Summary: We find fault with the care provider, Promedica24. Its care worker did not follow the correct procedures when Mr W expressed an intention to take his own life. Although Mr W has since died and we cannot therefore remedy any injustice to him, these failings caused avoidable distress to his daughter for which the care provider will apologise and complete service improvements.

The complaint

1. Mrs Y complained a care worker did not follow the correct procedures when her father said he intended to take his own life.
2. The care provider then refused to respond to Mrs Y’s complaint because it said a further investigation would not add to the coroner’s findings.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))
5. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (Local Government Act 1974, section 26A or 34C)
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(1), as amended)
7. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

8. I considered evidence provided by Mrs Y and Promedica24 (the ‘care provider’) as well as relevant law, policy and guidance.
9. Mrs Y and Promedica24 had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

10. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards registered care providers must achieve. The Care Quality Commission (CQC) has guidance on how to meet the fundamental standards. The standards relevant to this complaint are:
• Regulation 10 requires providers to treat people with dignity and respect and in a caring and compassionate way.
• Regulation 12 requires providers to assess and mitigate risks to people's health and safety.
• Regulation 16 requires providers to operate an effective system for receiving, investigating and responding to complaints.

What should happen

11. The care provider’s policies set out clear expectations that staff must escalate concerns where a service user is at risk of self‑harm or suicide. The ‘Self‑Harm and Suicide Awareness Policy’ says in cases where a service user is in “immediate physical danger to themselves”, staff must call 999, stay with the person, and inform the emergency line or their line manager, as well as complete relevant documentation.
12. The same policy says staff must communicate information about self‑harm sensitively to other team members and may need to contact other professionals such as GPs or mental health services to obtain or share relevant information.
13. Similarly, the ‘Out of Hours and Emergency On Call Cover Policy’ is clear that staff should use the out‑of‑hours system to seek advice in an emergency and relay urgent information. This may include escalating serious or crisis situations.
14. The care provider's ‘Complaints and Compliments’ policy is clear all complaints from service users, relatives or stakeholders should be taken seriously and handled through the complaints procedure. The policy says complaints should be dealt with promptly, fairly and sensitively, and welcomes them as opportunities to improve services.

What happened

15. Mr W was an older adult who lived at home. In the period during the matters complained about, Mr W received home care from a ‘live in’ care worker employed by the care provider.
16. The records do not show Mr W had any diagnosed mental health conditions or a history of self-harm or suicidal thoughts. Mr W was also independent with many parts of his day-to-day life, including the administration of medication.
17. In late December 2024 Mr W started to talk to the care worker about wanting to die. He said his health conditions affected his quality of life and he felt burdensome.
18. The records show the care worker had regular contact with Mr W’s daughter,
    Mrs Y, over text message. The contact was mostly about day-to-day matters, such as medication and food shopping. The care worker would also report on Mr W’s general wellbeing.
19. Contact between the care worker and Mrs Y became increasingly informal. On 30 December 2024 the care worker told Mrs Y:

“Your dad moaning so hard from morning today about he don’t want be here [sic] I want die [sic] and everything bla bla bla”.

20. The following day Mr W had a conversation with the care worker about his
    end-of-life wishes, funeral plans and how he intended to share any assets among family. Mr W also said he would like to make a gift to the care worker, which they declined.
21. The care worker did not report this conversation to anyone at the time.
22. After the conversation, the care worker hid Mr W’s sleeping pills as they had concerns Mr W may take an overdose. Mr W went to bed as normal.
23. The next morning, the care worker reported that Mr W had not awoken at his usual time. The care worker checked Mr W and discovered he was conscious but drowsy. Mr W said he had taken an overdose of over-the-counter pain medication and a nutritional supplement which had been in his bedroom.
24. The care worker later said they had not realised Mr W had access to
    over-the-counter painkillers and had only been aware of his prescribed medication.
25. The care worker notified Mrs Y and relayed the intentions Mr W had expressed the previous evening. The care worker told Mrs Y in a text message that:

“Nothing’s wrong with him, [medication name redacted] is a painkiller… He’d have to eat the whole package at once to finish him off”.

26. The care worker called 999 and an ambulance arrived later that day to transport Mr W to hospital.
27. After a short period in hospital, Mr W passed away.
28. The coroner opened an inquest into the death of Mr W and concluded:

“On the night of 1 January 2025 [Mr W] informed his carer he would take “something” as he was fed up of being unwell and being a burden. The carer moved his sleeping tablets out of reach, but other medication remained accessible in the house, this included [medication name redacted] which was not prescribed, the whereabouts of which were unknown to the carer. The family were not contacted until the morning of 2 January 2025 when [Mr W] was found to be very drowsy and it was at this point [Mr W] notified his daughter that he had taken [medication name redacted]. There were a number of missed opportunities in the care and treatment afforded to [Mr W]. Once [Mr W] had expressed thoughts of taking his own life on the evening of 1 January 2025 the care emergency line should have been contacted, and it is more likely than not following the call the family of [Mr W] would have been notified. That said, it is unclear if the emergency call would have resulted in [Mr W] not taking the overdose. The outcome of this call would be difficult to determine but it is a missed opportunity for something meaningful to be done…”.

