl i nki ng her eyes. Al though Dr Meyer fel t i t woul d not be i n her best i nterests to
move, she was medi cal l y fi t to move. Mrs Beddows transferred to Val e Court
Nur si ng Home on 6t h December 2011.
On 8tn December 2011 Mr Beddows wrote to the PCT. He referred to the previ ous
l etters to hi s wi fe' s MP. Mr Beddows confi rmed that he has onl y made one
compl ai nt to the care home si nce 2009 about the Matron al l egedl y gi vi ng the GP
fal se i nformati on and bei ng aggressi ve i n nature toward hi m. He stated that he feel s
hi s compl ai nt has never been ful l y i nvesti gated and the repl i es from the home have
not been sati sfactory. He made a request for the matter to be i nvesti gated further by
someone wi t h medi cal exoer i ence.
2012
On 10th Apri l 2012 PCT wrote to Mr Rourke at El derhol me Nursi ng Home, Nei l
Ryder, Di rector of Corporate Affal rs, NHS Commi ssi oni ng Support Servi ce, and Mr
Dave Jones, Compl ai nts Manager at the Di rectorate of Soci al Servi ces (DASS)
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 10 of 19
requesti ng an i nvesti gati on and response to outl i ned concerns by 22nd May 2012.
On 18th June 2012 the PCT and DASS provi ded a
j oi nt
response to Mr Beddows.
The l etter i nformed Mr Beddows that they woul d be wi l l i ng to commi ssi on an external
compl ai nts i nvesti gati on offi cer to exami ne the i ssues rel ati ng to Mrs Beddow' s
' evi cti on'
from El derhol me and the subsequent safeguardi ng referral . A
j oi nt
apol ogy
was gi ven to Mr Beddows i n acknowl edgement that the servi ce he recei ved had not
met hi s expectati ons and caused upset and i nconveni ence to Mr Beddows.
There i s no evi dence i n the records that El derhol me Nursi ng Home have made a
resoonse to the l etter from the PCT
Terms of reference and Fi ndi nqs
TOR 1: Revi ew the care provi ded by El derhol me Care Home to Mrs Doreen
Beddows, speci fi cal l y rel ated to the ti meframe associ ated wi th the compl ai nt
made by Mr Leonard Beddows. Determi ne i f there i s any evi dence to i ndi cate
that Mrs Beddows cl i ni cal care fel l bel ow expected standards at any ti me
dur i ng t he sai d per i od.
Backqr ound
Mrs Doreen Beddows was transferred to the Wal ton Centre i n June 1999 for acute
management havi ng suffered a catastrophi c i ntra-cerebral haemorrhage. She
undenvent crani otomy and evacuati on of the haematoma the same day as her
col l apse. Her best post-operati ve neurol ogi cal status was fl exi ng to pai n. Her
recovery was compl i cated by several chest i nfecti ons. She was admi tted to
El derhol me Nursi ng Home i n October 2000 fol l owi ng di scharge from Wi rral Neuro-
Rehabi l i t at i on Uni t .
At thi s ti me Mrs Beddows was descri bed as bei ng i n a vegetati ve state and al though
she experi enced some spontaneous eye openi ng there was no evi dence of
purposeful response to sti mul i . She had a supra-pubi c catheter and Percutaneous
Endoscopi c Gastrostomy (PEG) feedi ng tube i n pl ace. She was di agnosed wi th
epi l epsy and suffered sei zures. Her care needs were cl earl y i denti fi ed at thi s ti me
and management of care was prescri bed by Speci al i st Regi strar and Ward Manager.
