Summary: We will not investigate Mrs Y’s complaint about the care provided to her late grandmother, Mrs X. That is because further investigation would not lead to a different outcome, and we cannot achieve the outcome Mrs Y wants.

The complaint

1. Mrs Y complained about the standard of care provided to her late grandmother, Mrs X. She said the care workers failed to stay the full 30 minute allocated for her care visits; and that they did not complete Mrs X’s personal care and general cleaning tasks as specified in her care plan.
2. Mrs Y also complained that a care worker requested an ambulance for Mrs X when it was not needed. She said the care worker then provided false information to the ambulance crew which resulted in them making an adult safeguarding referral for Mrs X.
3. Mrs Y said that safeguarding referral delayed Mrs X’s discharge home from hospital, where she subsequently died from an infection. Mrs Y wants the care worker responsible for contacting the ambulance investigated and disciplined as she believes they are responsible for Mrs X’s premature death. She also wants financial compensation for the time she has lost with Mrs X.

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The Ombudsman’s role and powers

4. The Ombudsman investigates 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 may decide not to continue with 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
• we cannot achieve the outcome someone wants. (Local Government Act 1974, section 24A(6))

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How I considered this complaint

5. I considered information provided by the complainant and the Council.
6. I considered the Ombudsman’s Assessment Code.

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My assessment

7. Mrs X first started receiving care from the Care Provider in 2017. Mrs Y said the standard of care began to deteriorate in 2019 and the Care Provider and the Council met with her in 2019 to resolve these concerns. Mrs Y said she continued to raise concerns with an Officer at the Care Provider and the standard of care would improve for a short period. However, these improvements were not sustained.
8. In April 2021, a care worker sought medical advice after Mrs X had been wheezy for a couple of days. Mrs X was admitted to hospital and died a few days later. Following that, Mrs Y complained in June 2021. The Care Provider sent its final response in April 2022.

Mrs Y’s complaint about the standard of care

9. In the Care Provider’s response to Mrs Y, it said it had no records of any previous complaints and that the Officer she spoke with had left the organisation. However, it said it had reviewed the care records, care reviews, quality monitoring and evidence provided by Mrs Y and confirmed the quality of care delivered to Mrs X did at times, fall below reasonable expectations. It said in future, where the standard of care fell below what was required it would notify staff and provide guidance around their roles. It also said it had reviewed its complaints training and introduced a central recording system.
10. We will not investigate this complaint further. The Care Provider has accepted fault in both its complaint handling and for the care provided to Mrs X. It has apologised and recommended service improvements. We could not add anything to the existing investigation.

Mrs Y’s complaint about the care hours delivered

11. The Care Provider confirmed that Mrs X did not always receive the full 30 minutes of care allocated. In response to my enquiries, the Council confirmed it is auditing the Care Provider’s records and will calculate any reimbursement owed to Mrs X’s estate. That is a suitable remedy for any injustice caused, therefore we will not consider this complaint further.

The care workers decision to call an ambulance

12. The Care Provider did not uphold this complaint. It said the care worker contacted 111 for advice for Mrs X. It said 111 had dispatched an ambulance and it was the ambulance crew’s decision to admit Mrs X to hospital and to make a safeguarding referral. It said it was not responsible if Mrs X had contracted an infection in hospital.
13. We will not investigate this complaint further. Evidence provided indicates Mrs X had been wheezy in the days before the Care Provider contacted 111, therefore, it is unlikely we would find fault with its decision to get medical advice. Nor could we make a finding on what the care worker said to the ambulance crew. There is a discrepancy between her account and the ambulance crews; however further investigation would not resolve that.

Further still, we cannot achieve the outcome Mrs Y wants. We would not find the Care Provider responsible for Mrs X’s death. Nor could we make the Care Provider take any disciplinary action against the staff member.

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Final decision

14. We will not investigate Mrs Y’s complaint because further investigation would not lead to a different outcome.

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Investigator's decision on behalf of the Ombudsman