Summary: We will not investigate Mr B’s complaint about the actions of his mother’s, Mrs C’s care provider following a fall. This is because further investigation by the Ombudsman could not provide Mr B with a different outcome to that already provided by the care provider or one that Mr B wants.

The complaint

1. Mr B complained to his mother’s Mrs C’s, care provider that she was denied medical care for 42 hours following a fall in the home. Mr B says Mrs C ‘s care provider should have visually noticed the changes in her appearance as she was admitted to hospital having sustained five fractured ribs and pneumonia. Mr B says the care provider lacked the ability to recognise a serious injuries and as a healthcare professional of many years the injuries Mrs C sustained would not have gone unnoticed as recorded.

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The Ombudsman’s role and powers

2. We investigate complaints about adult social care providers. 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 further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants, or

(Local Government Act 1974, sections 34B(8) and (9))

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How I considered this complaint

3. I considered the information and documentation Mr B provided. 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 says Mrs C’s care provider should have recognised sooner the severity of the injuries she sustained when she fell.
5. The care provider says Mrs C was found sitting upright on the floor with her legs straight in front of her by night staff during the 6am check. Staff checked her over and Mrs C said she was okay and wanted to get up. Two staff members assisted Mrs C back onto the bed and completed a first aid check, looking for cuts, bruises, grazes, swelling, decolourisations, or signs of facial grimacing/pain. It completed an accident report and contacted the Out of Hours service who conducted a telephone assessment. The care provider says it explained Mrs C had slipped off the bed, suffered with constipation and had not had her bowels open for a few days. Mrs C said her ‘tummy felt sore’ and said she felt ‘a little out of sorts’.
6. The care provider says this prompted it to seek advice from Mrs C’s GP. Mrs C appeared confused and had increased incontinence. It says a urine sample proved positive for a Urinary Tract Infection (UTI). The care provider says it told the Out of Hours service and Mrs C’s GP there was no evidence of any injuries and was advised to monitor Mrs C and contact them again if she deteriorated.
7. The care provider says following the fall, Mrs C washed and dressed herself, walked into the dining room and ate a full breakfast. She spent the day in the communal areas with her friend and changed into day clothes in the evening refusing to change into night wear. The care provider says Mrs C stayed in her room the following morning then came up for dinner and stayed in the communal areas for the remainder of the day. It says Mrs C was assisted to bed by night staff when she became unwell, went pale and vomited. The care provider says it immediately contacted the Out of Hours service who called for ambulance. Mr B says Mrs C was admitted to hospital at approximately 4:00am having sustained five fractured ribs and associated right side closed pneumothorax.
8. Mr B says the care provider should have noticed the injuries sooner, but we could not make this finding even if we investigated. The care provider has explained Mrs C showed no physical signs of injury until the following evening and had no reason to believe she was in pain. The care provider confirmed it had completed risk assessments prior to Mrs C being admitted to her home, completed a full accident report following the incident and had contacted the Out of Hours service and Mrs C’s GP following the fall. It is unlikely any further investigation by the Ombudsman could provide Mr B with a different outcome.
9. Mr B says he has not had answers to all his questions about the delay in contacting the emergency services when there were clearly severe injuries and he disputes the care provider’s record around how Mrs C would have presented following the fall. Mr B says as a health care professional he has never seen anyone with such injuries not displaying some evidence of pain and trauma which should have been picked up by her carers. The Ombudsman could not provide Mr B with the answers he wants. We could not say how Mrs C presented the day and following day following the fall or say she did not appear pain free.

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Final decision

10. We will not investigate this complaint. This is because further investigation by the Ombudsman could not provide Mr B with a different outcome to that already provided by the care provider.

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Investigator's decision on behalf of the Ombudsman