Mrs Beddows requi red spl i nts and passi ve exerci ses for her l i mbs to prevent the
devel opment of contractures. She requi red the admi ni strati on of mul ti pl e
medi cati ons and feeds; and moni tori ng of symptoms by a regi stered nurse. She had
a t endency t o bi t e her l ower l i p and r equi r ed or al hygi ene. Reposi t i oni ng was a
cri ti cal el ement to her care as sne experi enced vomi ti ng i t snefi afEpi Sfrr,eO too
qui cki y afGi a feed and probl ems wi th breathi ng due to poor neck posture. She
requi red 3 e for al l reposi ti oni ng to ensure effecti ve head control . Her opti mum
+, - - >-
ti m-i h-a wheel chai r was 4 to 5 hours. She al so experi enced excessi ve sal i vati on
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 11 of t 9
She requi red careful moni tori ng of her bl adder, bowel s and ski n i ntegri ty, and
requi red the use of anti -embol i sm compressi on stocki ngs on a dai l y basi s.
She was i denti fi ed as requi ri ng hourl y moni tori ng
!q!."..
B-ai n,
si gns of catheter
' OypftStnj-and
signs of OetadneO PfC tufFnyalGlfreO nurse. She required the
supevi si Q1 ol _a gyql i fue_Q
l urse
duri ng al l transfers between bed and chai r, and
d u ri n g he r we_ekl y s gQ1p11o_l p"_!h
Anal vsi s of evi dence
Mrs Beddows care needs have been wel l documented as remai ni ng unchanged
throughout the whol e of the revi ew peri od. She requi res regul ar moni tori ng by a
r egi s t er ednur Seandr ev i ews f r omt heGP, di m, pr c nur s e,
and Communi t y Mat r on. I n r el at i on t o:
Cogni ti on: Mrs Beddows i s unabl e to demonstrate any ori entati on to her
envi ronment. She di spl ays no awareness of very basi c understandi ng. GP has
assessed her as havi ng some fami l i ari ty of her surroundi ngs, respondi ng to touch
and abl e to bl i nk i n acknowl edgement of extremel y si mpl e questi ons onl y.
Psychol ogi cal & Emoti onal needs: Has occasi onal epi sodes of di stress whi ch
respond to reassurance. These epi sodes can rel ate to epi sodes of anxi ety i n
rel ati on to coughi ng and attempts to cl eari ng her ai n,ray.
Communi cat i on: Mr s Beddows i s unabl e i o r el i abl y communi cat e even wi t h
maxi mum suppor t .
Mobi l i ty: Mrs Beddows i s compl etel y i mmobi l e and requi res a hoi st and the
assi stance of 3 peopl e for al l transfers, and 2 peopl e for al l care i nterventi ons.
Posi ti oni ng of head and neck support i s cruci al to mai ntai n ai rway. She requi res
speci al i st equi pment to support posture and to bathe. She requi res reposi ti oni ng 3
to 4 hourl y, and passi ve exerci ses to prevent contractures.
Nutri ti on
-
food and dri nk: Mrs Beddows i s ni l by mouth and requi red PEG feed for
al l nut r i t i onal i nt ake. She r equi r es moni t or i ng f r om a di et i ci an r egul ar l y. Fl ui d
bal ance r equi r es moni t or i ng dai l y. She r equi r es or al hygi ene dai l y. She i s at r i sk of
mal nut r i t i on and r equi r es wei ghi ng and BMI cal cul at ed r egul ar l y,
Conti nence: Mrs Beddows has a supra-pubi c catheter and requi res regul ar bl adder
washouts and management from conti nence servi ces. Her catheter i s probl emati c
and i s changed regul arl y. Her bowel s are managed wi th enemas prescri bed by her
GP who advi ses on a r egul ar basi s.
Ski n I nt egr i t y: PEG si t e r equi r es dai l y cl eansi ng and moni t or i ng. She r equi r es
reposi ti oni ng 2 to 3 hourl y to mai ntai n ski n i ntegri ty. Tol erance for sttti ng i n a chai r i s
4 t o 5 hour s. She i s at hi qh r i sk of ski n br eakdown due t o i mmobi l i t v.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 12 of 19
Breathi ng: Mrs Beddows i s prone to chest i nfecti ons. She needs support to cl ear
her upper respi ratory tract through correct posi ti oni ng of head and neck.