29. Dissatisfied with the actions of the care worker, Mrs Y complained to the care provider once the coroner had concluded its inquest. In September 2025 the care provider confirmed its decision to refuse to investigate the complaint, stating:

“After thorough consideration, we regret to inform you that we will not be proceeding with a further investigation into this matter. This decision has been made because the matter has already been addressed, and we feel that any further investigation would not change the outcome”.

30. Mrs Y approached us. She explained her intention to seek an apology and positive changes at the care provider to improve its services for others.

Was there fault causing injustice in the actions of the care provider?

Events leading up to the hospital admission of Mr W

31. The care worker failed to escalate a clear expression of suicidal intent. This was contrary to the provider’s policies, which required staff to treat such situations as an emergency and to seek urgent advice. It was also inconsistent with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, which requires providers to assess risks to people's health and safety and take appropriate action to mitigate those risks.
32. Furthermore, the care worker’s communication with Mrs Y was inappropriate and unprofessional. The tone of the messages lacked empathy and seriousness, including dismissive language about Mr W’s intentions. Regulation 10 requires providers to treat service users with dignity and respect, including supporting people in a caring and compassionate way. The care worker's communications were not consistent with those requirements, particularly in relation to serious matters involving suicide risk.
33. In addition, the care worker also displayed a lack of suitable knowledge and understanding of risk. This is shown by their response, which stated the tablets Mr W had taken were unlikely to cause harm unless taken in very large quantities. This reflects a failure to recognise and respond to the potential dangers of pain medication when a person has expressed suicidal intent.
34. Taken together, this amounts to fault because the care provider did not follow established procedures, had a lack of professional judgement in a crisis, and poor communication with Mr W’s family. The care provider’s actions are a potential breach of both Regulations 10 and 12.
35. We cannot say the outcome for Mr W would have been different had the care worker acted properly. The coroner found there were missed opportunities to act, but it is unclear whether earlier escalation would have prevented Mr W from taking an overdose.
36. However, the fault caused injustice to Mrs Y. The care worker’s failure to escalate the concerns meant Mrs Y lost the opportunity to act or be involved in decisions about her father’s care. More broadly, the failures have caused Mrs Y avoidable distress and uncertainty about whether more could or should have been done to support Mr W.

Complaint handling

37. The care provider’s refusal to investigate the complaint on the basis a coroner had already considered the death is not consistent with its own complaints policy.
38. The outcomes Mrs Y sought fell outside the remit of a coroner. The care provider’s policy only allows suspension of an investigation in limited circumstances, such as where legal action is being taken. There was no legal action in Mr W’s case.
39. The failure to investigate and respond to the complaint was fault. We have taken account of Regulation 16 which requires providers to have an effective and accessible system for receiving, handling and responding to complaints, including investigating complaints and taking proportionate action where necessary. The refusal to investigate Mrs Y's complaint is a potential breach of this regulation.

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Action

40. Where someone has died, we will not normally seek a remedy for injustice caused to the person in the same way as we might for someone who is still living. We would not expect a public or private body to pay someone’s estate. Therefore, if the impact of a fault was on someone who has died, we will not recommend an organisation make a payment to recognise, for example, the impact of poor care the person might have received while they were alive. This is because the person who received the care cannot benefit from a payment.
41. Within four weeks of the date of our final decision, the care provider will apologise to Mrs Y for the injustice caused by the fault in this statement. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The care provider should consider this guidance in making the apology I have recommended in my findings.
42. Within 12 weeks of the date of our final decision, the care provider will also:
• arrange refresher staff training to cover the following key matters:
1. ensure staff can appropriately recognise and respond to suicide risk, including refresher training on escalation procedures and self-harm awareness;
2. ensure that staff understand medication risks;
3. reinforce expectations around professional and sensitive communication with service users, their families and representatives;
• remind relevant staff of the need to accept and investigate complaints in line with its complaints policy. The reminder could be delivered via a team meeting, or a staff briefing paper. As part of the reminder to staff, the care provider should;
1. clarify guidance on the limited circumstances in which a complaint investigation may not start or be suspended; and
2. reinforce ways in which staff should respond sensitively to bereaved families.
43. The care provider will provide us with evidence it has complied with the above actions.

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Decision

44. I find fault causing injustice. The care provider will complete the agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman