What do complaints teach us about end of life care?

See our latest report on the lessons that can be learnt from our complaints about end of life care given in care homes and in the home.

Bolton Metropolitan Borough Council (25 015 114)

Category : Adult care services > Other

Decision : Not upheld

Decision date : 23 Jun 2026

The Ombudsman's final decision:

Summary: Ms X complained on behalf of Mrs Y that the Council delayed providing Mrs Y with the correct size toilet after an Occupational Therapy assessment. She also said the Council communicated poorly and its contractors were rude. I have ended this investigation because there is insufficient evidence of fault or of significant injustice to Mrs Y. Further there is no worthwhile outcome achievable through investigation.

The complaint

  1. Ms X complained the Council delayed in providing Mrs Y with the correct toilet seat after an Occupational Therapy assessment by nearly four months, causing Mrs Y distress.
  2. She said the Council communicated poorly to her complaints and the contractors it used were rude to Mrs Y.
  3. She wants the Council to apologise and provide a financial remedy for the injustice caused.

Back to top

The Ombudsman’s role and powers

  1. 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:
  • there is not enough evidence of fault to justify investigating, or
  • any fault has not caused injustice to the person who complained, or
  • there is no worthwhile outcome achievable by our investigation.

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

Back to top

How I considered this complaint

  1. I considered evidence provided by Ms X, Mrs Y and the Council as well as relevant law, policy and guidance.
  2. Ms X, Mrs Y and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

Back to top

What I found

Care assessment

  1. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.

What happened

  1. In mid-April 2025, after an occupational therapy assessment, the Council’s contractor fitted a new toilet for Mrs Y.
  2. At the end of April, Mrs X told the Council a 15-inch toilet had been installed rather than the assessment recommended 17-inch. The Council offered solutions of a plinth or toilet seat raiser, but Mrs Y declined these offers. She agreed to the original 19-inch toilet be reinstalled and this took place at the end of May 2025.
  3. In June 2025, Ms Y complained to the Council that the recommended 17-inch toilet had not been installed, the contractor had been rude, and the issue had taken time to resolve.
  4. Shortly after, the Council visited Mrs Y and organised for a 17-inch toilet to be installed, and this was completed at the start of July 2025. It said it would ensure future communications with contractors about toilet heights were confirmed before any installation.
  5. Ms X escalated the complaint on behalf of Mrs Y. She said while the desired outcome had now been achieved it had caused immense difficulties for Mrs Y.
  6. Mrs Y remained unhappy with the Councils responses and actions and asked us to investigate.

My Findings

  1. I ended this investigation because, after becoming aware the incorrect toilet had been fitted, the Council responded quickly and offered temporary solutions which were declined by Mrs Y. It then, within a month, reinstalled a 19-inch toilet at Mrs Y’s request.
  2. After Mrs Y raised further concerns, it again responded quickly and installed a 17-inch toilet. It has taken steps relating to contractor communication for the fitting of toilets.
  3. I am therefore not persuaded Mrs Y has experienced a significant personal injustice, further the correct toilet has now been fitted. For these reasons, I do not consider further investigation by the Ombudsman to be warranted.

Back to top

Decision

  1. I have ended the investigation into this complaint. There is insufficient evidence of fault in the Council’s actions with any injustice caused is not significant enough to justify our involvement. There is also no worthwhile outcome now achievable.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Privacy settings