Summary: We will not investigate Mrs X’s complaint that her husband’s care home took 40 hours to act on a fall her husband had. This is because we are not likely to find fault with the care provider for not seeking medical advice earlier. There does appear to be fault with the care provider’s record keeping. However, the potential fault has not caused any significant injustice.

The complaint

1. Mrs X complains her husband’s care home took 40 hours to act on a fall her husband had. It was identified her husband had six broken ribs when taken to hospital.

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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 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.

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

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How I considered this complaint

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

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My assessment

5. Mrs X’s husband, Mr Z, received care in a care home. On 28 December 2023, Mr Z was found on the floor by his bedroom by a staff member. It was noted no one had witnessed how Mr X came to be on the floor, but that Mr X reported he had been pushed by another resident. The care provider reported this to safeguarding.
6. The care records do not detail what checks were completed with Mr Z at the time he was found. However, the witness statement of the carer who found Mr Z does detail the full body checks completed to identify if he had sustained any injuries following the fall. It was noted no injuries found and Mr Z reported no pain. Mr Z was then assisted to walk back to his room and helped into bed.
7. The care records for the next day do not contain any entries about Mr Z being in pain or that any checks for injury were completed. However, the witness statements completed by carers reflected Mr X had reported some pain in his back in the morning and that staff had checked his back and sides. It was noted Mr Z had two little marks on the left side of his body, but the carer was not concerned as Mr Z reported they did not hurt. Further, it was noted Mr Z reported no pain when the checks were completed. Mr Z was given paracetamol to help with his pain.
8. Statements from carers who interacted with Mr Z in the afternoon noted Mr Z was walking around with no difficulty, reported no pain, and told staff he was fine when asked.
9. On 31 December, the care home contacted 111 to ask for advice as Mr Z was struggling to sit up and had bruising and swelling to his left side. Mr Z was taken to hospital where it found he had six broken ribs and some fluid on the lungs.
10. There is some evidence of potential fault with the care provider’s record keeping as the daily care records do not detail that Mr Z was checked for injury after he was found. Instead, all the information about what checks were completed was in the carer’s witness statement, completed two months after the fall.
11. However, I do not consider this potential fault has caused any significant injustice. This is because, even if accurate records had been kept, this would not have affected the outcome as it would not have led to the care provider seeking medical advice any earlier.
12. Further, an investigation is not justified as we are not likely to find fault with the care provider for not seeking medical advice earlier. The evidence available shows Mr Z had made little complaints of pain and told staff he was fine when asked. Further, Mr Z was not observed by staff to be showing any visible signs of pain when mobilising. When Mr Z had reported pain, appropriate pain relief was given, and he made no further reports of pain.
13. Therefore, we are not likely to criticise the care home for not seeking medical advice earlier as Mr Z was not presenting any signs to suggest further medical intervention was warranted until 31 December. Once the care home identified the bruising and swelling, it sought medical advice without delay.

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Final decision

14. We will not investigate Mrs X’s complaint because we are not likely to find fault with the care provider for not seeking medical advice earlier. There does appear to be fault with the care provider’s record keeping. However, the potential fault has not caused any significant injustice.

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Investigator's decision on behalf of the Ombudsman