My Complaint

My Complaint

Complaint about abuse and neglect at Hilltop Estate (name

changed) Nursing Home and failure of the Care Quality

Commission and the local Safeguarding Adults Board to

investigate this abuse

Dear Mr Burnham,

I ask you to investigate following case, as I am very worried about

the conditions at the nursing home where I have worked for the last

two and a half years. There are numerous worrying conditions at the

home, all known to the manager

Ms X.

As X also acted as head of care prior to becoming manager, I feel

she is personally responsible both for the home’s generally extreme

low standard of care as well as for a number of individual cases of

gross negligence and abuse. In neither of the positions X has held at

the home has she lived up to what can and should be expected from

somebody in charge of the care of vulnerable adults. Unfortunately,

despite concerns having been raised repeatedly not only by me but

by others, they have constantly been ignored by the home’s owner,

Ms Y.

Throughout the time I have worked at the home I have raised a

number of issues with X – all of which is carefully documented – but

on very rare occasions (only when my concerns once or twice have

been unfounded…) has there been a response; in all other cases I

have been met by silence.

There are a number of general issues of poor management resulting

in appalling conditions, and there are a number of specific cases

which need to be addressed separately. As X is fully aware of what

is going on at the home but does not act, I feel she is responsible for

these poor conditions of care of which following are examples.

  • People are not turned in their beds as they should. Due to

this laissez-faire attitude, serious pressure sores have been

allowed to develop, causing residents severe pain and

stress throughout the last months of life.

  • Residents are left unchanged with soaking and soiled pads

for prolonged periods. It is well known that residents are

not toileted according to their needs.

  • Call bells are generally not given to the residents. Not

giving residents their bell strings is routine at Hilltop

Estate. As residents in many shifts are not checked for

hours, this means these vulnerable people have no chance

of calling for help but are left to their own mercy. Another

method of avoiding buzzing is to slightly pull out the plug

from the socket; it looks like it is there, but this way the

call system has been put out of function.

  • Bruises on residents are commonly seen. Rough handling

is commonplace. Knowledge about this is on a regular

basis handed over between shifts, but X seems not

interested in finding out why residents – also those who are

completely unable to move their own limbs – can develop

bruises covering different parts of their bodies.

  • The general disorganisation is incredible. Just to mention

an example: it is often not possible to know which tooth

brush belongs to whom in a shared room. If somebody was

ever so lucky as to have her/his teeth brushed, it could very

well be done with the neighbour’s toothbrush.

  • Soap dispensers (including at staff‘s toilet) are repeatedly

empty when I come to work (I am only there in the week

ends), and there are only rarely paper towels to dry hands

in. Also at times when the home has been plagued by

diarrhoea this has not been reason for the manager to act.

As it is fair to expect that all staff (she included) use these

facilities, it is surprising that no action has been taken to

improve conditions. A poster recently put up showing how

to wash hands and turn of the water with the elbows is

hardly helpful, as it would request special hospital tap handles

to implement. It seems like this poster, as other

similar initiatives, is only there to give the impression that

hygiene is a concern. Better than posters would be to fill up

the soap and paper-towel containers.


  • Rarely drinks are given to the residents. It is common that

residents have no water or glasses in their rooms. If they

have, it is most often out of their reach. This is common

not only under normal circumstances but also during heat

waves and when the home has been plagued by bouts of

diarrhoea. It seems odd to notice that residents have been

written up to have oral rehydration solutions but have not

been given sufficient access to water…. Repeatedly I

notice that residents’ water glasses have not been changed

for several days and that some resident’s dishes from an

entire day have been building up on the table.

  • Pillows are more or less as a routine not properly placed

under the head of people in their beds. They have no

support for their heads but are, due to carelessness and lack

of staff supervision, regularly placed in very uncomfortable

positions and can stay so for hours.

  • It is common that residents are freezing in their beds due to

too thin and too few blankets.

  • Staff talk in foreign languages in front of residents and are

even chatting on mobile phones while feeding residents.

This is a widespread problem of disrespect well known to

the manager.

  • Repeatedly I have noticed (at start of my shifts) that radios

and television sets are tuned in to programs aimed at the

staff’s target group, not the residents’. Asked about this,

residents’ responses usually are that they do not like this

music, but ‘that is what the young people want’. I have

addressed this problem on numerous occasions and –

through the communication book – asked the manager to

act. After all, the residents live in the home, not the staff.

There has never been a response from the manager to any

of these entries.

  • A dangerous practice is widespread at the home: staff are

hoisting residents single-handedly. Because of lack of

implementation of instructions and due to some carers’

bullying of others, this can have (and has had) serious

implications for the safety of not only residents but also of

staff. Some members of staff dare not ask for help as

‘single-handling’ has been allowed to be the rule. The

saying is: ‘why can’t you when I can?’

