Summary: We will not investigate Miss X’s complaint, regarding her late mother Mrs Y, about the actions of the carer when Mrs Y died, the differing accounts of the incident, and the Council’s complaint responses. We cannot make a finding that the carer’s actions contributed to Mrs Y’s death. There is insufficient personal injustice to Miss X caused by the records issue to warrant investigation. We could not add to the Council’s investigation of the matters. We do not investigate councils’ complaint-handling where we are not investigating the core issues giving rise to the complaint. An investigation would not achieve a worthwhile outcome for Miss X.

The complaint

1. Miss X is the late Mrs Y’s daughter. Mrs Y was discharged from hospital to home after treatment and was receiving care there from Lily of the Valley Care Ltd, commissioned by the Council. Mrs Y died after bleeding from a wound related to her treatment. Miss X complains:
1. the carer in attendance when Mrs Y died initially called her manager and 111 instead of 999;
2. the Council and carer gave different accounts of whether the carer called their manager for advice before calling 111;
3. gave responses to her complaint which included inaccuracies regarding the events around Mrs Y’s death.
2. Miss X says the conflicting accounts, incomplete records and apparent delay to the call to 111 have caused her anxiety, panic and distress. She wants the care firm to change the processes for such emergencies, make accurate records and train staff on recognising life-threatening incidents.

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The Ombudsman’s role and powers

3. 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 or continue an investigation if we decide:

• any injustice is not significant enough to justify our involvement; or
• we could not add to any previous investigation by the organisation; or
• there is no worthwhile outcome achievable by our investigation.

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

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How I considered this complaint

4. I considered information from Miss X and the Ombudsman’s Assessment Code.

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My assessment

5. We recognise the great upset and distress to Miss X which has been caused and continues to feel as a result of the death of Mrs Y and the circumstances of it. The core issue is whether the actions of the commissioned care provider, such as not calling for help soon enough or calling the wrong medical service first during the incident, contributed to Mrs Y’s death. We cannot make such a finding. Only the coroner can make a finding on someone’s cause of death. So we could not find the outcome of the incident would have been different but for different actions being taken or in another order.
6. We realise a consistent record of the incident would have provided more clarity to Miss X and may have helped her with her distress. But the key cause of her distress is the loss of Mrs Y. The injustice to Miss X stemming directly from any fault in the recording of the incident is insufficient to warrant us investigating. We cannot consider or remedy any injustice to Mrs Y because we cannot do so once someone has died.
7. Furthermore, from the evidence Miss X has provided, it shows the Council has sought information to determine the events and their order. This included contacts with the 111 and 999 services to confirm call timings and responses to try to work out what happened and when. There would be no new or different information available to us which officers have not already considered when responding to Miss X’s complaint. An investigation by us cannot add to that Council investigation to provide more clarity on the incident for Miss X.
8. Miss X says the Council’s complaint responses are wrong about the time of Mrs Y’s death and whether the ambulance crew was there at the time. Her complaint to us indicates Miss X is aware those are inaccuracies, so they have not contributed to any uncertainty. We do not investigate councils’ complaint‑handling in isolation where we are not investigating the core issues giving rise to the complaint. It is not a good use of our resources to do so. That limitation applies here so we will not investigate this aspect of the complaint.
9. The outcome Miss X wants is the care firm to improve their processes and training. An investigation by us would not achieve a worthwhile outcome to the benefit of Miss X as she has no ongoing involvement with the firm. However, as it is a fundamental care standard of the Care Quality Commission (CQC) for providers to make and keep accurate records of their provision, we will refer this matter to the CQC. It will be for the CQC to decide how to use the information when making future assessments of the care provider.

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Final decision

10. We will not investigate Miss X’s complaint because:
• there is insufficient personal injustice to her caused by the matters we can consider to warrant an investigation; and
• we could not add to the Council’s investigation; and
• we do not investigate councils’ complaint-handling where we are not investigating the core issues giving rise to the complaint; and
• investigation would not achieve a worthwhile outcome for her.

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Investigator's decision on behalf of the Ombudsman