Summary: We will not investigate this complaint about Mrs Y suffering falls in a care home. We could not add to the investigation the Council carried out. Nor could we achieve a more meaningful outcome, as the care provider has already accepted it was at fault and apologised.

The complaint

1. Ms X complained about the care her mother (Mrs Y) received. She says the care home:
• Failed to properly assess and manage Mrs Y’s falls risk;
• Failed to keep Mrs Y's walking frame within reach;
• Failed to keep adequate records or notify family of several falls;
• Failed to provide accurate information to hospital about how many falls Mrs Y had suffered.
2. Ms X says this led to her mother suffering a life-changing injury and significant deterioration. She says Mrs Y suffered distress in the last year of her life. Ms X says the Council's safeguarding enquiry did not lead to anyone taking responsibility. She wants clarity, acceptance of fault and apologies.

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The Ombudsman’s role and powers

3. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• any fault has not caused injustice to the person who complained, or
• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

4. I considered information provided by the complainant and the Council.
5. I considered the Ombudsman’s Assessment Code.

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My assessment

6. Ms X’s complaint relates to her mother, Y, who suffered several falls in a care home. The family were not notified of every fall, however the care provider says it was agreed the care home would only contact Mrs Y’s family when she sustained an injury. Ms X says had the family known how often Mrs Y was falling, they would have taken action.
7. Ms X says the care home’s record of falls contained errors, and she doubts its reliability. The care provider accepted its communication with the family could have been better, and it apologised. I have not considered the record-keeping further. We could not say that Mrs Y’s injury would have been prevented by better communication or record-keeping.
8. From the information I have seen, it is unlikely we would find fault in how the care provider assessed Mrs Y’s falls risk. It is undisputed that Mrs Y was at high risk of falls, and the care home’s risk assessment identified this.
9. However, the Council identified through its safeguarding enquiry that the care provider did not take the necessary action as a result of its assessment, delaying referring Mrs Y to the falls team. The care provider took responsibility for this and apologised to Ms X. If we investigated, it is likely we would find fault in this. However, it is unlikely we would say this caused Mrs Y’s injustice, as the falls team discharged Mrs Y with no further action. We could not say Mrs Y would not have fallen, had this referral happened sooner.
10. Ms X says Mrs Y’s walking frame was often not placed within her reach, and she suspected it was not within her reach on the day of Mrs Y’s injury. The care provider says it was within her reach, but apologised to Ms X for this not having been the case at other times. We could not say now whether the walking frame was within Mrs Y’s reach on the day of her fall, and so we could not come to sound conclusions.
11. Investigation by the Ombudsman would not add to the investigation the Council carried out. We simply could not say that Mrs Y’s significant injury was a direct result of fault by the care provider. There were several factors that led to Mrs Y’s injury being life-changing, including an unsuccessful operation in hospital. We could not say Mrs Y would not have fallen, but for any fault.
12. Ms X says her aim in complaining to us was acknowledgement of fault and apologies. Ms X felt the Council’s safeguarding enquiry led to nobody taking responsibility. However, the care provider has accepted there were faults in its actions and apologised sincerely for this. Due to the reasons above, it is unlikely we would find further fault causing injustice that would warrant a further remedy.

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Final decision

13. We will not investigate Ms X’s complaint because we could not achieve anything further than the Council’s investigation already achieved.

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Investigator's decision on behalf of the Ombudsman