  There have been a number of drug errors happening due to

mismanagement. The examples go from ‘trivialities’ to serious

failures. Prescribed drugs for residents have not been given long

periods of time due to the fact we didn’t have them and because –

though X repeatedly was asked to do something about it – we never

got them.

  Some examples: a group of residents were on daily Senna tablets;

then supplies stopped without obvious reason, and the same

residents continued – for weeks – without this medication. The

question was – why? Why was the drug no longer supplied? Why

did X not rectify the error despite numerous reminders? And, why

were these people on Senna in the first place if they, apparently,

could manage without? The last question, as all the others, had still

not been answered the day these residents, after weeks without,

again started to be given this laxative. It was obviously not because

they needed it but because it again happened to be delivered…. I

think it is clear that medicine should be given because people’s

conditions require it, and not for historical or other reasons.

Another resident was on Tiotropium (for a reason I would expect)

but was not given it for four weeks – because the appliance needed

had disappeared. Though X was repeatedly asked to act, no new one

was in this time-frame ordered. This is just an example. X would

never respond.

  Repeatedly it has happened that Resident TK has run out of

Clexane/Enoxaparine before end of cycle and has not been given

this for him important drug for days. Though this happened on

numerous occasions, less than the number syringes needed

continued to be ordered – more about this case later in this letter.

On 9th November 2009 I wrote: ‘X, LP (has been) one week without

Atropine.’ No response. Therefore, on 16th November 2009 I added

this: ‘X, I wrote last week about LP’s Atropine. We still have none.

Any explanation? This is a continuing drug error. Has this been

handled according to the (home’s own) Medication Policy and

Procedures, i.e. reported according to paragraph 5? Relatives were

not informed.’

  Still, no response. I had, however, talked to the daughter the same

Sunday. I had asked her to contact the manager about the missing

eye-drops. This effort paid off; the medicine was ordered the same

Monday and was given the same Monday evening…. X ignores

staff but would not dare do the same with relatives. Thanks to that,

in this case the old woman could again have her eye drops, needed

to control her glaucoma.

  In Hilltop Estate Nursing Home’s Medication Policy and Procedure,

under paragraph 5, staff are being instructed in how to handle

medical errors. Among other things, nurses are here told to ‘inform

GP or out of hours service’ and ‘inform resident/relatives as

appropriate’. They are also asked to complete an incident form and

‘Regulation 37’. These instructions are signed by X in June 2009. In

none of the above mentioned cases of consistent drug errors – for

which the manager herself was ultimately responsible – the above

mentioned instructions were followed. Inquiries into why were met

with silence.

  In the same Policy and Procedures, under ‘Storage of Medication’,

nurses are instructed as follows: ‘Blister packs that have been

checked as correct are stored in the lockable clinical area.’ This is

not possible. Though it must be obvious also for the responsible

manager that this is impossible due to lack of a lock on the door, X,

for months, has done nothing to sort out this problem and follow her

own rules. This way all blistered drugs are kept accessible to

anybody entering the home. In addition, all discarded medication is

kept likewise – without any kind of safeguarding.

  Due to extreme carelessness in handling of catheters in the home

there have been a number of unacceptable incidents which have

been known to X without her ever taking action. Catheters are not

on a regular basis checked and emptied; therefore, on numerous

occasions they have been bursting full. In this condition they have

been hanging down from chairs and beds. On one occasion I have

myself seen a bag on the floor in the lounge – pulled out from the

resident’s bladder by pure weight. Intact was a ten millilitre balloon,

which had been pulled through the resident’s urethra….

  There have been other similar incidents reported. Night staff were at

one point officially at handing-over asked not to let the tube from

the catheter go beneath the bedrails down to the bag hanging from

the bedside (as they should). Why? Because it repeatedly had

happened that catheters had been pulled out with balloons intact

when staff slammed down the bed rails…. Proper action against this

serious malpractice was not taken.

  Other problems with catheters are that residents (who cannot

move…) repeatedly are laying on top of either bags or tubes,

causing not only stop in the flow but risk of pressure sores – not to

speak about discomfort. Example of documentation: ‘When we did

CP this evening we found her soaking wet due to the fact that she

was laying on top of the catheter bag.’ This resident had worsening

bedsores due to poor care, was later put on Oramorph for the same

and died a dismal death due to severe neglect and abusive ‘care’. In

another incident, which was reported to all staff, following is said to

have happened: a resident had had a fall; when she was lifted up

somebody stood on the tube, causing the catheter to be pulled out

(with balloon…).

