What do complaints teach us about end of life care?

See our latest report on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.

City of Wolverhampton Council (25 022 621)

Category : Adult care services > Assessment and care plan

Decision : Upheld

Decision date : 30 Jun 2026

The Ombudsman's final decision:

Summary: We will not investigate Mr X’s complaint about how the Council handled his care needs assessment. This is because we are unlikely to add to the Council’s response or achieve anything more for Mr X.

The complaint

  1. Mr X complains the Council carried out a care needs assessment that was unfair, inaccurate and did not meet his communication needs. He says the assessment failed to record important information he disclosed, took place in an unsafe environment and placed undue reliance on staff accounts rather than his lived experience. Mr X says these failings caused him stress, anxiety, distress and a loss of trust in the service. He wants the Council to complete a new assessment, communicate with him in writing, correct inaccurate records, acknowledge the faults in the original assessment and review its recording practices to prevent similar problems in future.

Back to top

The Ombudsman’s role and powers

  1. 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:
  • we could not add to any previous investigation by the organisation, or
  • further investigation would not lead to a different outcome, or
  • there is no worthwhile outcome achievable by our investigation.

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

Back to top

How I considered this complaint

  1. I considered information provided by Mr X and the Council.
  2. I considered the Ombudsman’s Assessment Code.

Back to top

My assessment

  1. The Council carried out a care needs assessment. Mr X complained about how the Council carried out this assessment. The Council told Mr X it accepted it may not have been clear why some information was recorded in his assessment. It also accepted the way some information was recorded could have been more thoughtful. The Council said the public space Mr X chose for the assessment may have affected the depth and nature of the discussion because of privacy considerations. It also said it was willing to revisit the assessment with a different worker to ensure Mr X's views were accurately reflected.
  2. Mr X complained the Council did not follow his communication preference. The Council accepted this was an oversight because his preference had not been recorded on its systems. It has since updated his records and confirmed it will respect his communication preference in future.
  3. I am satisfied the Council has acknowledged its faults and has taken proportionate action to remedy Mr X’s distress. It updated Mr X’s records to reflect his communication needs and offered Mr X a further assessment with a different worker. This is an outcome Mr X was seeking. The Council also reminded staff of the importance of accurately recording relevant information, avoiding potentially misleading information, and carefully considering how assessment settings and personal experiences are reflected in assessments. Given these actions, I do not consider an investigation by the Ombudsman would achieve a different outcome or achieve anything more for Mr X.

Back to top

Final decision

  1. We will not investigate Mr X’s complaint because an investigation is unlikely to add to the Council’s response or achieve anything more for Mr X.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Privacy settings