Summary: The Ombudsman will not investigate Ms B’s complaint about care provided to her late mother, Mrs C. This is because further investigation could not add to the Council’s response and he could not make a finding of the kind Ms B wants.

The complaint

1. Ms B complains about the quality of care her late mother, Mrs C received between 7-15 September 2018 from her care provider. Ms B says the care provider failed to tell her of a reduction in Mrs C’s care package or that her breathing had deteriorated. Ms B says if she had known of the deterioration in Mrs C’s health she may have been able to do something to avoid her untimely death. Ms B want the care provider to change its procedures and contact family members when asked to do so.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• the fault has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the Council, or
• it is unlikely further investigation will lead to a different outcome.

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

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How I considered this complaint

3. I discussed the concerns with Ms B and considered the information she provided. I sent Ms B a copy of my draft decision for comment.

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What I found

4. Mrs C sustained an injury to her leg when she was transferring from a care home back to her home and was hospitalised as a result. The care was commissioned by the NHS and actions of the care provider are currently being considered by the Parliamentary and Health Service Ombudsman (PHSO). However, the Council considered whether the injuries should be investigated under its responsibility for safeguarding and decided they did not meet the threshold for a safeguarding investigation. The Council advised the care provider to consider the complaints under its internal complaints procedures. The Ombudsman could not say this is fault.
5. Ms B is unhappy with the Council’s response to her concerns about not being contacted when Mrs C’s care and health changed and has asked the Ombudsman to consider it further.
6. The Council explained Mrs C had capacity and agreed to the reduction in her care package. It confirmed Mrs C’s lunch time call was to support her to have a main meal each day as Ms B was concerned she could not have her main meal late in the evening. The Council says the reduction from four to three calls a day related to the afternoon call which was to apply cream to her legs which could be applied during the teatime visit.
7. Ms B says Mrs C felt bullied into signing the agreement to reduce the calls and says the care provider should have informed her of the change as agreed. I understand when Ms B became aware of the change in the package of care she contacted the care agency about her concerns, so was able to voice her views. The Ombudsman could not make a finding on the allegation of bullying now Mrs C is deceased and could not say either Ms B or Mrs C was caused a significant injustice because of the reduction in the care package.
8. Ms B says it was inappropriate of the Council to provide Mrs C with a perching stool as she had just been discharged from hospital and needed rest. Ms B says Mrs C’s support worker was negative and unsupportive. The Council apologised if Ms B felt some of her concerns were not handled sensitively and explained the role of the support worker is to assess what a person can do and provide aids and equipment which might be useful. The Ombudsman could not say this is fault.
9. Ms B says she should have been notified on occasions when carers recorded Mrs C said she was tired, had slept poorly and was breathless. Ms B says if she had been notified that Mrs C was suffering breathlessness, she would have attended and may have been able to get help for her sooner.
10. The Council says given Mrs C’s age and that she was recovering from an injury, a record noting some tiredness was not unexpected. It explained it would have monitored the situation, but a note of tiredness would not necessarily trigger notification to the family.
11. The Council explained when carers attended on 15 September, the day Mrs C died, it recorded Mrs C said she did not sleep well and was breathless. The record also noted Mrs C was active throughout the day, putting on vegetables at lunch time and made herself a cup of tea prior to the teatime call. When carers attended the teatime call at 6:20pm they noted Mrs C had made herself a hot drink and requested toast and jam. Its response to Ms B ‘s complaints noted Mrs C was a smoker and used oxygen most of the time to assist with her breathing. It said there were no concerns about her health requiring contact with the family or medical intervention on that day.
12. Ms B says if she had been contacted she may have been able to intervene and get medical help sooner. The Ombudsman could not say there is any causal link between the actions of the care provider and Mrs C’s death. The Council has explained although Mrs C was breathless this was not unusual and there were no concerns regarding Mrs C’s health warranting medical assistance. The Ombudsman could not add to this or make a different finding even if he investigated.

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Final decision

13. The Ombudsman will not investigate this complaint. This is because further investigation could not add to the Council’s response and he could not make a finding of the kind Ms B wants.

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Investigator's decision on behalf of the Ombudsman