  X is fully aware of all this, but there has been no signs of any

actions. Any documented request to improve conditions has been

met by silence.

  In a number of individual cases X’s actions and/or inactions have

caused severe stress and suffering. In one of those a long-term

client, O, died under unnecessarily painful circumstances. After

suffering from severe back pain for several months without any

action (as far as it is known to me) being taken, the resident one day,

when her general condition quickly worsened and she became

terminal, all of a sudden was to be started on syringe-driver supplied

Diamorphine. As I arrived to work that evening Head of Care X was

still there, leading and directing the care of the now dying resident.

The syringe driver had just been set up by external help. As X

finally had left, I discovered that O had been moved over to a 5-6

cm thin mattress (one I had not seen in the home either before or

after) – this way resting almost directly on the bed’s metal slabs

(something which hardly could be beneficial to a patient treated in

terminal state by morphine for back pain…).

  Apart from this unsuitable positioning the resident had been left to

us in a miserable state messed in her own excrement and with her

‘kylie’ (incontinence protection) around her neck – clearly showing

no special attention had been given to this dying person’s most basic

needs. It was on this background I, one hour after X had left, had

her back on the phone persistently asking questions to the state of

the resident and wanting to give advice about all and sundry. This in

itself is nothing unusual with X. On occasions she rings the home

and ‘interviews’ the nurse in charge. Repeatedly I tried to get of the

phone in order to attend to O’s needs for pain relief. X, however,

insisted in prolonging the discussion and, as I did not find I could

put down the phone on my leader, this unnecessary and not

requested ‘help’ stole almost an hour of my time. As I finally

attended to O, she was in severe pain (most likely not helped by

resting on the metal slabs), and I decided to give break-through pain

relieve. The resident died about an hour later.

  I am not happy about the treatment this long-term nursing-home

resident was given on her last day. In hindsight I should at least

have put down the phone on X and devoted my time to the dying

person. For her behaviour this night X was reprimanded by the then


  After months of having asked night staff for something to eat it was

reported that 104 years old E’s faeces was green and slimy. At the

time I had no idea as to why. An African nurse knew better: sign of

probable starvation. Why wasn’t this woman fed though she

constantly asked for food? As it is common knowledge at the home

that people often are forgotten at meal time and not fed, it seems

obvious that X has seriously failed in her duty to oversee that in this

particularly vulnerable case one of the most basic needs was being


  However, E was not the only person having problems with being fed

properly. She died, probably of hunger, but there are other examples

of serious failure. Food is put too far away from clients; they cannot

reach or see it; people’s diets are often mixed up; some are

forgotten, are having nothing to eat, and some are fed twice at the

same meal….

  AB, who was close to terminal, was found at 8 pm by us, the night

staff, shortly after taking over. He had slid down in his bed (which

lacked a foot end) and lay with his legs up to the knees out of the

bed. AB had been positioned for his supper, or so it seemed. But the

food was too far away from him, and the cling film it had been

covered with when delivered had not been removed…. It was

obvious that he had been left with the tray besides the bed and not

been seen to thereafter for about 3-4 hours. I reported this, but no

action was ever taken by X to investigate – or secure that such things

would not happen again.

  S, a male resident, started to develop paranoid thoughts which

caused him extreme fear and stress. Especially after being put to bed

at night his paranoid fears of being murdered by two male members

of staff were terrifying. For weeks I appealed to the manager to have

this extremely suffering person seen urgently by a psychiatrist. X

did not respond to my appeals for several weeks.

  When the psychiatrist finally saw the resident he increased the

antidepressant drug and said he would re-assess in another 3-4

weeks. In itself I strongly question this treatment. I find the

attempted treatment of paranoia with antidepressant drugs to be

questionable practice. According to all literature this drug would

hardly be helpful but could even worsen the condition. However,

that aspect is not part of this complaint. S had been seen by a

specialist and this specialist’s recommendations and prescriptions

should have been followed.

  The dose was also increased for the first three-four days. However,

thereafter a new drug cycle commenced and all went back to

‘normal’. The nurses could do nothing about that, as the drugs are

meted out exactly in blister packs. It was X’s responsibility to see

that the increased dose was delivered. I repeatedly requested X to

act (to order additional tablets), but, as usual, no action. She never

responded to my repeated requests.

