A Kenton nursing home has been rapped for failing to ensure a dying woman was seen by a GP as her health deteriorated.
Both management at the home - Kirkwood Court - and Newcastle City Council have been censured by the Local Government and Social Care Ombudsman (LGO) over the case.
The woman in question, known as Mrs Y, was suffering from Alzheimer's disease. In late September 2020, she was taken to hospital in an ambulance after reporting feeling unwell. She was discharged and given a course of antibiotics.
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But over the following days she continued to not eat or drink properly, and calls with her daughter - referred to as Miss X - were cancelled.
In Mrs Y's medical notes, care home staff wrote: "If no improvement tomorrow contact GP."
Care provider HC-One are commissioned to run the home by Newcastle City Council.
Despite records showing she was eating and drinking better a day later, the subsequent days saw Mrs Y deteriorate and a number of worsening health issues were identified.
Her food and water intake declined, and suffered from gastrointestinal problems and drowsiness. Later that week, Miss X spoke to her mother and reported she "was not herself".
When this continued, Miss X requested staff contact a GP, but this did not happen. Two days later a GP finally visited Mrs Y and arranged for her to be taken into hospital. There nurses told the woman's daughter that her mum's illness had caused skin damage.
She then complained to the care home on the basis that she had not been told how ill Mrs Y was.
Shortly afterwards, she was diagnosed with a terminal illness.
After Miss X's complaint, Newcastle City Council began its safeguarding procedures, while HC-One also ran a safeguarding investigation.
HC-One's own investigation found "medical intervention was not sought in a timely manner and possibly delayed Mrs Y’s diagnosis" but Miss X was not informed about the outcome.
Mrs Y died in early November. In a response to a complaint from Miss X, HC-One accepted its communications were "very poor" and its staff had "missed opportunities" to refer Mrs Y to a GP.
The care home has admitted "falling short" and apologised to Mrs Y's family.
The LGO found: "The care home did not start food and fluid charts until 10 October despite Mrs Y not eating and drinking consistently since she came out of hospital. This delay was fault. Had it done so it may have taken action sooner to address this."
They added the care home had failed to keep records of the woman's health and found fault with the delays in seeking further medical attention.
The LGO also said Newcastle City Council should have discussed its safeguarding process with the woman's family, and that there was no evidence the authority had followed up with HC-One to ensure the "lessons learned" had been implemented.
The council has been told it must ensure the results of safeguarding investigations are promptly fed back to families of those concerned.
The ombudsman added: "The delays in the care home seeking medical attention caused Miss X avoidable uncertainty, as to whether her mother’s skin, and general health would have deteriorated to the extent it had if it had sought medical intervention sooner."
In response, a Kirkwood Court spokesperson said: "Our priority is to deliver the best possible care for each resident we serve, so we deeply regret that on this occasion we fell short of the standards residents and their loved ones rightfully expect and deserve. We apologise to the family affected."
“As noted by the Ombudsman’s report, we have already learned lessons from this family’s experience, including taking steps to strengthen our documentation and resident monitoring processes.
"We are also making sure we work more closely with and seek greater input from our GP partners, so that we are consistently providing the best possible care.”
A Newcastle City Council spokesperson said: "As a council, we expect the highest level of standards from our providers and were disappointed to find, in this instance, the care received fell below the standard we would expect.
"On occasions such as this it is important we acknowledge and learn lessons from the issues raised to improve the experiences of all residents. We fully accept the findings of this judgement, have apologised to the complainant, and are working through the required actions."
The council has agreed to pay Miss X £300 in recognition of the injustice caused.
