Summary: We found fault by Harbour Healthcare with regards to the care it provided to Mr Y when he was resident in Kingswood Mount Care Home. This caused his wife, Mrs Y, significant distress and uncertainty. Harbour Healthcare will apologise to Mrs Y, pay her a financial remedy and take action to prevent similar problems occurring in future.

The complaint

1. The complainant, who I will call Mrs X, is complaining about the care provided to Mr Y by Kingswood Mount Care Home (the care home) when he was resident there between October 2021 and January 2022. The care home is operated by Harbour Healthcare 1 Ltd (Harbour Healthcare).
2. Mrs X complains that the care home:

• registered Mr Y with a different GP practice without his family’s knowledge or consent;
• failed to hoist Mr Y from his bed and assist him to mobilise;
• caused Mr Y to aspirate food through improper feeding techniques, causing aspiration pneumonia;
• delayed in identifying the aspiration pneumonia;
• failed to communicate effectively with Mr Y’s family and did not keep them informed about his health and progress;
• failed to provide Mr Y’s wife, Mrs Y, with clear advice about COVID-19 testing and would not allow her to visit him;
• provided Mr Y with a small room that was in poor condition. Furthermore, the care home failed to keep the room clean and staff were not responsive to Mr Y’s needs; and
• failed to inform Mr Y’s family that it would not be accepting him back as a resident following his discharge from hospital.

3. Mrs X says Mr Y’s health deteriorated during his time in the care home and that this poor care and neglect caused his family distress. Mrs X says the care home’s poor communication made this worse.
4. Mrs X would like Harbour Healthcare 1 to offer Mr Y and his family financial recompense that is proportionate to the harm they suffered because of the poor care he received in the care home.

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The Ombudsmen’s role and powers

5. 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)
6. If an adult social care provider’s actions have caused injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4)). Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
7. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

8. In making my final decision, I considered information provided by Mrs X. I also considered information and documentation from Harbour Healthcare, including the care records.
9. I invited comments from all parties on my draft decision statement and considered the responses I received.

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What I found

Relevant legislation and guidance

Care Quality Commission

10. The Care Quality Commission (CQC) is the statutory regulator of care services. It keeps a register of care providers that meet the fundamental standards of care, inspects care services, and reports its findings. It can also enforce against breaches of fundamental care standards and prosecute offences.
11. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the Care Regulations) introduced fundamental standards below which the care provided to people must not fall. This Act also placed a duty on the CQC to produce guidance for care providers on how to comply with the Regulations.
12. The CQC guidance provides information for care providers on how to meet the necessary standards in twenty domains. Most of these domains relate to care and treatment. These include dignity and respect, safe care and treatment and premises and equipment.

Background

13. Mr Y had a diagnosis of Parkinson’s Disease. He also had a history of constipation.
14. On 6 May 2021, Mr Y suffered a fall from height. He was admitted to hospital that day where he was found to have sustained multiple fractures. Mr Y had also suffered a brain injury that impaired his communication.
15. Mr Y remained in hospital for several months for treatment. During this admission, the treating clinicians inserted a Percutaneous Endoscopic Gastrostomy (PEG) tube. This is a tube that passes directly through the abdominal wall and into the stomach. This was used to feed Mr Y and administer medication.
16. Mr Y was noted to be doubly incontinent. He required assistance from two care workers with all personal care tasks. This included washing and dressing.
17. Mr Y was discharged from hospital to the care home on 29 September to await a Continuing Healthcare (CHC) assessment. The placement was funded by the NHS until 1 November. From that point, Mr Y funded it.
18. On 12 November, Mr Y’s son visited him at the care home and found him to be unwell. Care home staff continued to monitor Mr Y over the following days. However, when Mr Y’s condition had not improved by 16 November, the care home arranged for him to be taken to hospital.
19. Mr Y was subsequently diagnosed with aspiration pneumonia. This is a type of pneumonia in which inflammation or infection is caused in the lungs by particles of food or liquid being breathed into the airways instead of swallowed.
20. Mr Y was discharged back to the care home in December. However, he was subsequently readmitted in late January.
21. In February 2022, Mr Y was considered ready for discharge. The care home declined to accept Mr Y back on the basis that it could not meet his complex needs.

Analysis

GP registration

22. Mrs X complained that the care home registered Mr Y with a different GP Practice without the family’s knowledge or permission. Mrs X said the family only became aware of this when they attempted to arrange a visit from Mr Y’s original GP.
23. The Social Care Institute for Excellence (SCIE) produces guidance entitled GP services for older people: a guide for care home managers. This guidance says that “[a] new resident should be involved, with their relatives where appropriate, in the decision about whether to remain registered with their current GP practice, or transfer to the list of a GP practice with which the care home has arrangements”.
24. The guidance goes on to say that “[t]he home manager, together with the social worker or care manager, if one is involved, should take steps to help the resident and relatives make an informed decision.” This would include providing advice on the potential benefits and drawbacks of each choice.
25. In its response to my enquiries, Harbour Healthcare acknowledged there is no record of a conversation with Mrs X regarding the change of GP. However, it provided a copy of a clinic letter that it says shows Mrs Y spoke to the new GP on 4 October 2021. Harbour Healthcare said this shows Mrs Y was aware of the change of GP.
26. Furthermore, Harbour Healthcare said a change of GP “would usually be discussed with the resident if they are deemed to have capacity or the person holding the appropriate Power of Attorney if the resident is deemed not to have capacity.”
27. I have reviewed the letter Harbour Healthcare refers to above. This does not demonstrate that Mrs Y spoke to the new GP on 4 October. Rather, this is a clinic letter from a consultant urologist at the local hospital Trust. The letter refers to a telephone consultation between the consultant urologist and Mrs Y on 4 October and is addressed to the Mr Y’s new GP.
28. In summary, there is no evidence care home staff discussed the change of GP with Mr Y’s family or Mrs X. This was fault. This meant the family was denied an opportunity to make an informed decision about Mr Y’s care.

Lack of physiotherapy and failure to hoist

29. Mrs X complained that, shortly after Mr Y arrived in the care home, staff stopped hoisting him out of bed. Mrs X said Mr Y was instead left in bed all day. She also provided photographs of Mr Y which she said show him with his feet crushed up against the footboard. Mrs X said Mr Y had only been seen once by a physiotherapist during his time in the care home.
30. I have reviewed the transfer form completed by the hospital on 29 September 2021 which described Mr Y’s care needs. These included full assistance with continence care, washing and dressing. In addition, the form detailed Mr Y’s PEG feeding regime and Parkinson’s Disease medication schedule. However, there was no suggestion that Mr Y required physiotherapy.
31. Regulation 9 of the Care Regulations relates to person-centred care. The CQC guidance emphasises the need to “do everything practicable to make sure that people who use the service receive person-centred care and treatment that is appropriate, meets their needs and reflects their personal preferences whatever they may be.” The CQC guidance also refers to the importance of completing a thorough assessment of a person’s needs and a clear care plan setting out how these needs will be met.
32. The care records show the care home completed a mobility care plan for Mr Y. This set out that his mobility was poor and that he was unable to weight bear. The care plan noted that Mr Y required a hoist and sling for transfer and that he should be hoisted into his chair daily with the assistance of three staff. The care plan noted that staff would monitor Mr Y’s mobility and refer him to the community physiotherapy service if necessary.
33. I understand the care home subsequently did refer Mr Y to the physiotherapy service, though I was unable to locate a copy of the referral in the records.
34. In any case, the care records show a community physiotherapist visited Mr Y at the care home on 8 November. The physiotherapist noted that Mr Y had no rehabilitation potential due to “[a]dvanced ankle/achilles contractures” and his brain injury. The physiotherapist noted that staff should ensure Mr Y’s feet were supported when sitting in his chair. The physiotherapist also recommended supportive ankle boots.
35. The physiotherapist visited again on 11 November to fit Mr Y’s the ankle boots and provide him with bed-based exercises. The physiotherapist noted he would call again on 16 November to assess Mr Y’s progress and discharge him from the service.
36. I was unable to find any evidence to suggest this call took place or that the care home chased it up. Harbour Healthcare’s complaint response referred to “[several] remote consultations”. I was unable to locate any notes of these consultations in the care records provided to me.
37. The failure to record these consultations means I cannot reach a robust view on whether Mr Y received the necessary follow-up physiotherapy care. This represents fault by Harbour Healthcare.
38. Nevertheless, I am satisfied this did not have a significant impact on Mr Y’s care. This is because the physiotherapy records show Mr Y’s limited mobility meant he would not have been suitable for ongoing physiotherapy sessions.
39. Mr Y’s mobility care plan made clear that he should be hoisted from his bed daily to sit in his chair. The subsequent physiotherapy visits led to further recommendations for Mr Y’s feet to be supported as he was sitting in his chair to prevent further contractures of his Achilles tendons.
40. Care home staff reviewed the care plan three times between November 2021 and January 2022. Each review noted that Mr Y required the use of a hoist and sling, with the assistance of two staff, to transfer.
41. The daily care records suggest that, for around the first week of Mr Y’s time in the care home, staff were transferring him to sit in his chair. However, from this point I was unable to find any evidence of regular transfers. Indeed, there are several entries in the daily care notes that make clear Mr Y remained in bed throughout the day and night. This was not in keeping with the requirements of Mr Y’s mobility care plan. This was fault by Harbour Healthcare.
42. It is clear from the case records that Mr Y had only very limited mobility. The physiotherapist who assessed him considered he did not have any rehabilitation potential due to the contractures in his Achilles tendons and his brain damage. It is not possible to say to what extent Mr Y’s condition deteriorated as a result of him remaining in bed for long periods. Nevertheless, this caused Mr Y’s family unnecessary distress and uncertainty.

