Summary: Mrs X complained about the care provided to her late mother at the care home. She complained the care provider failed to administer pain relief medication, failed to update risk assessments and care plans, failed to take a urine sample and failed to manage her end of life care. This caused Mrs X significant distress. We have discontinued the investigation because the coroner’s enquiries are ongoing and their conclusions will be directly relevant to any Ombudsman investigation.

The complaint

1. Mrs X complained about the care provided to her late mother, Mrs Y at Riverdale Care Home. She complained the care provider failed to administer pain relief medication and to review and update her care plan and risk assessment which led to a further fall and a deterioration in Mrs Y’s condition. She says it delayed submitting a urine sample to the GP and failed to manage Mrs Y’s end of life care appropriately resulting in a further fall. It also delayed responding to Mrs X’s complaint and failed to fully address the issues she raised. This has caused her significant distress.

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The Ombudsman’s role and powers

2. 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 care provider, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is another body better placed to consider this complaint.

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

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How I considered this complaint

3. I have considered the information provided by Mrs X and have spoken to her on the telephone. I have considered the care provider’s complaint responses to Mrs X.
4. I gave Mrs X and the care provider the opportunity to comment on a draft of this decision and considered any comments I received in the final decision.

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What I found

5. Mrs Y lived at the care home for around five years. She had dementia. In early 2019 Mrs Y had a fall and broke her hip. She was admitted to hospital and discharged back to the care home after a week. The GP visited and prescribed pain relief.
6. In early February Mrs Y hit her head while moving about in bed and was admitted to hospital. At that time Mrs X became aware the care home had not obtained the pain relief prescription and so had not administered pain relief to Mrs Y. Mrs X complained to the care home about this.
7. Mrs Y had a further fall at the care home. She died two days later, in late February 2019.
8. The care provider responded to Mrs X’s complaint in April 2019. Mrs X remained dissatisfied. The care provider sent a further response in May 2019. Mrs X remained unhappy and complained to the Ombudsman.
9. The coroner held an inquest into Mrs Y’s death in October 2019. Mrs X says the coroner is continuing to make enquiries with the care provider regarding the revised procedures it has introduced.

Findings

10. The coroner is currently investigating the events surrounding Mrs Y’s death. The coroner’s conclusions are likely to be directly relevant to any investigation the Ombudsman may undertake. I have therefore decided we should not investigate whilst the coroner is considering the matter. It will be open to Mrs X to come back to the Ombudsman if she considers there is an outstanding injustice once the coroner has reached a verdict.

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Final decision

11. I have discontinued my investigation. This is because the coroner’s court is currently investigating and is best placed to make recommendations at this stage.

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Investigator's decision on behalf of the Ombudsman