Palm Court Care (Dawlish) Limited (20 008 195)

Category : Adult care services > Residential care

Decision : Not upheld

Decision date : 31 Mar 2021

The Ombudsman's final decision:

Summary: Ms X was not named as Mr B’s contact when he was in the care home. The care provider notified the late Mr B’s sister, whom he had named as his primary contact, when he died. It was not the fault of the care provider that Ms X did not learn of his death for some months.

The complaint

  1. Ms X (as I shall call the complainant) says the care provider did not notify her of her father’s death. It was not until several months later when she telephoned the care home that she was informed he had died. She says as a result she lost the opportunity to visit him before he died.

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The Ombudsman’s role and powers

  1. 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

  1. I considered the information provided by Ms X and by the care provider. Both Ms X and the care provider had the opportunity to comment on an earlier draft of this statement and I took their comments into account before I reached a final decision.

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What I found

Relevant guidance

  1. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
  2. Regulation 10 says that service users must be supported to maintain relationships that are important to them while they are receiving care and treatment.
  3. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. A person must be presumed to have capacity to make a decision unless it is established that he or she lacks capacity.

What happened

  1. Mr B went to live as a resident in the care home in 2010. The care provider says he was assessed as having capacity to make all his own decisions during the whole time he lived at the home.
  2. Mr B nominated his sister as his next of kin and primary contact. She is the only emergency contact noted in the care home files for Mr B. There are frequent references to contact between the care home and Mr B’s sister in the care home records of daily care.
  3. When Mr B fell ill in 2019 the care provider contacted his sister as usual. Sadly Mr B died in October 2019.
  4. Ms X says she telephoned the care home to ask about her father’s welfare in August 2020. She says she had suffered a period of ill health after the death of her mother and so had not contacted the home for some time. She says prior to that she had called regularly to speak to staff and to her father. She believed her name was on his records as a contact, along with that of his sister.
  5. Ms X says she was shocked when a staff member returned her call and said Mr B had died in October 2019. She says the staff member told her the home did not have Ms X’s contact details on file. It was suggested details may not have been transferred when the files were computerised in 2018.
  6. Ms X made a formal complaint to the care provider. She said in the past the home had contacted her to tell her if her father had been admitted to hospital or needed an operation. She said she could not understand how her details had been lost and she asked for an explanation.
  7. The care home manager responded in October 2020. He said Ms X was not listed in any of the documents held since Mr B’s admission, so she was not contacted about his ill-health. He said staff had notified Mr B’s sister who Mr B had named as his next of kin.
  8. Ms X complained to the Ombudsman. She said she had been unable to see her father before he died, or to grieve properly for him after his death. She still did not know where his remains were.
  9. The care provider says it had “minimal” contact with Ms X while Mr B was in the home. It says there has been no contact from her since the care provider computerised its records in 2018. It says the manager remembers one call from Ms X early on in Mr B’s residence to arrange a visit which Mr B agreed, but Ms X did not attend.
  10. The care provider has given the details of Mr B’s interment as it understands them.
  11. Ms X says she never received the letter from the care provider. She says she does not believe the documents which the care provider has now produced and believes her details were simply lost from the files.


  1. The care provider complied with the regulations by ensuring the person nominated by Mr B to be his contact was notified of any changes in his health.
  2. In the absence of Ms X’s details as a contact it was not possible for the care home staff to notify her.
  3. It was sad that Ms X did not learn of her father’s ill-health and death at the time but that was not caused by the care provider.

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Final decision

  1. I have completed the investigation as there is no evidence that the actions of the care provider caused injustice to Ms X.

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Investigator's decision on behalf of the Ombudsman

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