Summary: We will not investigate Mr C’s complaint about care and support provided to Mrs D before she died. This is because further investigation could make a finding of the kind Mr C wants. We could not now provide Mrs D with a remedy even if we investigated and found evidence of fault.

The complaint

1. Mr C complained about the care and support provided to Mrs D prior to her death in December 2021. Mr C says Mrs D’s care provision was inadequate, Mrs D had male carers she did not want, was not provided with three meals a day, and did not receive her medication for six days prior to being hospitalised. Mr C says carers called an ambulance for Mrs D, then left her in pain and distress for five hours waiting for an ambulance to arrive. Mr C says the impact of the poor care Mrs D received hastened her death three weeks after being admitted to hospital and if the Council had contacted her family or neighbours her death may not have occurred so quickly. Mr C says he waited eight months to get a response from the Council which was vague and unacceptable.

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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 Council has explained the circumstances do not warrant investigation under its Safeguarding Adults Review Procedures. The Council has acknowledged Mrs D’s care plan was not clear regarding the administration of medication and will pass this onto the relevant team for learning. We could not add to this.
6. We could not make a finding that the sequence of events is such that any action or omission by the Care Provider or the Council contributed to Mrs D’s dying. The hospital would have contacted the coroner if it was concerned poor care provision contributed to her death. The coroner, if not satisfied with a cause of death, can investigate further. Mr C says he has not had all the answers he wants to what happened to Mrs D is concerned the Care Provider is inadequate. It is not the role of the Ombudsman to provide him with the answers he wants. Our role is to provide a remedy for injustice caused by fault. Mr C can contact the Care Quality Commissioner, who is the regulator of Care Providers about his concerns with Mrs D’s provider. We could not now provide Mrs D with a remedy to any fault which might be uncovered during an investigation even if we investigated.

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Final decision

7. We will not investigate Mr C’s complaint because further investigation could not provide Mr C with the outcome he wants. We could not now provide Mrs D with a remedy even if we investigated and found evidence of fault.

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Investigator's decision on behalf of the Ombudsman