Aspiration pneumonia

43. Mrs X said Mr Y’s son visited him on 12 November and found him to be very unwell. Mrs X said the care home delayed in identifying that he was suffering from aspiration pneumonia and did not arrange for him to be seen by a doctor or given any medication. Mrs X said Mr Y was eventually admitted to hospital at the insistence of his family.
44. On 12 November 2021, Mr Y’s son visited him at the care home. He was concerned that Mr Y appeared unwell. Mr Y’s son said he reported his concerns to a nurse, who said she would monitor him.
45. I have reviewed the daily care records for the period 12 to 16 November. There are two entries in the care records for 12 November. Neither refers to Mr Y feeling unwell or to a conversation with his son. On 13 November, a nurse noted that he “complained of feeling sickly and feverish.” However, when the nurse took Mr Y’s observations, these were within the normal range. The nurse recorded that Mr Y was “reassured” by this.
46. The three entries for 14 and 15 November again suggest Mr Y was settled and slept well. There is no evidence of nurses undertaking any further observations during this period.
47. Mr Y’s son visited him again on 15 November. He remained concerned that Mr Y’s condition was deteriorating and spoke to a nurse. Again, I found no record of this conversation in the care records.
48. There are then three entries for 16 November, the day of Mr Y’s hospital admission. The first of these (recorded at 6.37am) makes no mention of Mr Y being unwell. However, the next entry says “[s]poke to GP surgery to request ABX for [Mr Y’s] chest as very chesty.” Subsequently, at 6.30pm, a nurse recorded “[p]honed ambulance due to [Mr Y] being very chesty, spoke to [Mr Y’s son] who informed me he had been chesty since Saturday and he reported his concerns to nurse in charge and the female nurse on Monday 15/11/21. He was not seen yesterday, appears that no action was taken.”
49. Regulation 12 of the Care Regulations relates to safe care and treatment. The guidance accompanying this regulation says that “[a]ssessments, planning and delivery of care and treatment should include arrangements to respond appropriately and in good time to people’s changing needs.”
50. I am satisfied, based on the available records, that Mr Y’s son did raise his concerns about his father’s deteriorating condition on 12, 15 and 16 November. Despite this, care home staff took no meaningful action to monitor Mr Y. I found no proper record of Mr Y’s symptoms and staff took Mr Y’s observations only once (on 13 November).
51. Furthermore, I found no evidence to suggest staff sought clinical input (such as from a GP) until 16 November. It was then a further 12 hours before staff arranged an ambulance for Mr Y (at around 6.30pm). This strongly suggests care home staff were not responsive to Mr Y’s changing presentation. This care was not in keeping with the Care Regulations. This was fault by Harbour Healthcare.
52. I am unable to say whether Mr Y’s hospital admission would have been avoided even if he had received GP input and medication earlier. This has left Mr Y’s family with distress and uncertainty as to whether the outcome of his care would have been different with more responsive care.
53. Mrs X was concerned that Mr Y developed aspiration pneumonia as a result of poor feeding technique by care home staff.
54. I have reviewed Mr Y’s nutritional care plan. This recorded that Mr Y received most of his meals via his PEG feed. The plan set out that Mr Y could receive sips of fluid and small quantities of pureed food. This was intended to allow Mr Y to maintain a higher quality of life by ensuring he could continue to enjoy smaller quantities of food and drink orally. However, Mr Y’s poor swallow (known as dysphagia) meant that aspiration of food or drink particles was a recognised risk. This is often called ‘feeding at risk’.
55. The daily care records show care home staff encouraged Mr Y to take oral fluids and diet and supported him to do so appropriately. I understand Mr Y’s family also supported him to eat and drink small amounts during visits. While I appreciate it was distressing for Mr Y’s family that he developed aspiration pneumonia, I found no evidence to suggest this was a result of neglect or omissions in the care provided by the care home. Rather, this was a recognised risk to Mr Y of continued oral feeding. I found no fault by Harbour Healthcare on this point.