  The resident recovered from his paranoia after a couple of months’

constant fear of being the target of two, as he in his severe psychotic

state saw it, hired killers. This spontaneous recovering is in itself

nothing unusual, as mental health problems can come and go, with

or without outside interference. However, one idea of treatment is to

shorten these periods of extreme suffering. In this case suffering

was prolonged unnecessarily, and the improvement of the resident’s

mental state was fully down to nature. Being the right drug or not,

the prescribed medication was not given for about a month – this

despite several reminders from my side. None of them was

responded to. The failure around the medication for this resident I

therefore see as a serious ongoing deliberate drug error. No surprise,

the planned re-assessment of the resident never happened, and the

questioning of that of course remained unanswered….

  Not only did S suffer tremendously from his dreadful mental state

that blighted his last months of life, but he was also very unhappy

with other aspects of the ‘care’. Among other things he complained

about the feeling of being choked while being fed, because

everything ‘should’ go so fast that he hardly felt he had time to

swallow. Due to this it was often reported between shifts that S had

refused his food…. It seems to me that X was not interested in

finding out why this person apparently had lost his appetite….

  Two extremely serious cases of bedsores I claim were the results of

X’s negligent management and poor leadership. GB was an old

woman who finally died in a dismal state with numerous wounds

caused by negligent and abusive ‘care’ – all under the supervision of

the head of care turned manager. Due to the result of negligence this

resident ended up having morphine. Bedridden and unable to turn

herself she was totally dependent on others for the most basic needs.

In all aspects the home failed to live up to that responsibility.

  Every time I came on duty this resident was extremely thirsty (apart

from being a type 2 diabetic she was on Lithium). She could drink

around three pints (!) of water in one go with her evening tablets. I

kept documenting this and asked X to stress to staff that GB must be

given sufficient fluid during the day – and that her underlying health

conditions had to be taken into account as well. There was never a

response to these requests. However, to my surprise, I could read in

‘Dr’s notes’ that she (GB) ‘could no longer swallow’…. The same day

as I read that and that she was ‘nil per mouth’ (i.e. MUST not even

be offered any drinks) she again drank with me three glasses of

water all in one go…. No arrangements were ever made as to how

this resident should be prevented from dying of thirst in case such

instructions were to be followed. It appeared to me that X arbitrarily

just had decided to stop giving her drinks…. There was no other

instruction. She could easily drink, but even in the ‘Dr’s notes’ it had

been decided she couldn’t, and there the story seemed to be intended

to end. Was withholding fluid from this resident on purpose or just

the result of extreme negligence and incompetence?

Despite being on a modern air mattress GB’s skin broke down and

serious sacral wounds developed. Repeatedly I wrote in the care

plan and in the communication book that she was thirsty and that

she was in a ‘desperate need of being turned, cleaned and cared for

on a regular basis’. But it was all to no avail; there was never a

response from the head of care turned manager. No actions were

ever taken.

  GB died in a dismal state; she ended her life on morphine due to

home-made bedsores. In the worse of those a ten years old child’s

fist could fit; it went all the way into the sacral bone.

PL recently died in a state similar to GB’s. Also in this case sacral

wounds as result of very poor care developed without responsible

people intervening. Though suffering from frequent bouts of

diarrhoea, PL was only sporadically (two-three times a day)

changed and cleaned, and, for a start (until bedsores were evident

and my consistent campaign on her behalf had gone on for several

weeks), she was never turned but lay constantly flat on her back.

Nasty pressure sores developed all over her buttocks with a deep

cavity on the sacral area right into the bone.

  Only at this point PL started to be turned (outside of my few shifts).

And, fortunately, even this slight improvement in the care showed to

be immensely beneficial for the resident and improvements soon

began to show. However, instead of leading to further advances,

these improvements, likely due to a total void in guidance,

encouraged a new onset of the home’s widespread laissez-faire

attitude. While the sacral area was healing due to the resident being

on her sides, this led to further complications as the time spent on

either side on each occasion far exceeded what would be seen as

permissible – leading to break downs of skin on both hips. With

deteriorating wounds on both sides – one of them deep and infected

and with the sacral area still a cavity and extremely vulnerable –

there was no real opportunity to place her without provoking further

damage: on her stomach she couldn’t be because of the peg; all

other positions led to deterioration.

  As PL died in the aftermath of this serious development she also

suffered from other pressure sores on numerous parts of the body –

from her shoulders all the way down to the ankles. Faced with all

this and a daily life totally void of any kind of stimulation, death

must have come as a relief.

  As in all other cases, on no occasion did X respond to pleas for

improvements in the ‘care’ given to this woman. No, X never

responded to any concerns. Example of this: on 23rd August 2009 I

wrote, ‘why has this resident with serious bedsores not been seen by

Dr B regarding this condition? Why are dressings and treatment not

prescribed?’ No reply from the manager. On 14th December 2009 I

wrote: ‘X, PL’s right hip is now necrotic. We are heading for serious

problems if care is not improved again for this resident.’ On 21st

December 2009 I wrote: ‘We have had no wipes. (We) bought some

baby wipes in Sainsbury’s Saturday morning. PL’s skin is breaking

down – all because of negligent care. We need expert help to save

her from a disaster. Please contact tissue-viability nurse for advice.’