Drug Therapi es, medi cati on & Symptom Control : Mrs Beddows i s prescri bed
mul t i pl e medi cat i ons i n addi t i on t o PEG Feeds as f ol l ows:
.
Oxybutyni n 2.Smgs twi ce dai l y (for uri nary symptoms)
.
Ascorbi c Aci d 500mgs twi ce dai l y (vi tami n c)
o Domperi done 1mg three ti mes dai l y (anti -emeti c)
.
Senna 1Smgs at ni ght ( f or const i pat i on)
. Bacl ofen Smgs twi ce dai l y (muscl e rel axant)
o Carbamazapi ne 200mgs three ti mes dai l y (anti convul sant and mood
stabi l i ser)
.
Par acet amol sol ubl e 1g f our t i mes a day ( anal gesi a)
In addi ti on, she has a Latex al l ergy and requi res al l medi cati on to be admi ni stered
vi a her PEG. Over the revi ew
peri od
Mrs Beddows has been
prescri bed
anti bi oti cs
as fol l ows:
. 2008- 5cour ses
.
2009- 2cour ses
o 2010- 4cour ses,
o 2011
- 2cour ses,
nasal cr eam and eye oi nt ment
eve oi ntment
Mrs Beddows has compl ex needs. Her posture i s cruci al to mai ntai ni ng her arrway
and combi ned wi t h moni t or i ng her f or si gns of pai n, epi l epsy, and pot ent i al pr obl ems
wi th her PEG and catheter, and frequent moni tori ng of her ski n i ntegri ty. The nature,
i ntensi ty, compl exi ty and unpredi ctabi l i ty of her care needs mean that she requi res
regul ar moni tori ng every hour.
Al tered State of Consci ousness: Mrs Beddows has a di agnosi s of epi l epsy and
has a hi story of sei zures. She i s prescri bed medi cati on.
Care Records
The care pl ans refl ect al l the care needs for Mrs Beddows. Care pl ans are revi ewed
regul arl y and updated. However, there are some anomal i es. Over the years
reposi ti oni ng charts and fl ui d bal ance charts have been compl eted. There i s
si gni fi cant i nconsi stency as to where fl ui d bal ance and reposi ti oni ng have been
recorded. On occasi on fl ui d bal ance has been captured on reposi ti oni ng charts and
vi ce versa. In addi ti on i t i s cl ear that there i s i nconsi stency i n recordi ng of fl ui d
output, parti cul arl y i n rel ati on to measurement. Often uri ne output i s noted but the
amount i s not recorded. In 2006 new charts are i ntroduced. In 2010 new
personal i sed charts are i ntroduced that onl y records i nput. Throughout the whol e
revi ew peri od the dai l y i nputs and outputs are not total l ed. Wei ght, BMl , bl ood
pressure and pul se were recorded consi stentl y throughout the peri od.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 13 of 19
Overal l , the ti mescal es for i nterventi ons vary consi derabl y. Whi l st care pl ans are
si gned none of the dai l y i nterventi on charts are si gned on a regul ar basi s, often there
i s onl y one set of i ni t i al s.
The charts i denti fy that there i s a l ack of i nterventi on for reposi ti oni ng between the
hours of 5/6 am and 9/10 am on a dai l y basi s and i nconsi stency between the hours
of 2l 3pm and 6pm. Checki ng Mrs Beddows i s more consi stentl y recorded than
reposi ti oni ng. The l atter may be rel ated to vi si ts and tri ps out wi th Mr Beddows, but
thi s i s not cl ear from the records as ti mescal es for these tri ps out are not i denti fi ed.
There i s al so a l ack of evi dence to i denti fy how ski n i ntegri ty i s managed when Mrs
Beddows i s si tti ng i n her chai r. The use of both care charts, reposi ti oni ng charts and
fl ui d bal ance charts has resul ted i n i nformati on bei ng recorded i n any one of three
pl aces.