Communication with family

56. Mrs X said the care home failed to keep the family informed about Mr Y’s health. Mrs X said the family met with the care home manager in December 2021, but he insisted on meeting in the foyer with people passing by. Mrs X said she subsequently sent several emails to the care home manager between 20 December and 20 January asking for updates. However, she said the care home manager did not respond until 21 January, when he replied with a brief email.
57. In its response to Mrs X’s complaint, Harbour Healthcare said staff had acted appropriately and in keeping with COVID-19 restrictions in not providing a meeting room. Harbour Healthcare did not respond to Mrs X’s wider complaint about communication.
58. With the emergence of the COVID-19 pandemic, the Department of Health and Social Care introduced guidance for residential care homes on managing visits. This was entitled Guidance on care home visiting.
59. The guidance did not place any nationally set restrictions on visits. However, the guidance gave residential care homes discretion to manage visits in such a way as to keep staff and residents safe. The guidance placed an emphasis on the use of suitable personal protective equipment (PPE) and ventilation.
60. I am satisfied the care home acted appropriately in requiring the meeting to take place in a well-ventilated part of the care home. Nevertheless, I accept this was not ideal for Mr Y’s family. I found no evidence in the email communication between the care home manager and Mrs X to suggest he made her aware that the meeting could not take place in a private meeting room. In my view, some of the family’s frustration might have been avoided with improved communication.
61. On 20 December, Mrs X sent the care home manager an email regarding the events leading up to Mr Y’s hospitalisation in November. When Mrs X did not receive a response, she sent a chasing email on 23 December 2021. The care home manager responded the following day to say he would investigate her concerns and ask a GP to call Mrs Y.
62. Mrs X contacted the care home manager again 2 January 2022 as she had heard nothing further from him and Mrs Y had not received a call from a GP.
63. On 4 January, the care home manager replied to say that Mrs Y should call the GP Practice with any questions.
64. Mrs X contacted the care home manager again on 6 January to explain that she had left a voicemail message for him but had received no response. Mrs X also said she had been unable to speak to a GP. The care home manager did not respond to this email.
65. Mrs X contacted the care home manager on 18 January with several other concerns about Mr Y’s care. When she did not receive a response, Mrs X chased this on 20 January. The care home manager responded the following day. The response was limited. The care home manager said clinical observations did not suggest an infection and that “[t]he nurses on duty for three of the days concerned do not work for us regularly and came via an agency.”
66. I have commented on the events leading up to Mr Y’s hospital admission above and will not duplicate my analysis here.
67. However, the evidence shows communication with Mr Y’s family and Mrs X was very limited during this period. This was fault by Harbour Healthcare. This caused Mr Y’s family further frustration and put Mrs X to unnecessary time and trouble.

