Summary: We will not investigate Ms Y’s complaint about the Council‑commissioned care provider’s actions during her late father Mr X’s end-of-life placement. We could not now remedy injustice to Mr X, and there is not sufficient personal injustice to Ms Y caused by the matter complained of to warrant an investigation.

The complaint

1. Mr X was Ms Y’s late father. Mr X was in an end-of-life care home placement commissioned by the Council. Ms Y complains the care provider:
1. did not tell Mr X’s family when they placed him on a ‘nil-by-mouth’ arrangement or do a Speech and Language Therapy (SALT) assessment;
2. told off Ms Y and her sister for feeding Mr X a small amount of food.
2. Ms Y says she and her sister were caused deep upset and trauma by the staff response to them feeding Mr X the food, when they did not know about the ‘nil‑by‑mouth’ approach. Ms Y says staff told them he could aspirate or choke, said in front of Mr X. Ms Y wants the care home to communicate with and fully inform families and be aware when people in their care can hear what staff say.

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The Ombudsman’s role and powers

3. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide:

• any fault has not caused injustice to the person who complained; or
• any injustice is not significant enough to justify our involvement; or
• further investigation would not lead to a different outcome.

(Local Government Act 1974, section 24A(6))

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How I considered this complaint

4. I considered information from Ms Y, and the Ombudsman’s Assessment Code.

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My assessment

5. Where someone involved in a complaint has died, we will not normally seek a remedy for injustice caused to that person as we might for someone who is living. If the impact of a fault was on someone who has died, we will not investigate where, for example, the complaint is one of impact of poor care that person might have received while they were alive. This is because the person who received the poor care cannot benefit from any remedy. I understand Ms Y may consider there was injustice to Mr X from the incident complained of, particularly the staff comments about the risks to him from his eating. But as we could not now effectively remedy any injustice to him, we will not investigate this aspect of the complaint.
6. We consider complaints where the person bringing the complaint has suffered significant personal injustice as a direct result of the actions or inactions of the organisation. This means we will normally only investigate a complaint where the complainant has suffered significant loss, harm, or distress as a direct result of faults or failures. We will not normally investigate a complaint where the alleged injustice is not a sufficiently significant matter. I realise the incident where Ms Y and her sister were told off by care home staff for feeding Mr X would have been upsetting for them at the time. Also the incident would have been unlikely to have happened if the care staff had kept her informed of the approach being taken to Mr X’s feeding. But while I sympathise with Ms Y, the injustice caused by this incident is not so significant to warrant us investigating.

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Final decision

7. We will not investigate Ms Y’s complaint because:
• we could not now remedy the late Mr X’s injustice;
• there is not sufficient personal injustice caused to her by the matter to warrant an Ombudsman investigation.

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Investigator's decision on behalf of the Ombudsman