Summary: We will not investigate Mr X’s complaint about delay by his late mother Ms Y’s care provider in contacting the family about an injury she sustained at the care home, or how it investigated and reported on the incident. There is not enough significant injustice to Ms Y’s family from the delay in contacting the family to warrant investigation. Ombudsman investigation of the incident and how the care provider dealt with it would not add to that investigation, nor achieve a different outcome for the family.

The complaint

1. Mr X is Ms Y’s son. Mrs Y was in her 80s and had Alzheimer’s. She moved to a care home run by the care provider in June 2022. Later that year, an incident occurred when Mrs Y fell and fractured her hip. Ms Y died in early 2023.
2. Mr X complains the care home failed to:
1. tell him or the Ms Y’s family about the her injury until the next day;
2. give them a clear account of how Ms Y sustained her injury in line with their duty of candour;
3. take the matter seriously.
3. Mr X says in Ms Y’s final months she could no longer walk and she was quite miserable. He says Ms Y’s husband has been upset and distressed by the matter. Mr X says the family is suspicious of the care firm, frustrated and disgusted at the way they responded to the incident. He says he and his sister Mrs Z have had additional stress and worry trying to find out what happened. Mr X wants the family to have a financial remedy to provide some type of justice, and to demonstrate to the firm that this was a matter they should have taken seriously.

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The Ombudsman’s role and powers

4. 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)
5. 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:

• the injustice is not significant enough to justify our involvement; or
• 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

6. I considered information from Mr X and the Ombudsman’s Assessment Code.

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My assessment

7. We understand the delay of about 13 hours in Mr X and Mrs Z becoming aware of Ms Y’s injuries would have been upsetting. But the family was able to visit Ms Y the next day, after the care home contacted Mrs Z’s husband. There is not enough ongoing significant personal injustice to Mr X or the family from this issue to warrant us investigating what happened now.
8. We recognise Mr X wanted clear and unambiguous information about what happened to Ms Y when she broke her hip, which may have helped to set the family’s minds at rest. He also considers the care firm did not take the matter seriously enough. But the incident was not witnessed by a staff member. Those involved, including Ms Y, have or had forms of dementia or memory loss which meant evidence gathered was not always be reliable or consistent. The documents show the care firm appropriately gathered the information available to it to produce its responses. An Ombudsman investigation of that matter would not now add to that investigation, such as by unearthing new information, to provide any more accurate or serious report of the incident. Our further involvement would not be able to determine what happened to cause Ms Y’s injury and provide a different outcome which warrants an investigation.
9. The most significant impacts of this matter were on Ms Y. But even if we were to find the care provider’s actions caused significant injustice to her, we cannot provide a remedy to her as she has now died. The care firm has apologised to Mr X and his family for the delay in contacting them after Ms Y’s injury. This is the type of outcome we may have achieved for the family here. There are no grounds for us to pursue any further remedy for the family for the way the firm responded to the incident and the subsequent complaint for the reasons given above.

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Final decision

10. We will not investigate Mr X’s complaint because:
• there is not enough significant injustice to Mr X and his family from the delay in contacting them about Ms Y’s injury to warrant investigation; and
• investigation of the incident and how the care provider dealt with it would not add to that investigation, nor achieve a different outcome for the family.

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Investigator's decision on behalf of the Ombudsman