Summary: We will not investigate this complaint about the end-of-life care provided to the complainant’s mother (Mrs Y). Further investigation by the Ombudsman would be unlikely to add anything to the Care Provider’s response or make a different finding. Sadly, Mrs Y has passed away, so we could not provide her with a remedy even if we investigated and found evidence of fault causing injustice.

The complaint

1. The complainant, Mrs X, complains about the end-of-life care Mrs Y received from the Care Provider. Mrs Y was resident in a care home. Mrs X complains the Care Provider delayed calling the District Nurse when Mrs Y’s health deteriorated.

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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 we could add to any previous investigation by the Care Provider, or
• it is unlikely further investigation will lead to a different outcome.

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

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How I considered this complaint

3. I considered information provided by the complainant and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. The Care Provider said the following in its responses to Mrs X:
• On the night Mrs Y passed away she was receiving two hourly checks.
• Mrs X identified her mother’s breathing had deteriorated and asked for the District Nurse to be called. At 03.15 it was discovered this had not happened and the District Nurse was called. They arrived at 04.15.
• The District Nurse remained until 06.40 when they gave Mrs Y two anticipatory medicines. Mrs Y passed away at 09.00.
• The Senior Care Assistant had not received end-of-life training – contrary to the Care Provider’s policy.
• There was a lack of effective communication between staff.
• There had been no personal condolences or follow-up call to Mrs X from the Care Provider.
• Changes had been made including:
• Reviewing care and support plans – all end-of-life care plans would now be reviewed by two members of staff.
• All staff had completed learning on end-of-life care plans.
• Ensuring managers or chaplains would contact families when a resident passed away.
6. I understand how upset Mrs X is by the issue at the heart of her complaint. But if we were to investigate, it is unlikely we could add anything to the Care Provider’s response. It has identified what went wrong and explained the changes it has made. Because Mrs Y has passed away, even if we were to investigate and find fault causing injustice, we could not now do anything to remedy this. We will not therefore investigate.

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Final decision

7. We will not investigate Mrs X’s complaint because it is unlikely we could add anything to the response she has already received or provide a remedy for Mrs Y.

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Investigator's decision on behalf of the Ombudsman