Summary: The Ombudsman will not investigate Mr X’s complaint about the respite care his brother received. This is because there is not enough evidence of fault, and it is unlikely we could add anything to the response Mr X has already received.

The complaint

1. The complainant, whom I shall call Mr X, complains about the respite care his late brother (Mr Y) received. Mr X says his brother was given powerful sedatives and the care home failed to properly monitor him, which led to his death. Mr X says he has received conflicting information about the medication Mr Y received.

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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 would find fault, or
• the fault has not caused injustice to the person who complained, or
• it is unlikely we could add to any previous investigation by the Council, 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)

3. 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)

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How I considered this complaint

4. I considered Mr X’s complaint to the Ombudsman and the information he provided. I also gave Mr X the opportunity to comment on a draft statement before reaching a final decision on his complaint.

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What I found

What happened

5. Mr Y suffered from Lewy Body Dementia and was admitted to a respite care placement in 2020. Mr X says he visited his brother and was concerned about his health. Mr X believed his brother had been sedated – which the care provider denied. Mr Y’s wife then visited him later the same day. Mr X says the care provider told Mr Y’s wife that he had been sedated. Mr Y was admitted to hospital shortly afterwards. He was then discharged to nursing care but died shortly afterwards.
6. Mr X complained to the care provider about his brother being sedated. He also referred to a bruise on his brother’s arm he had noticed the week before the events set out above.
7. The care provider responded and said Mr X was given one Lorazepam tablet on 19 August 2020. A carer had recorded the bruise on 08 August. It said Mr Y was “prone to falls and challenging behaviour which can result in bruising”.
8. Unhappy with the response, Mr X complained to the Council. As the Council organised the respite placement, we consider Mr X’s complaint to be against the Council.
9. In its response to Mr X’s complaint the Council said:
• It was sorry Mr X had received conflicting information about the medication given to Mr Y.
• It had obtained Mr Y’s Medication Administration Record (MAR) from the care provider.
• The MAR showed Mr Y had been prescribed 56 lorazepam tablets. The care provider had given him a single tabled on 19 August.
• The Council could not conclude the care provider used medication to keep Mr Y sedated.
• Mr Y was admitted to hospital on 25 August due to problems with his breathing. This was a common problem with Mr Y’s illness. When the hospital discharged Mr Y, he required 24-hour nursing care.
• Mr Y sadly passed away on 21 September 2020.

Assessment

10. We do not investigate all the complaints we receive. In deciding whether to investigate we need to consider various tests. These included the likelihood of finding fault, and if an investigation is likely to achieve anything more. We also need to consider the alleged injustice to the person complaining.
11. I understand how upset Mr X is about the events at the heart of his complaint. I also recognise his concerns about the conflicting information he received about the medication given to Mr Y. But the Council has considered Mr X’s concerns and investigated. It has viewed Mr Y’s MAR and there is no evidence the care provider wrongly used medication to sedate Mr Y. The record of the single sedative given matches the care provider’s formal response. Based on the evidence available there is not enough evidence of fault for us to investigate.
12. Mr X is also concerned the care provider’s actions led to a decline in Mr Y’s health, and ultimately, his death. Sadly, as Mr X has passed away, any injustice to him cannot now be remedied. But we could also never say the care provider’s actions (acting on behalf of the Council) led to Mr Y’s death. The care provider has also explained the bruising to Mr Y’s arm. It is difficult to see what more we could add to the responses Mr X has received and we will not therefore investigate
13. If Mr X wants to raise further concerns about the care provider, he could contact the Care Quality Commission (CQC) as the appropriate regulatory body.

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Final decision

14. We will not investigate Mr X’s complaint. This is because there is not enough evidence of fault, and it is unlikely we could add anything to the response Mr X has already received.

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Investigator's decision on behalf of the Ombudsman