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Oxfordshire County Council (18 016 587)

Category : Adult care services > Residential care

Decision : Closed after initial enquiries

Decision date : 28 Mar 2019

The Ombudsman's final decision:

Summary: The Ombudsman will not investigate this complaint about lost dentures in a care home. This is because the complaint about the substantive issue is made late, and there are no good reasons to exercise the Ombudsman’s discretion to consider it now. In addition, we could not add anything to the Council’s previous investigation into the other issues raised.

The complaint

  1. The complainant, who I refer to here as Mrs N, says that the Care Home where her mother lives:
    • lost her dentures and did not take adequate care of her oral hygiene; and
    • lost or removed data entries from her mother’s file regarding this issue.

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The Ombudsman’s role and powers

  1. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
  2. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended
  3. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe it is unlikely we could add to any previous investigation by the Council. (Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

  1. I considered the evidence provided by Mrs N and by the Council. I have also sent Mrs N a draft decision for her comments.

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What I found

  1. Mrs N’s mother, M, entered a care home in 2016. At some point after that, M’s dentures sent missing, and were never located.
  2. In December 2017 M was referred to the dentist, who said that due to poor oral health, her gums had shrunk too much for a new set of dentures to be made.
  3. Mrs N was not happy with the situation and complained several times to the Care Home. In June 2018 she asked for a copy of her mother’s records, but when she received them, she was unable to find a data entry noting the loss of the dentures. She says that a section of the notes referring to oral hygiene was missing.
  4. Mrs N complained to the Council, but is dissatisfied with its response. She believes that the dentures were lost earlier than the Care Home says, and that the Care Home did not pay adequate attention to M’s oral hygiene.
  5. Mrs N also believes that the missing pages of M’s notes were removed by the Care Home to hide the actions of the staff.
  6. She has now brought the complaint to the LGSCO but we will not investigate it. This is because the complaint about the substantive issue, the loss of the dentures, is made late. We cannot investigate matters that were known to the complainant more than 12 months previously unless there are good reasons to do so.
  7. There are no good reasons in this case, as we are unlikely to be able to add anything to the previous investigation by the Council.
  8. Mrs N is also dissatisfied with the Council’s response regarding the missing case notes, but I do not consider that further investigation would be able to establish what happened to them. The Care Home has undertaken to review its procedures and training to ensure that this does not happen in the future, and we could not add to this outcome.

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Final decision

  1. Subject to any comments Mrs N might make, my view is that the Ombudsman should not investigate this complaint. This is because the substantive matter is late, and we could not add anything further to the previous investigation by the Council.

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Investigator's decision on behalf of the Ombudsman

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