Summary: The Ombudsman will not investigate Mr B’s complaint about the care provided to his late grandmother, Ms C. This is because there is no significant injustice to Mr B from the actions of the care provider warranting an Ombudsman investigation.

The complaint

1. Mr B complained about the care his late grandmother, Ms C received from her care provider. Mr B says:

• Ms C’s glasses were missing for over a week;
• Ms C’s shared room was a mess and was a health and safety concern;
• it took the care provider10 minutes to respond to an alarm call;
• Ms C spent too long in bed and her care provider did not assess her for a pressure mattress;
• Ms C was not assessed by the Speech and Language Team (SALT) and he was not told she needed to be observed when eating and drinking;
• Ms C was admitted to hospital when she choked on her food;
• Ms C was dropped from a hoist on two separate occasions and suffered a broken collar bone in 2018;
• he complained in July 2019- had no response from the care provider and wants to see a copy of the safeguarding report.

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The Ombudsman’s role and powers

2. 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)

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How I considered this complaint

3. I considered the information and documentation provided by Mr B and Ms C’s care provider. I sent Mr B a copy of my draft decision and considered his comments on it.

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What I found

4. Mr B complained to Ms C’s care provider concerned about the level of care she was receiving.
5. Ms C was admitted to hospital as a result of choking on her porridge where sadly she died.
6. Mr B is concerned he has not had a full response to his complaints about the care Ms C received, which were also considered by the local authority under its responsibility for safeguarding vulnerable adults.
7. Sadly, Ms C is now deceased so any injustice to her from any fault the Ombudsman might uncover even if he investigated cannot be remedied. Mr B has now received the report and additional information he wanted and although he is unhappy with its content, there is no separate injustice to him warranting an investigation by the Ombudsman.
8. Mr B says he did not know and was not told Ms C needed to be observed when eating and drinking and says she was given solid food. Mr B says if Ms C had received a SALT assessment sooner, she may have been on liquified foods which could have prolonged her life. Ms C choked on her porridge whilst being observed by her care staff and hospitalised at the earliest opportunity. The Ombudsman could not say Ms C would not have died if she had been given liquified foods sooner. Mr B has not been caused any significant injustice by not being told Ms C required observation when eating and drinking.
9. Mr B is concerned about the level of care other residents may be subject to. Mr B can ask the Care Quality Commission (CQC) as the regulator of care providers to monitor his concerns during it inspections. Information about the CQC can be found on the website below:

https://www.cqc.org.uk/give-feedback-on-care?referer=CQCExplorecolumn1

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Final decision

10. The Ombudsman will not investigate this complaint. This is because there is no significant injustice to Mr B from the actions of the care provider warranting an Ombudsman investigation.

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Investigator's decision on behalf of the Ombudsman