Summary: We will not investigate Mr X’s complaint further. This is because we cannot achieve the outcome Mr X wants or link the injustice he claims to the actions of the Council and its commissioned care provider.

The complaint

1. A solicitor acting on behalf of Mr X (the complainant) says the actions of the Council and its commissioned care providers caused his late mother (Mrs A) suffering and distress; he says witnessing this and being vilified for his subsequent complaints caused Mr X considerable anxiety resulting in a heart attack.

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The Ombudsman’s role and powers

2. 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:

• any injustice is not significant enough to justify our involvement; or
• we cannot achieve the outcome someone wants; or

3. It is our decision whether to start, and when to end an investigation into something the law allows us to investigate. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended)
4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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How I considered this complaint

5. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
6. Mr X and the Council had an opportunity to comment on my draft decision. I considered their comments and the photos Mr X’s solicitor provided before making a final decision.

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What I found

Relevant law and guidance

7. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
8. The Mental Capacity Act 2005 introduced the “Lasting Power of Attorney (LPA)”. This replaced the Enduring Power of Attorney (EPA). An LPA is a legal document, which allows a person (‘the donor’) to choose one or more persons to make decisions for them, when they become unable to do so themselves. The 'attorney' or ‘donee’ is the person chosen to make a decision on the donor’s behalf. Any decision has to be in the donor’s best interests.

What happened

9. Mr X lived close to his elderly mother Mrs A, who had dementia, and provided most of her care. He had power of attorney for her health and welfare finances.
10. In October 2023 Mr X arranged a period of respite care (in Care Home A) while he went on holiday. On his return from holiday, he told Mrs A’s social worker he thought she had had a chest infection. He said her appetite had been declining and it had been difficult for some time to get her to drink enough fluids: he believed she was dehydrated.
11. A few days later Mr X raised a safeguarding alert about Care Home A. He said Mrs A was severely dehydrated and suffering delirium. The GP who visited Mrs A on 27 October was satisfied all her levels were normal and she was not dehydrated. The care home says it called an ambulance on the GP’s advice as Mr X was insistent. Mr X’s solicitor said by this time Mr X had been able to give his mother some fluids.
12. Mrs A was assessed in A and E. The manager at Care Home A would not accept Mrs A back due to Mr X’s behaviour which she said included filming staff, demanding particular care which was not necessary to meet Mrs A’s needs, taking photographs of Mrs A without her consent which allegedly showed white foam in her mouth. The manager said the home could meet Mrs A’s needs but not the demands of her son.
13. The Council placed Mrs A in another care home (Care Home B). It concluded the safeguarding enquiry as any risk to Mrs A had been removed with her admission to a different home.
14. The manager of Care Home B told the Council Mr X was very difficult to deal with: she said he walked round the home making notes on a clipboard, was rude to staff, had been seen filming Mrs A without her consent, and wanted to remain in the room while she had personal care. She said her main concern was that Mr X tried to get Mrs A up from her chair when she was assessed as needing the assistance of two people: she said bruising had been noticed on Mrs A’s wrists and when she had asked Mr X about this he said it was because Mrs A was “not playing ball”.
15. At a meeting with the Council in January 2024 Mr X presented the social worker with a list of 17 items of concern to him at the care home.
16. In January 2024 the manager served 28 days’ notice on Mrs A because of Mr X’s behaviour. Mr X had alleged there was human waste on a table in Mrs A’s room and insisted on another relative coming to view it. Mr X then said he wanted to move his mother to another care home anyway because it had a better environment.
17. Mr X made a Subject Access Request to the Council for his mother’s records. The Council replied with Mr X’s personal data. It said it was reasonable to include some of his mother’s data where he had specifically made contact about her care. It said it would not disclose the rest of Mrs A’s data as it did not have her explicit consent to do so; to do so might prejudice social work; it had to consider Mrs A’s best interests.
18. The Council raised concerns about moving Mrs A again. The care home Mr X preferred did not have any vacancies. Other care homes canvassed by the Council would not accept Mrs A due to the reported behaviour of Mr X. The Council also notified the Office of the Public Guardian that it had concerns Mr X was not acting as LPA in his mother’s best interests.
19. Care Home B asked Mr X to abide by a visiting regime to which he did not agree. As no other home would agree to accept Mrs A, she remained at Care Home B. The Council continued to discuss a way forward with Mr X which would enable him to visit while ensuring Mrs A’s placement remained secure. The social worker told him Mrs A had said she wanted to remain in Care Home B. She also proposed mediation.
20. In March Mr X complained to the Council about his mother’s care, and he said he had been ‘targeted’ as a result of complaining. The Council replied. It noted the safeguarding alert had been closed as Mrs A had moved to another home and so any risk was removed. It said in those circumstances it did not have a legal duty to pursue the investigation. However, it added that his concerns had been passed to the CQC (the regulatory body) and to the Council’s contracting team “to consider the quality of care being provided and the potential for any transferable risk to other residents within the care home”.
21. In April 2024 Mr X suffered a heart attack and was hospitalised. Sadly Mrs A died shortly afterwards.
22. In February 2025 a solicitor complained on Mr X’s behalf to us. He said the complaint had been delayed because of Mr X’s ill health.
23. The Council would not investigate the complaint as it concerned events over a year old from when the matters complained about first took place.
24. We exercised discretion to investigate the complaint on the grounds of Mr X’s long-term ill health.
25. Mr X’s solicitor says Mr X was “subjected to gross abuse of his fundamental rights, discrimination, defamation of character, distress, depression and ultimately a massive heart attack”. He says in consequence Mr X is claiming over £250,000 in “damages”.

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Decision

26. I am discontinuing this investigation as we cannot achieve the financial outcome Mr X wants. Any injustice suffered by Mrs A cannot be remedied and we cannot link the heart attack Mr X suffered to any actions of the Council or its commissioned provider.

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Investigator's decision on behalf of the Ombudsman