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Cheshire East Council (19 018 012)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 01 Feb 2021

The Ombudsman's final decision:

Summary: Ms E complained that the care home where her late grandmother, Mrs F, was a resident took too long to call for an ambulance and her family before she died. She also complained there was a do not attempt resuscitation decision missing from Mrs F’s file and her room was not cleaned the day after she died. We find the Council was at fault because there was no process in place to review the do not attempt resuscitation documentation and Mrs F’s room was not cleaned after she died. The Council has agreed to our recommendations to address the injustice caused.

The complaint

  1. Ms E complained that the care home where her late grandmother, Mrs F, was a resident took too long to call for an ambulance and the family before she died. Ms E also says there was a do not attempt resuscitation (DNAR) decision missing from Mrs F’s file.
  2. Ms E also complained when her dad visited the care home the following day, Mrs F’s room had not yet been cleaned. Ms E says it has been an extremely distressing time for her family.

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The Ombudsman’s role and powers

  1. 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’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:
  • their personal representative (if they have one), or
  • someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)


  1. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)
  2. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
  3. Under our information sharing agreement, we will share this decision with the Care Quality Commission.

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How I considered this complaint

  1. I considered the information Ms E submitted with her complaint. I made written enquiries of the Council and considered information it provided in response.
  2. Ms E and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

  1. Mrs F was a resident at Ingersley Court Care Home. The Council arranged and partly funded Mrs F’s care.
  2. The daily records show that Mrs F complained about feeling sick and having a stomach-ache at 7pm. The carer reported this to the team leader on duty. Mrs F went to bed early.
  3. A carer checked Mrs F at 10:15pm. She reported that she felt ill during the early evening, but that she was comfortable at that time.
  4. Mrs F reported having a stomach-ache at 10:47pm. She felt clammy and cold. The carer stayed with Mrs F.
  5. The carer called for an ambulance at 11:15pm. The ambulance service call handler told a member of staff to stay with Mrs F until an ambulance arrived. As Mrs F was deteriorating, the carer called 999 again. They arrived just after midnight. When the paramedics arrived, they wanted to find out whether Mrs F had a DNAR decision on her file. The carer could not locate a DNAR decision on Mrs F’s file, and so phoned her daughter at around 0:28am to tell her of Mrs F’s deteriorating health and ask her about the DNAR decision. She told the carer Mrs F did have a DNAR decision on file. However, as there was no record of this in Mrs F’s file, the paramedics started resuscitation.
  6. Mrs F sadly died at 0:55am. A member of staff contacted Mrs F’s daughter at 0:57am.
  7. Ms E complained to the care home. She said it took too long for it to call for an ambulance and Mrs F’s daughter. She also complained the DNAR decision was missing from Mrs F’s file and her room was dirty when the family visited the following day.
  8. The care home responded to Ms E. It said Mrs F did not have a DNAR decision in place. It also said its staff called for an ambulance when they were concerned about Mrs F’s health. It said its staff contacted Mrs F’s family as soon as they could, and their priority was being with Mrs F. Finally, it apologised for Mrs F’s room not being cleaned after she died. It said in future any additional duties would be delegated to domestic staff to avoid the same thing happening again.
  9. Ms E was unhappy with the care home’s first response to her complaint and asked for a review. The care home issued its final response Ms E’s complaint and apologised again for not cleaning Mrs F’s room after she died. It also said it had called for an ambulance at the right time when it saw Mrs F was deteriorating.
  10. The Council also investigated Ms E’s complaint. It said the following:
  • The carers could not call the family sooner as they were trying to manage an emergency.
  • The carers called for an ambulance when they saw Mrs F deteriorating.
  • The care home manager spoke with Mrs F’s GP and it did not have a record of a DNAR decision.
  • It recommended the care home reviewed its DNAR records regularly, clearly recording the wishes of a resident to avoid contacting families in an emergency.
  • Mrs F’s room was unacceptable, and the care home had reflected on how it should have agreed a mutual time when it knew the room was satisfactory for family members to attend.
  1. Ms E was unhappy with the Council’s response and referred her complaint to the Ombudsman. She said the care home should have sought medical assistance and contacted her family much sooner.

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  1. The evidence shows the care home first called for an ambulance at 11:15pm. Ms E says Mrs F was unwell from 7pm, so care home staff should have called for an ambulance much sooner. Although the records do show Mrs F reported feeling sick at 7pm, she began to deteriorate as the evening went on. When care home staff had cause for serious concern, they acted quickly and called for an ambulance. The team leader on duty was aware of the situation and stayed with Mrs F while waiting for the paramedics to arrive. The care home’s policy says if there are concerns regarding the health of residents that staff cannot manage, then the emergency services must be contacted. I am satisfied that care home staff adhered to this policy and that appropriate steps were taken in the circumstances. I therefore do not find fault.
  2. Ms E is also unhappy the care home did call the family sooner. The Council says care home staff acted in Mrs F’s best interests and because her health deteriorated so quickly, they could not call the family sooner. It says staff were trying to manage that emergency and ensure the safety of Mrs F and other residents. I appreciate why Ms E feels her family should have been called sooner. However, care home staff were right to prioritise dealing with an emergency. I am satisfied they called Mrs F’s family at the safest opportunity.
  3. Ms E says Mrs F had a DNAR decision in her file. I have reviewed Mrs F’s life plan, and it says there was no DNAR decision in place. The care home also contacted Mrs F’s GP and it also did not have record of a DNAR decision. Therefore, the paramedics attempted resuscitation. However, the care home did not have a process to regularly review its DNAR records. This is fault. When the Council responded to Ms E’s complaint, it recommended that the care home should review its DNAR records regularly to avoid contacting the family in an emergency. The care home has confirmed it has implemented this. I welcome this recommendation by the Council, but a further remedy is due to address the injustice caused to Mrs F’s family. If the care home had a process to review the DNAR records, it would have avoided calling Mrs F’s daughter in an emergency because it would have had a clear record on file. Mrs F’s family did not want her to be resuscitated, but because the care home did not have a proper review process in place, the paramedics had to attempt resuscitation. This caused avoidable upset and distress for Mrs F’s family.
  4. The care home and the Council have both apologised for Mrs F’s room not being cleaned after she died. The care home has confirmed it has learnt lessons and has changed its approach to agree a mutual time for family members to attend after a resident has died. I welcome the steps the care home has taken. However, the Council needs to go further in remedying the distress Mrs F’s family has suffered. Ms E says it was upsetting for her dad to see Mrs F’s room. I accept this would have caused even more distress for Mrs F’s family at an already upsetting time.

Agreed action

  1. When a council commissions another organisation to provide services on its behalf it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the service of Ingersley Court Care Home, I have made recommendations to the Council.
  2. To address the injustice caused by fault, by 1 March 2021 the Council has agreed to:
  • Apologise to Ms E for the upset and distress caused by failing to have a proper process in place to review the DNAR documentation.
  • Pay Ms E £300.

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Final decision

  1. I have found fault by the Council, causing an injustice to Ms E. The Council has agreed to my recommendations and so I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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