As happened to all other written pleas for the manager to act and

enforce a decent treatment of this resident, also these attempts were

met with silence….

  TK is a highly educated man living in this home. He has been a

resident at Hilltop Estate for about two years. This retired

professional reads and studies all day long, underlining important

passages in numerous books, which he all takes in turns. They are

mainly in English and in his ancestral tongue, but he also finds an

interest in studying German and Latin. As I come in to him he

always enjoys discussing daily events from the news.

  Nothing of this reminds me of a person who has given up his desire

to live. But, disregarding that, this man’s life has been deemed not

worth living by Manager X. As X still was in her old position as

head of care of the home she, single-handedly, decided that TK

should not in the future be sent to hospital (with no specification

regarding possible exceptions to this rule) and that he should not be

subject to life-prolonging actions. In special instructions to the

nurses she wrote: ‘note that in event of deterioration (this man was

absolutely not terminal, not by any definition, my comment) they

(son and daughter in law, my comment) would not like TK

transported to hospital ——–X.’ On the handing over sheet of 18th

December 2008 it was written ‘NFR (Not For Resuscitation, my

comment), no hospitalization’. Further to that, the day nurse the

following day had been instructed to carefully and strictly hand over

this new regime to all other nurses.

  The document which X used to implement this decision over

another person’s life was the ‘Advanced Care Planning’ (ACP). This

is clearly contrary to the stated purpose with this document. On the

ACP form itself it is unambiguously stated that it ‘should be used as

guide, to record what the patient does wish to happen’, not ‘what

he/she does not (my underlinings) wish to happen’, and that it is

‘different from a legally binding refusal of treatments document’.

The ACP asks ‘what elements of care are important to you?’ (not

him/her, my comment), and it asks if there is anything that ‘you

worry about or dread happening?’ It also says that this is a ‘dynamic

planning document’ and not an Advanced Directive or DNR (Do

Not Resuscitate, my comment).

  These are very important difference and shows how misleading X’s

use of this document is. As it was and is being used by the manager

(though she recently has added a DNR document – still without the

resident’s involvement) it could cause serious harm not only to TK

but legally also to any nurse complying with it. If a nurse

indiscriminately would follow this directive (as it is intended) this

person could end up unlawfully withholding necessary treatment

from a person in need and would be legally accountable for that.

Though the ACP is not a living will, I believe X has let it appear as

if it were. Contrary to its purpose she seems to have used it in order

to let it appear as if it would legalise a non hospital-referral, non

life-prolonging regime for this person. She did that on her own; she

did not consult the then manager, and she did not involve the GP – at

least there is no documentation of that.

  Knowing the person subject to this planning-for-his-demise, I was

taken by surprise by this document. Others might have been as well:

in the ‘nurses’ notes’ we can read from 25th December 2008 that he

‘enjoyed x-mass lunch with other residents’ and on the following

New Years Day that he ‘enjoyed red wine before lunch’. TK ‘sat

with other residents and appeared cheerful and looked very smart’, it

has also been written in his file from around the same time. It does

not sound like something written about a person who better is left to

die. Certainly not, and I am fairly sure this wasn’t and isn’t his own

desire either; I am sure he would express his own opinion had he

just been asked to do so.

  Nothing, however, indicates that TK himself had been present at the

discussion leading to this decision…. Such a conclusion is

supported by an entry from 22nd January 2009 in the ‘nurses’ notes’.

Only five days after he has been reported to have ‘enjoyed party

with family’ it is stated by X that the issue around TK has been

‘D/W (discussed with) family – (and) ACP (is) active’. She does not

write ‘discussed with TK and family’. No, TK was not present; he

was not asked as to his own opinion, and he was not asked to sign.

Most likely he has still not been informed. X claimed in the

document that the resident was ‘not able’ to sign. I am certainly not

convinced. I think it is vital to question this strange ‘inability’.

There are other dubious parts in the document as well. I note that the

expressed wishes under the headline ‘Thinking ahead…’ on page

two are expressed in a language which is unlikely to come from the

resident himself or even from relatives. ‘Maintain dignity,’ and ‘keep

comfortable and pain free’ are typical care-staff expressions. I think

it is reasonable to think that TK would want that (we all would), but,

the wording leads me to believe he has not been asked. If asked, I

believe this person would have come up with other things as well.

The document is intended to express residents’ views. Who is the

author of those nursing expressions intended to express TK’s?