Essential care giver

68. Mrs X complained that the care home removed Mrs Y as Mr Y’s essential care giver as she had not complied with the required COVID-19 testing regime. Mrs X said the care home did not give Mrs Y any warning before removing her as essential care giver.
69. In its complaint response, Harbour Healthcare said that it had communicated the need for regular testing to residents and families. However, it acknowledged that “communication was not detailed enough to support the essential caregivers and nominated visitors.” Harbour Healthcare did not explain its findings further.
70. The Guidance on care home visiting set out provision for each care home resident to have an ‘essential care giver’. An essential care giver was allowed to visit a resident more often to provide additional companionship and care and support. This included during periods of isolation or outbreaks of COVID-19.
71. The guidance required essential care givers to take a polymerase chain reaction (PCR) test, as well as a minimum of two lateral flow tests, per week. In addition, essential care givers were required to wear appropriate PPE. The guidance went on to explain that essential care givers should be briefed on relevant infection control measures.
72. Mrs Y was Mr Y’s nominated essential care giver.
73. On 21 January, the care home manager wrote to Mrs X. He said that “[u]nfortunately in reviewing the testing data it appears [Mrs Y] has not complied with the weekly request for PCR testing and requires an escort to visit [Mr Y] which is not covered in the guidance or something we have done for any other resident”. The email went on to say that “[Mrs Y] can no longer be classified as an essential care giver”.
74. In its response to my enquiries, Harbour Healthcare said Mrs Y had been made aware of the testing requirements and that this information was also displayed on the door of the care home and in the foyer.
75. The care home had a responsibility to reduce the risk of infection to both staff and residents. It was appropriate, therefore, for the care home to require visitors and essential care givers to comply with the testing requirements set out in the guidance.
76. However, the decision to remove Mrs Y as essential care giver for Mr Y was a significant step. I found no evidence in the records to suggest care home staff discussed their concerns with Mrs Y. Nor did they warn her that she would be unable to continue as essential care giver unless she complied with testing requirements. Rather, Mrs Y did not become aware of this until Mrs X received the email from the care home manager on 21 January.
77. This is further evidence of poor communication on the part of the care home. This was fault by Harbour Healthcare. This caused Mrs Y additional distress.

Condition of room

78. Mrs X said Mr Y’s room was small and in poor condition. As an example, she pointed out that Mr Y’s door did not have a handle for several weeks. This meant the door had to be propped open, offering no privacy to Mr Y and his family. Mrs X said there was no bin in the room and that rubbish was allowed to accumulate.
79. In its complaint response, Harbour Healthcare “fully upheld” this aspect of Mrs X’s complaint. However, it did not provide any further information about its findings.
80. Regulation 10 of the Care Regulations relates to dignity and respect. The accompanying guidance says “[e]ach person’s privacy must be maintained at all times including when they are asleep, unconscious or lack capacity.” The guidance goes on to say that “[p]eople’s relationships with their visitors, carers, friends and family…should be respected and privacy maintained as far as reasonably practicable during visits.”
81. Regulation 15 of the Care Regulations relates to premises and equipment. The guidance accompanying this regulation makes clear that all premises and equipment should be clean, secure and properly maintained.
82. As part of her submission to the Ombudsmen, Mrs X provided photographs that show rubbish on the floor of Mr Y’s room, as well as dirty surfaces and a broken bed. Furthermore, Mrs X provided photographs that show Mr Y’s door without a handle. Mrs X says it remained in this state of disrepair for several weeks. This meant Mr Y’s door had to be propped open with a chair.
83. The evidence provided by Mrs X clearly shows there were periods during which Harbour Healthcare failed to keep Mr Y’s room clean, secure and properly maintained. This was contrary to the requirements of the Care Regulations and represented fault.
84. This caused Mr Y’s family avoidable distress. This was compounded as Mr Y’s privacy and dignity were compromised by the need to prop his door open. This caused his family further distress.
85. Harbour Healthcare has offered to reduce Mr Y’s outstanding care fees. It is my view that this is an appropriate recognition of the fact that Mr Y did not receive the service he could reasonably have been expected to receive.
86. However, Harbour Healthcare has agreed to make an additional financial remedy which recognises the distress, confusion and uncertainty caused to Mr Y’s family by the fault I have identified. This is set out in the ‘agreed actions’ section of this decision statement.

