Summary: We will not investigate this complaint about lack of end-of-life care being provided to Mrs C. This is because further investigation by the Ombudsman could not add to the care provider’s responses or make a different finding.

The complaint

1. Ms B complained about carers attending her late mother, Mrs C, on the day she died. Ms B says there was no end-of-life plan in place, carers should have called the emergency services to attend Mrs C even though Mr C said he wanted to wait until lunchtime, records minimised the severity of Mrs C’s health needs, she was more than unwell, records show her breathing was laboured. Carers did not act in Mrs C’s best interests and should have supported Mr B not left him to deal with an imminent death alone. Ms B says there should be an independent investigation into Mrs C Care Provider’s to ensure other families do not have to go through a similar occurrence. Ms B says Mrs C was left without appropriate medical support and did not die in peace or with dignity.

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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 effect on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start an investigation if the tests set out in our Assessment Code are not met. (Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

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

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My assessment

5. The Care Provider says carers attending Mrs C the morning she passed away recorded Mrs C as being sleepy and not responsive. It says carers advised Mr C to call for medical assistance, but he did not want to risk Mrs C being admitted to hospital as she had only recently been discharged. The carer contacted the Care Provider’s on-call emergency service who advised Mr C’s wishes should be respected and to report back following the lunch time call. Mr C advised carers attending the lunch call that he had called 111 and was waiting for a call back. He also advised he was trying to contact his son.
6. The Care Provider says it should have recorded an offer to help contact relatives and apologised this was not clearly recorded. The Care Provider says all staff undertake end of life training and, as a result of Mrs B’s complaint, arranged for additional training for staff to recognise and respond to the signs of customers approaching the end of life. It says it has already amended its internal care plan to include a section on wishes and preferences for end-of-life care and has an end-of-life specific care plan which focusses on joint working with other professionals and managing pain and symptoms.
7. The Care Provider says the on-call representative should have contacted Mr C directly rather than passing messages on through carers and this could have assured him regarding seeking medical advice. The Care provider says there was no indication Mrs C was approaching the end of her life and, although she had a number of health concerns, carers understood Mrs C was unwell because of a UTI as she had recently been discharged from hospital suffering with this.
8. While Ms B has not had all the answers she wants about what happened to Mrs C, it is not the role of the Ombudsman to provide her with these. The Care Provider has explained what it has done to minimise the risk of a similar occurrence in the future, and we could achieve no more even if we investigated. Ms B is concerned Mrs C died without peace or dignity. Records show Mrs C was unresponsive when the carers attended. We could not now provide a remedy for any injustice caused to Mrs C from any fault an investigation might uncover. We are satisfied the Care Provider has taken appropriate action to ensure correct processes and procedures are now in place to minimise the risk of a similar situation occurring again.

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Final decision

9. We will not investigate Ms B’s complaint because further investigation by the Ombudsman could not add to the care provider’s responses or make a different finding.

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Investigator's decision on behalf of the Ombudsman