Summary: We will not investigate this complaint about the actions of Mrs C’s Care Provider shortly before she died. This is because further investigation by us could not add to the Care Provider’s response or make a different finding of the kind Mrs D wants.

The complaint

1. Mrs D complained about the actions of her mother’s, Mrs C’s, Care Provider, and lack of contact with her on the night she died. Mrs D says she was initially contacted and advised Mrs C had fainted when it was clear she was unconscious. Mrs D says the Care Provider failed to provide Mrs C with appropriate medical care and she was not kept informed about the severity of the situation. Mrs D says she was told after the initial call, she would be contacted back within 5 minutes with an update but was not. Mrs D says she wants an apology, an investigation into what happened on the night Mrs C died and an acknowledgment that not everything was done as it should have been.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse effect on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start an investigation if the tests set out in our Assessment Code are not met. (Local Government Act 1974, section 24A(6), as amended)

Back to top

How I considered this complaint

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

Back to top

My assessment

5. The Care Provider says Mrs C became unresponsive whilst receiving care at 21:20 hrs. The emergency call bell was activated, and a nurse attended. Vital assessments were carried out and the emergency services contacted. The Care Provider says the action taken by the nurse and staff was appropriate and timely. We could not add to this even if we investigated. It would have been for a coroner to investigate further if there were concerns about the actions of medical staff involved in a person’s death.
6. Mrs D complained about poor communication she had with the Care Provider on the night Mrs C died. The Care Provider’s initial response to Mrs D’s complaint said due to staff providing emergency care to Mrs C, it was unable to liaise with the family as quickly as they would have wished. It says it has ensured staff are aware they should keep family members informed of events unfolding where possible. Following further investigation, the Care Provider says the phone log from the duty nurse showed 6 calls to Mrs C’s family that night. The first at 22:26, then 22:28 and subsequent calls made at 22:36, 22:37 and 22:52. The Care Provider says the home was well managed that night, staff took every possible action to address Mrs C’s needs and keep Mrs D informed. It apologised for not sending the full complaints procedures and advised Mrs D it has amended this. We could not add to this even if we investigated. The Care Provider apologised and advised Mrs D of the changes it has made to improve communication with families and of the calls made during the night to Mrs C’s family. If Mrs D is concerned this is not the case she can ask the Care Quality Commission (CQC) who is the regulator of care provider’s to consider her concerns.

Back to top

Final decision

7. We will not investigate Mrs D’s complaint because further investigation could not provide Mrs D with a different outcome to that she has already received from Mrs C’s care provider.

Back to top

Investigator's decision on behalf of the Ombudsman