The words ‘ACP active’ could lead anybody reading the document to

assume that this is more than just a resident’s expression of what he

generally ‘wishes to happen’ during his stay at the home. My belief

is that it is so worded so as to make it sound like a legal

proclamation of a DNR (Do Not Resuscitate) regime. And, precisely

so this document was understood by the nurses; this is how it was

clearly handed over. By following these instructions, a nurse in

charge could very well have been misled into breaking fundamental

laws. It all makes me repeat following still unanswered questions:

  • • Why did X use a document which, as seen above, is not

meant for the apparent purpose?

  • • Why did she not discuss the issue with the resident


  • • Why did she not ask for his opinion?


  • • Why did she not ask him to sign the document? As earlier

mentioned, this person constantly worked with his pencil in

numerous books. However, then it came to this document,

where X intended to sign him off from life-saving

treatment, then he was not ‘able to sign’, and he was not

even present at the discussion.

  • • Why was the resident’s GP not involved?


  • • And, not least, why this resident?


Precisely: why was it about TK and not about all others? At the time

this man was the only resident being given this ‘attention’ – despite

he was by far the youngest and by far the most mentally active. I

wonder why somebody can have had an interest in arranging for

precisely this man not to be treated in hospital (for whatever

condition, according to the original statement).

  Yes, why? It does not look like Dr B had any concerns or any

interests in that direction. He has not made any entries about the

issue in the resident’s notes. His two most recent entries before the

issue of the ACP were on 20th November 2008 when he writes ‘all

well’ and on 24th January 2009 when his entry reads ‘Fluvax left

arm’. None of those entries would lead anybody to suspect that we

deal with a terminally ill person who is better left to die in case of

‘deterioration’. By the way, TK has a deep dislike of needles; he

hates having his daily injection. I find it difficult to understand why

he would accept a flu jab (though there is reason to suspect he

wasn’t asked about that either) if his intention was to avoid any

treatment to prolong his life….

  Repeatedly I requested to get X to answer my questions regarding

this matter. I did so because I seriously questioned the legality of

her actions. In the home’s communication book I over and over

again addressed the issue without getting any kind of reply. I wrote

on 20th and 27th December 2008, on 23rd January 2009 and finally

on 1st February 2009, asking X to clarify her actions.

  The whole case around TK has left me with a number of

unanswered questions. An important one: if TK himself had been

committed to not to have hospital treatment for whatever condition

 (as ordered by X), why has he not been advised to have a ‘Living

Will’ or ‘Legal Advance Document’ properly written, signed and

witnessed? That would, as far as I can see, have been the

appropriate way to follow. Is it because he has never expressed such

views? Is it because he has never been involved in this discussion?

Is it because he has still this day no idea this discussion about his

life has been going on at all? Or, is it because he would never sign?

All these options seem plausible to me. No, he has never been

involved. So it seems, and that conclusion is confirmed in a new

DNR document issued on 28th of January 2010. In this document –

now also signed by a (new) GP – the reason for not involving TK is

‘lack of capacity’. I would question on what basis this conclusion of

‘lack of capacity’ was reached; it does not seem congruent with the

legislation on mental capacity.

  Still, with those words it is clearly stated that the patient has not

been asked. He is still capable of studying Latin, but, obviously, not

signing his name – and definitely not deciding over his own life…

X’s directives regarding this resident have led to serious uncertainty

as to how nurses at the home are expected to react in cases of

emergency. Contrary to the orders given by the head of care turned

manager, one day one nurse had sent TK to hospital after coming to

the conclusion he needed urgent medical attention due to being

unresponsive and having a very low blood pressure. The nurse in

charge at the time had called ‘doctor on call’ and was advised to call

for an ambulance. The patient recovered quickly in the hospital and

returned to the home in his normal condition. Following this X

reprimanded the nurse, stating that she (X) had spoken to the son of

the resident who (allegedly) was upset about the fact that his father

had been sent to hospital. The son (again allegedly) expressed the

view that his father should not in the future be sent to hospitals, nor

should he be resuscitated. I have only met the son briefly, but I

question that he would have made such a comment had he been

fully informed about the circumstances around his father’s situation.

In entries from end September 2009 we can follow another episode

closely attached to X’s policies and directives. TK has now had a

fall, or at least so it seems. How this in fact had happened is still this

day not clarified: the resident is hemiplegic; nobody volunteered

what had taken place; it is not known he has been found on the

floor, and, while ‘investigating’, X apparently never asked the

resident himself….

  Yes, there are still a number of questions, but the following at least

are facts: days after something must have taken place TK

complained about pain and would not allow staff to touch his arm.

Another two days later, 30th September, a physiotherapist saw the

arm and recommended it to be x-rayed. However, instead of acting

firmly on that professional advice, X now chose to inform the GP

and arrange for him to see the resident the following (!) day –

thereby allowing (well knowing there was a suspicion of fracture)

TK to wait for one more day before he would be transferred to


  It seems obvious that not only this last postponement but also the

general instruction about ‘no hospital referral’ in the end had delayed

assessment of TK’s broken arm and prolonged his suffering.

Therefore, as this, in hindsight, must have become clear also to X, it

appears she decided to look for a scapegoat. So it happened that one

of the nurses (one who repeatedly had been used for similar

purposes in the past) was singled out to face blame. The manager’s

decision to wait another day – at a time when she did have every

reason to suspect a fractured arm – could now be conveniently


  Trying to find the true answer to what happened to TK, one needs to

look at the following: there are conditions prevailing in the home

which clearly have contributed to the situation, among them a

severe blame-culture forcing staff to cover up everything that can

ever be used against them. Most of staff fear facing X’s disciplinary

actions. Not to be forgotten is also the fact that the home is

dominated by one single group of carers in a catastrophic void of

professional leadership and that a few members of the staff have

been singled out by the ‘others’ and by the manager for ‘special

treatment’. It is my opinion that the basic for this state of affairs is to

be found in a clear culture of racism pervading the daily work

atmosphere. As I see it, this is stoked by both the manager and the


  In this intricate system of race-related perks and disciplinary actions

Indian nationals come out in the top with other ethnic minorities

(whites among them) in the middle and a now kicked out scapegoat,

a Chinese woman, at the bottom.

  Apart from the individual victim’s psychological hardship dealing

with this institutionalized bullying, it can have other serious

consequences as well: single-handling of difficult and heavy

residents is one of the most serious consequences of these

conditions, refusing to help colleagues who have been ‘allocated’

those residents to handle is another, but closely related. Though this

unacceptable practice is putting these members of staff in serious

risk of hurting not only themselves but also their clients, X has done

nothing to put a stop to it. In contrary it seems like it is all condoned

by the manager.

  It is very likely that a combination of all these conditions led to

TK’s fall and fracture of an arm. It is also likely that X’s ‘lack of

desire’ for full clarification of this case was due to her fear of having

all circumstances unravelled and out in the open – among them

planning a vulnerable staff member for two successive 12 hour

shifts the morning it all might have happened….

  Finally, what should not be necessary to stress, at least not in light

of the broken arm, is that an admission to hospital of course must

not automatically be equivalent to resuscitation. As mentioned

before, there was and is no specification as to what kind of

treatment this man is denied by his own son (allegedly) and by X. In

addition, I would claim that none of them can have a legal right to

make such a decision for an autonomous human being. This is the

basis of all health care ethics.

  When it comes to the nurse/manager, it is my opinion that her

actions are in contravention not only to the NMC’s Code of Conduct

but to all other laws regarding this area, including the Human Rights

Act. In the latter it is clearly stated that every human being in this

country is entitled to ‘the right to life’. It is also said that ‘if any of

these rights and freedoms are breached, you have a right to an

effective solution in law, even if the breach was by someone in

authority…’. It is my hope that these rights can be safeguarded and

secured while TK is still among us, and not after he is gone.

Before ending the story about this man, it might be interesting to

note that he is the same person who, as mentioned under ‘drug

errors’, repeatedly has been running out of for him very important

medicine: Clexane/Enoxaparine. Regarding this, it has on quite a

few occasions appeared to me that it cannot have been top on X’s

agenda to provide TK with available and prescribed remedies to

prevent further damage to his health….

  I am very concerned that Manager X is acting outside the NMC

Code of Conduct and would request an urgent investigation of this

matter to happen.

  Recently I was verbally attacked and exposed to threatening

behaviour by two relatives of another resident. I reported the

incidence to Home Owner Y. Disregarding a history of episodes

with one of these men, the owner came to the conclusion that I ‘had

not been attacked’. She also, without any reason or evidence,

concluded that I ‘had been conducting “improper” conversations

with the related resident’. I was upset by these unfounded and false

allegations and, during a telephone conversation, I strongly advised

Y to withdraw them and apologise.

  However, Y did not appreciate being advised by one of her staff, as

she put it, and following this I received a written ‘invitation’ (for the

next day…) to attend a meeting with her, Manager X and ‘one other

director’ of the company. At this meeting we were expected to

‘discuss’ how I had ‘behaved myself’ during the phone conversation

and what had led to the incident with the relatives. The ‘invitation’

was formal.