Communication around residency

87. Mrs X said the care home failed to inform Mr Y and his family that he would not be able to return to the care home following his hospital admission in January 2022. She said the family did not find out until they were told by hospital staff in late February. Mrs X said they were told this was because he was at high risk of aspiration pneumonia and so required a general nursing placement.
88. In its complaint response, Harbour Healthcare said the care home completed a detailed reassessment of Mr Y’s needs and concluded it could no longer meet them. However, Harbour Healthcare acknowledged that it failed to share this information with Mr Y’s family “in a timely manner”.
89. I found no evidence in the care records of the detailed assessment Harbour Healthcare refers to in its response. However, Harbour Healthcare was able to provide a copy of an internal email summarising the outcome of the assessment. This was dated 15 February. The email explained that Mr Y’s challenging behaviour and PEG feed meant he required a general nursing placement to meet his needs.
90. Regulation 9 of the Care Regulations relates to person-centred care. The accompanying guidance says “[p]roviders must make every reasonable effort to provide opportunities to involve people in making decisions about their care and treatment, and support them to do so…It may include involving people in discussions, inviting them to meetings and encouraging them to ask questions and providing suggestions.”
91. Harbour Healthcare had discretion not to accept Mr Y’s return as a resident if it considered it would be unable to provide him with care and support to meet his needs. The available evidence suggests Harbour Healthcare had made this decision by 15 February.
92. This decision was likely to have a significant impact on Mr Y’s ongoing care as it effectively left him without accommodation. Despite this, I found no evidence to suggest Harbour Healthcare discussed this decision with Mr Y’s family. Indeed, it was hospital staff that eventually informed Mr Y’s family that he would be unable to return to the care home. This communication was not in keeping with the requirements of the Care Regulations. This was fault by Harbour Healthcare and caused Mr Y’s family distress and confusion.

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Agreed actions

93. Within one month of my final decision statement, Harbour Healthcare will:

• write to Mrs Y to apologise for its failure to provide Mr Y with appropriate care when he was a resident in Kingswood Mount Care Home between October 2021 and January 2022;
• pay Mrs Y £850 in recognition of the distress and uncertainty caused to her by this fault. This is in addition to the reduction in care fees proposed by Harbour Healthcare;
• write to Mrs X to apologise for its poor communication when she raised concerns about Mr Y’s care; and
• pay Mrs X £150 in recognition of the additional time and trouble she was put as a result.

94. Within three months of my final decision, Harbour Healthcare will explain what action it will take to:

• ensure it has a robust record-keeping protocol in place. This should make clear the importance of maintaining clear, accurate and complete records for all residents. Harbour Healthcare should also explain what it will do to ensure care staff are aware of this protocol and what it will do to monitor the standard of record-keeping at the care home on an ongoing basis;
• ensure there is a robust process in place for seeking clinical, or other specialist, input from NHS and partner organisations for residents where necessary. This should include a clear process for making and following up referrals;
• develop a clear communication policy to ensure effective communication with residents and their families or carers. This policy should make clear the need to properly involve residents and their families in key decisions about their care and to accurately record any discussions;
• put in place a comprehensive cleaning and maintenance schedule to ensure premises and equipment are kept clean, secure and properly maintained in accordance with the requirements of the Care Regulations; and
• ensure it has a robust complaint handling process in place that allows Harbour Healthcare to respond to complaints in a timely and effective manner. This should make clear the need to acknowledge complaints promptly and keep complainants informed of progress.

95. Harbour Healthcare should provide us with evidence that it has complied with the above actions.
96. The Ombudsmen will share a copy of their final decision statement with the CQC under the terms of their information sharing agreement with that organisation.

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Final decision

97. I found fault by Harbour Healthcare with regards to the care provided to Mr Y and its handling of Mrs X’s complaint. This led to an injustice for Mrs Y and Mrs X.
98. I am satisfied the actions Harbour Healthcare has agreed to undertake represent an appropriate and proportionate remedy for the injustice caused to Mrs Y and Mrs X by the fault I identified.
99. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman