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Woman left to die alone in Surrey care home, Ombudsman investigation finds

An elderly woman was left to die alone by Surrey care home staff while her daughter was waiting in a nearby room, the Local Government and Social Care Ombudsman (LGSCO) has found.

The woman’s daughter complained she had been called too late to the care home Surrey County Council commissioned for her mother when her mother’s condition deteriorated in August 2019.

When she arrived at Puttenham Hill Care Home, owned by BUPA, she was left in a waiting area. Care workers told her that her mother was suffering with breathing difficulties and she had a headache. She said she was not told her mother was seriously ill and care workers were running round and the nurse ignored her.

The daughter went into her mother’s room 15 minutes later and found dried blood on the floor and oxygen pipes in her mother’s nose. It was apparent her mother had died, but nobody had prepared her for this.

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The agency nurse looking after her mother told paramedics who attended what had happened, but never spoke to the daughter or offered her any sympathy, according to the investigation.

A coroner’s inquest later found the woman had passed away from a brain haemorrhage, which would have been difficult to spot.

The Ombudsman found a number of issues with the care home’s handling of the death. It criticised the care home’s record keeping of the events that happened - the home's records had discrepancies about when emergency phone calls were made. The investigation also found the woman’s care fell below expected standards and there was not an effective way of working with the NHS in place to ensure the woman received timely medical care from paramedics.

The watchdog also discovered the care home did not have enough appropriately qualified staff, and appropriate action was not taken in response to the problem.

Michael King, Local Government and Social Care Ombudsman, said: “The daughter was not able to be with her mother as she died and her mother should not have been alone in the final moments of her life.

“Nobody should be left to find their mother in this way when they could have been prepared for the situation. But I cannot imagine the distress caused for this to then be compounded by a lack of compassion by care staff in the immediate aftermath.

“The council has already gone some way to investigating the daughter’s complaints, and I hope the further recommendations I have made should ensure that relatives are better considered when loved ones are receiving end of life care.”

Following the investigation, the council agreed to apologise to the daughter and make a symbolic payment of £500 to her.

Surrey also agreed to work with the care home to ensure it is regularly assessing staffing capacity and requirements so there are enough appropriately qualified staff at the care home.

The council has made additional plans to ensure all care staff at the home receive training in communication skills and bereavement.

“This should not have happened and we’re very sorry to the family involved for the distress this has caused them," a Surrey County Council spokesperson said.

They added: “We have fully accepted all the Ombudsman’s findings and apologised to the family, as well as making a payment. We’ve worked with the care provider to make sure they always have enough qualified staff on duty and we’re regularly monitoring that. We’re also making sure the provider gives all care staff training in communication skills around bereavement.

“Over and above that, we’re making sure this case informs our wider working with private and independent care providers to ensure that end of life care is always handled with the sensitivity and professionalism it deserves.

“Our thoughts and sympathies remain with the family following their loss.”

Linda Marks, Regional Director for the care home at BUPA, said: "This was an isolated incident and doesn’t reflect current practices at the home. We pride ourselves on high standards but fell short in this instance, and have sincerely apologised to the family.

"In the years since, we've introduced comprehensive measures to prevent it from happening again. These include further staff training and a significant reduction in the use of agency staff.”

BUPA has been working with the Local Safeguarding team and put an agreed action plan in place.

Adam Carey

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