  I informed Y that I would attend, but that my union-rep. would need

time to prepare. I also informed her that, in order to discuss the

second point, I would request the two nurses’ communication books

and the diary-in-use (2009) to be presented. Furthermore I informed

her that the last of the communication books had been taken out of

use (unfinished) shortly before the above mentioned inspection by

the Care Quality Commission and that it had not been replaced….

For a long time I had been writing all comments and questions, as

quoted above in this complaint, in those three books (I had

continued in the diary after X removed the communication book). If

not before, now, I would say, the owner would have had a fairly

good reason to read them. I never received a reply to that e-mail. Y

suddenly lost interest in the whole matter…..

  Repeatedly I and others have tried to bring Ms Y’s attention to the

actions and non-actions of the head of nursing turned manager. But,

unfortunately, the owner has shown no interest in listening. Now

when she was advised that a number of entries in all these three

books existed, and I wanted them presented and discussed, she was

no longer interested in the meeting she had called herself. Therefore,

and also because of another meeting on 25th September 2009 (as

seen below), no later than around this time Ms Y has been fully

aware of the conditions at her home. By not carrying through with

the meeting with me, she has demonstrated that she is colluding in

negligence (and worse) of vulnerable adults.

  On 24th September 2009 Hilltop Estate Nursing Home was

‘unannounced’ visited and inspected by the Care Quality

Commission. Prior to this ‘unannounced’ inspection the home had

employed a short term administrator who had put in an enormous

effort in order to prepare the home’s chaotic administration for the

coming scrutiny. This certainly helped. Nevertheless, administration

aside, nursing care is precisely about that – care, and I strongly

challenge the two stars (just below the three given for excellent

service) awarded by CQC to the home.

  The report issued by the inspector might not deserve being taken

seriously, but still, it includes one interesting detail. On page 17 I

read: ‘Prior to the inspection CQC received an anonymous e-mail

raising some concerns. We referred these concerns to the local

authority’s safeguarding adult team. The planning meeting was due

to take place the day after the inspection (25th September, my

comment) and the manager and the provider were due to attend.’

I was the anonymous e-mail writer. However, this e-mail, signed by

‘John Blog’, did not contain any direct mentioning of concerns….

What it did was to ask CQC to access the (surreptitiously)

remaining ‘nurses’ communication book’, nothing else. As the

inspection was due (we all knew that), this book (which, together

with the previous one, contains information about ALL that is

mentioned in this complaint) had, as mentioned before, been taking

out of use. In the general ‘tidying up’ it had, together with lots of

other documents, landed outside of the office – ready to be removed

from the site. I found the book there one evening and put it back on

the shelf – turned so that it would be safe(r) from being ‘accidentally’

found and removed again. For somebody who specifically would

look for it, however, it would be no problem finding it. I saw the

book on the shelf in the weekend before the inspection, and I saw it

again – clearly untouched – the weekend after….

  As mentioned in the report, CQC gave this e-mail on to the local

authorities. However, it would seem they did not look for the book

themselves…. There is no mentioning of such a thing in the report.

As the book would have led the inspectors on to me, and would

have given them basically the information included in this

complaint, I find it ‘odd’ that I have not been contacted and asked for

further evidence. At least immediately after the meeting which, as

mentioned, took place the day after – involving the safeguarding

adult team, Manager X and Provider Y – this should have happened.

No later than that day should everything in this complaint have been

known to all people involved, CQC and the council authorities

included. No, there is nothing that indicates to me that the book was

ever touched, and I was never approached….

  As a result of all this it is obvious that not only CQC and its

inspector RS but also the local authorities’ safeguarding adult team

no later than on 25th September 2009 should have had all reasons to

initiate an impartial and thorough investigation of these abusive

conditions. None of them did, and nobody responsible has ever

contacted me for further details. Shortly after these events the book

on the shelf disappeared. I find all this evidence of a cover up.

Therefore I hold The Care Quality Commission Inspector RS and

The Local Council’s Safeguarding of Adult Team responsible for

neglect of duty. I would like their roles in this case investigated on

equal terms with X’s and Y’s.

  In Hilltop Estate Nursing Home’s entrance a folder issued by the

local authorities’ Safeguarding Adults Board says: ‘Every day

people say nothing! What to do if you suspect a vulnerable adult is

being abused.’ The folder asks people to ‘please say something’. It

tells the reader: ‘don’t ignore it, don’t promise to keep it a secret,

don’t put it off.’ It tells that ‘everyone has a right to live free from

violence, fear and abuse, and to be safeguarded from harm and

exploitation’. I have some difficulties taking this concern from their

side seriously.

Further evidence proving this case will be provided on request.

Yours Sincerely

Lars G Petersson