Calls for Care Investigation After Tragic Death

A woman suffered pain and discomfort before her death at Haldane House Nursing Home in Sandhurst, an ombudsman has found.

She was sent there for end-of-life care after leaving hospital, placed by the NHS Frimley Integrated Care Board and Bracknell Forest Council under the Mental Health Act.

Her daughter complained staff failed to look after a pressure sore on her heel and did not properly manage her food and fluid intake.

An investigation found dressings were not changed often enough, causing malodour, and staff failed to monitor her fluid intake. Towards the end of life she could not take fluids and needed mouth care, but her care plan was not updated to reflect this.

Staff suspected a stroke when they noticed a facial droop at 11.40am and called an ambulance at 12pm; the GP later concluded no stroke had occurred. The daughter said her mum showed signs a day earlier.

The care provider said it found no shortfalls; the council said the complaint was "substantiated". The daughter asked the Local Government and Social Care Ombudsman (LGSO) to review the case.

"I cannot say on balance, but for the service failure I have identified, the woman would have lived longer.

"However, the daughter has the uncertainty, distress and frustration that her mum's pain, quality of life and dignity for the last weeks of her life could have been better.

"In particular, the delay in assessing and treating the pressure sore, which would have left her in pain and discomfort and the uncertainty caused by the failure to properly record the mouth care provided."

The ombudsman asked the care provider and the council to apologise and to make service improvements. The daughter received £300 compensation, with £150 from Bracknell Forest Council and £150 from the care provider.

Dr Raj Krishnaiah from Haldane House Nursing Home said: "Following the events detailed in the complaint to the LGSO, ownership of the Haldane House has since been transferred to a new provider in March 2025.

"However, during our own investigation, we found that at the time of the incident, the home worked with the ambulance service, the resident's GP and the local authority in the provision of care.

"It reported the incident to the local authority adult safeguarding unit and to the home's regulatory body, the Care Quality Commission (CQC). We, the new owners, have since cooperated openly and with complete transparency with all external investigations into this case.

"The home's new management team is committed to a programme of continuous improvement. The organisation has also engaged Fulcrum, external specialist advisers, to provide independent expertise and support in the delivery of our continuous improvement programme.

"We have made a lot of changes in running the home to provide the best care and have also appointed a new manager to run the home.

"We are cooperating fully with the CQC and adult safeguarding throughout this process.

"We fully accept the LGSO report findings and the recommendations for action where it sees improvements can be made. We have acted on all clinical recommendations as a matter of priority.

"We would be happy to talk to any of our residents and their families if they have any concerns in relation to this story and reassure them of our absolute commitment to safeguarding and the provision of quality care to all our service users."

Grainne Siggins, executive director for people at the council, said: "The council welcomes the Ombudsman's investigation and has accepted its findings and recommendations in full.

"The Ombudsman did not find fault with the council's safeguarding investigation and concluded that it acted appropriately and proportionately in response to the safeguarding concerns raised.

"We are aware the Ombudsman found service failures by the care provider. As a result, the council is strengthening its oversight arrangements and will support ongoing service improvement.

"Work is already underway to implement agreed actions, including undertaking additional contract monitoring activity to review the provider's recording practices, care planning and service improvements.

"It would not be appropriate to comment further on the details of the individual case."

James Aldridge, Local Democracy Reporter