Concl usi on
It i s the requi rement of the care home and i ts care staff to keep contemporaneous
and accurate records for each pati ent. Whi l st the_care pl ans for Mrs Beddows
refl ected al l of her care needs and were regul arl y revi ewed and updated, the dai l y
charts did not reflect that the care had been consis-te-n,tLy m-a.naged.
TnEre is
- =- - a- =- - -
- . -
evi dence that tI-ere were ti mes when checki nq Mrs Beddows was undertaken and
recorded more consi stentl y than reposi ti oni ng. l nformati on was recorded i n di fferent
pl aces at di fferent ti mes. Dai l y records and summari es of i nterventi ons were not
det ai l ed. Whi l st t he dai l y summar i es wer e si gned, t he dai l y char t s wer e not
consi stentl y si gned, often they were i ni ti al l ed, and often by onl y one person.
[' tj t
u
opi ni on of the revi ewer that due to the l ack of consi stent record keepi ng cl i ni cal care
was compromi sed and fel l bel ow expected standards.
TOR 2: Revi ew the acti ons taken by the Conti nui ng Care Team speci fi cal l y
rel ated to the ti meframe associ ated wi th the compl ai nt made by Mr Leonard
Beddows. Exami ne i f the Conti nui ng Care Team fai l ed, or not, to fol l ow
expected standards i n respect of i ts responsi bi l i ti es and/or duti es rel ated to
Cont i nui ng Heal t hcar e commi ssi oni ng r esponsi bi l i t i es.
Backqround
As Mrs Beddows i s i n recei pt of NHS Conti nui ng Heal thcare fundi ng she recei ves
regul ar revi ews undertaken by the CHC Team, In l i ne wi th the requi rements of the
Nati onal Framework for NHS Conti nui ng heal thcare the revi ews take pl ace annual l y.
There i s no evi dence to suggest that the revi ews have not been undertaken
appropri atel y. As the care needs of Mrs Beddows have remai ned unchanged, she
has remai ned el i gi bl e throughorl t the revi ew peri od.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 14 of 19
l n May 2010, Mr Beddows wrote to the PCT, vi a emai l , fol l owi ng a conversati on wi th
Matron Heather Ward. Mr Beddows stated that Matron wanted to di scuss the i ssues
of hourl y checks and subsequent recordi ng on charts.
Mr Beddows expressed concern that the care needs of hi s wi fe were bei ng
compared to that of other resi dents i n the home and the fees that are made. He
stated he had rai sed hi s concern about the atti tude of the Matron wi th the Care
Qual i ty Commi ssi on, but that they had referred hi m back to the Matron to resol ve.
Mr Beddows suggested, i n rel ati on to hi s wi fe, that
' i deal l y
her care pl an shoul d be
revi ewed by her consul tant or GP' but asked that i n the meanti me can the PCT
rei nforce that the care pl an must be adhered to. He asked
' can
you tel l me to whom
I can l ook to to hel p me wi th thi s probl em because I am reachi ng the end of my
sani ty i n what i s a very stressful experi ence anyway' .
In response, Paul i ne Hurst, Physi cal & Sensory Di sabi l i ty Revi ewi ng Offi cer from the
Conti nui ng Care Team wrote that
' fol l owi ng
the revi ew of Mrs Beddows conti nui ng
heal thcare needs a recommendati on had been made for Consul tant Dr Pi nder to
revi ew Mrs Beddows' . In her response, she stated that havi ng fol l owed thi s up wi th
Dr Pi nder' s secretary a referral had yet to be recei ved. She al so referred to the fact
that she understood Mr Beddows conti nued to have di ffi cul ti es concerni ng hi s wi fe' s
care pl an and i t' i mpl ementati on, but stated that unfortunatel y the PCT
' do
not hol d
the contracts wi th the care home and therefore have no i nfl uence over the
measuri ng of who gets how much etc.'
