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
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,
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
- 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
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
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
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
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
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
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
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
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’
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
Further evidence proving this case will be provided on request.
Lars G Petersson