Summary: Mrs X complained the Care Home administered cardiopulmonary resuscitation to Mr Z despite a ‘Do not Resuscitate’ form being in place. She also complained about an incident where Mr Z went missing, and an incident where two tablets were found in his chair. We have ended our investigation. This is because we cannot investigate matters being taken to court, and further investigation into the other matters is unlikely to achieve a different outcome.

The complaint

1. Mrs X complained on behalf of her father, Mr Z, about the care provided to him at his care home placement. Mrs X said Mr Z went missing from the care home, was administered CPR (cardiopulmonary resuscitation) despite having a DNR (Do Not Resuscitate) in place and had two tablets found in his chair at a recent visit.
2. Mrs X said the matter caused distress and was detrimental to Mr Z’s wellbeing.

Back to top

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 further investigation would not lead to a different outcome. (Local Government Act 1974, section 24A(6))
4. We cannot investigate a complaint if someone has started court action about the matter. (Local Government Act 1974, section 26(6)(c), as amended)

Back to top

How I considered this complaint

5. I have considered information provided by Mrs X and discussed the complaint with her.
6. I have considered information provided by the Care Home.
7. Mrs X and the Care Home had the opportunity to comment on the draft decision. I considered comments before reaching a final decision.

Back to top

What I found

Background

8. The chronology below is not a comprehensive overview, but a summary of key issues.
9. Mr Z has dementia and lived in the Care Home. In December 2021, Mr Z was found to be missing. Staff at the care home searched the building and the wider community. Mr Z was found several hours later and returned to the Care Home.
10. The Care Home completed an internal incident form. It informed the family of the matter, the safeguarding team at the local authority and the CQC. Its incident form recorded it had made the building secure, changed security codes and increased the frequency of check-ins for Mr Z to ensure he was safe. The Care Home also recorded it had completed service improvements including reminding staff to check all exits at the start and end of shifts and throughout the day, and to ensure no doors were left open.
11. The Care Home also held a meeting with Mrs X and explained what it had done to ensure the issue did not reoccur. Mrs X was satisfied with the action taken by the Care Home at the time.
12. In August 2022, Mr Z was found unresponsive in his room. Mrs X reports CPR was conducted on Mr Z despite a DNR being in place.
13. Mrs X attended a meeting with the Care Home to discuss her concerns about the actions it took in August 2022. The Care Home subsequently provided a written response explaining its view about what had happened.
14. Mrs X wrote to the Care Home and requested the matter be raised with the regional manager. Mrs X additionally raised concerns that she had recently found two tablets in Mr X’s chair during a visit.
15. The Care Home responded and repeated its views about the actions it took in August 2022. It explained that it was aware of the two tablets found in Mr Z’s chair and accepted this should not have happened. It said it raised a care concern with the Council after speaking with the Council’s monitoring officer, but it had yet to receive a response. It said it had conducted further training and supervision of staff to ensure the incident did not reoccur.
16. Mrs X remained dissatisfied and brought her complaint to us.
17. Mrs X said she has started legal proceedings against the Care Home for its actions in August 2022.

Findings

18. Mr Z was able to leave the Care Home and went missing. The records show the Care Home acted at the time to notify relevant safeguarding bodies, secure the premises, and monitor Mr Z to prevent reoccurrence of the issue. The Care Home also said it conducted additional training with relevant staff. As Mrs X was satisfied with the actions at the time, it is unlikely further investigation into the matter would achieve a different outcome, so I will not investigate this matter further.
19. Mrs X has started legal proceedings regarding the Care Home’s actions in August 2022 when CPR was administered despite a DNR being in place. We cannot investigate matters that are subject to court proceedings, so I will not consider this matter further.
20. Mrs X complained she found two tablets in Mr X’s chair. The Care Home accepted this should not have happened and explained action it had taken in response. As we cannot investigate the substantive matter being taken to court, and it is unlikely further investigation into this matter would achieve a different outcome, I will not investigate this matter further.

Back to top

Final decision

21. I ended this investigation because it is unlikely further investigation would achieve a different outcome.

Back to top

Investigator's decision on behalf of the Ombudsman