It was i ncorrect to state that the PCT cannot i nfl uence the management of care i n
care homes. As responsi bl e commi ssi oner for the care of Mrs Beddows the PCT
shoul d act i n her best i nterests, provi di ng support for any i ssues between the care
home, pat i ent and t hei r f ami l y t o r esol ve any i ssues. As r esponsi bl e commi ssi oner
the PCT can assess, and revi ew, the standard of care and support the care home to
i mprove the care provi si on to i ndi vi dual pati ents. In addi ti on, the opportuni ty to
di scuss Matron' s concerns about the care
pl an
was mi ssed. Mr Beddows cl earl y
i ndi cated that he needed to support to address the i ssues. l t i s not cl ear from the
records i f seni or management were i nformed of the si tuati on by the nurse so that
support coul d be offered.
Mr Beddows responded further on 27th May 2010 to i nform the PCT, vi a Paul i ne
Hurst, that Matron had i nformed hi m that hourl y checks woul d no l onger be
i mpl emented and referred to the home not getti ng extra payments. As Mr Beddows
understood a referral was bei ng made to Dr Pi nder he spoke to the GP because he
thought an updated nursi ng needs assessment coul d be undertaken. The GP
confi rmed that he had not recei ved a referral from the home to contact Dr Pi nder. Mr
Beddows stated that GP DR Meyer spoke to Matron the same day and that Matron
rei nforced to hi m that the hourl y checks woul d not be conti nued as the care pl an had
been wri tten by the previ ous Matron and she di d not have to fol l ow i t.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 15 of 19
Mr Beddows al so stated that the Matron i nformed Dr Meyer that she had not asked
the GP to refer Mrs Beddows to Dr Pi nder because after further di scussi on wi th other
nurses they fel t a referral to Dr Pi nder was unnecessary as Mrs Beddow' s care
needs has not changed. Dr Meyer tol d Mr Beddows that he agreed wi th the Matron.
The revi ewer i s unabl e to establ i sh from the records i f the GP agreed wi th Matron
that a referral was not requi red and/or that Mrs Beddows care needs had not
changed. The records refl ect that Matron agreed Mrs Beddows care needs had not
changed and therefore there i s no i ndi cati on that a change i n care pl an was requi red.
Her rati onal e to GP Dr Meyer appears contradi ctory to her statement about Mrs
Beddows needs, and the need to al ter the care
pl an. l n the same emai l Mr Beddows
asked the di rect questi on of the PCT
' are
you sure that your department has no
authori ty to demand a revi ew?' He al so enqui red as to how can a care home wri te a
care pl an, revi ew i t monthl y and then deci de not to fol l ow i t wi thout consul tati on. Mr
Beddows al so referred to orevi ous correspondence at the end of hi s emai l i n rel ati on
to potenti al overchargi ng on hi s part i n rel ati on to the care of hi s wi fe.
There i s a l ack of cl ari ty as to why GP supported the deci si on of the Matron. The
CHC Team shoul d have addr essed t hi s so t hat t her e was cl ear under st andi ng i n
order to reassure Mr Beddows. l t was a reasonabl e request to request a revi ew of
Mrs Beddows needs to understand i f the care pl an needed to change, and Mr
Beddows was happy for thi s to happen. l t was al so i mportant that unti l a revi ew
establ i shed that a change i n the care pl an was requi red that the exi sti ng care pl an
shoul d remai n unchanged. Otherwi se, how coul d the PCT be assured that al l ri sks
were bei ng managed appropri atel y and care needs bei ng met. The revi ewer al so
notes that Mr Beddows, not for the fi rst ti me, has i nformed the PCT of hi s concerns
i n rel ati on to care fees.
Revi ew Meeti ng 3Oth Jul y 2010.
Thi s meeti ng was attended by Paul i ne Hurst and Manager Dawn Vasco from
Conti nui ng Heal thcare Team, Heather Ward, Matron and Nurse Rachel Bl ackl ock
from El derhol me Nursi ng Home, and Mr Beddows. Notes were recorded by Sharon
Shackl ady from the PCT.
The mi nutes refl ect al l the areas of di scussi on concerni ng the care pl an and
management of Mrs Beddows. l t i s noted that the reassurance gi ven to Mr Beddows
that 3 staff al ways carry out transfers when he i s not present was recei ved wel l . The
mi nutes of the meeti ng record the nurse i n attendance as sayi ng
' changi ng
Mrs
Beddows posi ti on earl y morni ng between 6am and 9am woul d depend on whi ch
carer was on duty, as Mrs Beddows woul d be l eft ti l l l ast i f a mal e carer was on duty' .
Whi l st Nurse Hurst stated that Mr Beddows requi red reassurance that hi s wi fe was
checked, she di d not take the opportuni ty to state that the care needs of pati ents do
not fi t around the staffi ng l evel s, i t shoul d be the other way round.
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
Page 16 of 19
Nurse Hurst al so stated that
j ust
because care was not documented i t di d not mean
i t had not happened. She f ai l ed, as di d her col l eague, t o under st and t hat how coul d
assurance be gi ven that care had been provi ded i f i t wasn' t documented. Nurse
Hurst went on to state that Mr Beddows had no probl em wi th the l evel of care gi ven,
he
j ust
wanted to be assured that the care pl an was fol l owed. Nurse Hurst fai l ed to
understand that the l evel of care i s di ctated by the care pl an.
The mi nutes al so refl ected the Matron' s concern about provi di ng hourl y checks for
Mrs Beddows bei ng documented. Matron stated that the care pl an sai d
' checks
not
document checks. Wi l l not document but wi l l al ways check hourl y. She stated that
thi s was putti ng staff on l i ne, puts too much onus on them' . Matron was not asked to
expl ai n thi s further, however, the PCT nurse suggested that am and pm i nterventi ons
were col l ated and then recorded. Mr Beddows sai d he woul d be happy wi th thi s.
However, i t i s uncl ear how i nformati on that i s not recorded can be col l ated. Matron
stated that
qual i fi ed nurses wi l l be the ones documenti ng, taki ng i nformati on from
carers. Nurse Bl ackl ock, from the care home, stated that
' staff
are onl y human,
mi stakes wi l l be made' . Matron stated that
' these
are l egal documents. Staff are
worri ed i f they put thi ngs on forms, and a chart i s not compl eted hourl y, then they
feel they woul d be l i abl e i n a court of l aw.' The CHC nurses di d not respond to these
comments and rei nforce the need to provi de contemporaneous nursi ng records.
There was an agreed outcome and the PCT agreed to revi ew Mrs Beddows i n 3
mont hs.
On 30th November 2010 a revi ew by the CHC Team was undertaken, Pri or to thi s
vari ous emai l and l etter correspondence had been sent to the PCT i n whi ch Mr
Beddows i ndi cated that there remai ned i ssues wi th how hi s wi fe' s care was bei ng
managed. He al so outl i ned concerns i n terms of the rel ati onshi p between care and
the care fees. He al so i denti fi ed the remai ni ng outstandi ng i ssue of compl ai nt wi th
regard to the recommendati on that a referral be made to Dr Pi nder and the
subsequent deci si on not to do so by the Matron. He fel t that thi s i ssue remai ned
unexpl ai ned. Ther e i s no evi dence i n t he PCT r ecor ds i n r el at i on t o t hi s i ssue at t hi s
ti me. The outcome of the revi ew was Mrs Beddows remai ned el i gi bl e for NHS
Conti nui ng Heal thcare.
Record Keepi ng
It was noted that the PCT records were not robust, parti cul arl y from the perspecti ve
of the database. l t i s not cl ear i f responses were made to al l the l etters and emai l s
from Mr Beddows. Where responses were made the ti mescal es were i nconsi stent.
For exampl e, the response, dated January 2011, to Mr Beddows l etter of December
2010, di d not reach Mr Beddows unti l Apri l . There i s no recorded expl anati on of why
t hi s happened.
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Concl usi on
Mr Beddows fi rst contacted the CHC Team i n May 2010. The Revi ew meeti ng di d
not t ake pl ace unt i l Jul y 3ot h 2010. l t i s uncl ear why i t t ook so l ong t o ar r ange t hi s
meeti ng. The CHC Team shoul d have met earl i er wi th a vi ew to resol vi ng the i ssues
between Mr Beddows and the care home. There are concerns noted earl i er i n
rel ati on to statements made at the meeti ng that were i naccurate and i nappropri ate
by both the care home staff and the CHC Team.
The i ssue concerni ng the recommendati on of a referral to Dr Pi nder for revi ew has
never been i nvesti gated. The rati onal e offered by the Matron to the GP contradi cts
her statement that the care needs of Mrs Beddows have not changed, thus negati ng
the need for a referral . l t has not been establ i shed wi th whom thi s deci si on was
agr eed.
The CHC team records were not robust and i t was evi dent that the team had
!a' (
responded to al l emai l s and l etters sent by Mr Beddows. There was evi dence that
there were del ays i n communi cati ng wi th Mr Beddows by the CHC Team and the
PCT general l y. There are no documented reasons for the del ays.
Lastl y, the CHC Team and PCT have fai l ed to respond to the need to i nvesti gate the
rel ati onshi p between the i ssues rel ated to care fees and the care pl an for Mrs
Beddows The PCT shoul d have stri ved to separate the two i ssues i n order to
mai nt ai n cl ar i t y, i n l i ne wi t h i t s r esponsi bi l i t i es i n r el at i on t o t he Nat i onal Fr amewor k
f or NHS Cont i nui ng Heal t hcar e.
Over al l Summar y and Concl usi ons
Havi ng consi dered al l the evi dence and after consi derati on of the terms of reference
i n rel ati on to the revi ew, i t i s the opi ni on of the revi ewer that due to the l ack of
consi stent record keepi ng cl i ni cal care for Mrs Beddows, at El derhol me Nursi ng
Home, was compromi sed and fel l bel ow expected standards. Furthermore, the
Conti nui ng Care Team, fai l ed to fol l ow expected standards i n respect of i ts
r esponsi bi l i t i es and dut i es under i t s Cont i nui ng Heal t hcar e ( commi ssi oni ng)
r esoonsi bi l i t i es i n r el at i on t o Mr s Beddows.
Recommendat i ons
1. An acknowl edgement from the PCT that the care pl an for Mrs Beddows
shoul d not be al tered wi thout a formal revi ew of her care needs, by the
appropri ate professi onal s, and onl y where a formal revi ew be i ndi cated
because there i s a change i n need i denti fi ed.
2. A revi ew of the care home records at El derhol me to ensure the dai l y records
are bei ng compl eted i n l i ne wi th the i denti fi ed care pl ans of pati ents.
3. A revi ew of the record keepi ng of the CHC Team and entri es on the database.
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4. Tr ai ni ng and Devel opment i n r el at i on t o commi ssi oni ng r esponsi bi l i t i es of t he
PCT andi or CHC Team and t he PCTs r esponsi bi l i t i es concer ni ng t he Nat i onal
Framework for NHS Conti nui ng Heal thcare.
5. An i nvesti gati on i nto the response of El derhol me Nursi ng Home to Mr
Beddows' compl ai nt . Thi s shoul d i ncl ude a r evi ew of t he Home' s compl ai nt
poi l cy.
6. A revi ew of the payments made by Mrs Beddows i n rel ati on to her care. l t i s
cl ear t hat Mr s Beddows car e needs have not changed si nce di schar ge f r om
Wi rral Neuro-Rehabi l i tati on Uni t. l t i s not cl ear that al l care costs have been
met by t he NHS.
Thi s report wi l l be scruti ni sed by NHS Wi rral i n order to ensure compl i ance wi th the
terms of reference of the review.
Lorrai ne Norfol k
Cl i ni cal Lead, NHS Funded Car e
NHS Mer seysi de
3' o February 2013
NHS Hal ton and St Hel ens, Knowsl ey, Li verpool and Sefton worki ng together
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