Summary: We will not investigate Ms X’s complaint about the care provided to her relative, Ms Y, in a Council-commissioned care home. This is because further investigation would not lead to a different outcome and we cannot achieve the outcome Ms X wants.

The complaint

1. Ms X complains about poor care provided to her relative, Ms Y, in a Council-commissioned care home. She says poor care led to an unnecessary hospital admission and ultimately to Ms Y’s death. She wants the Council to accept that poor care led to Ms Y’s death and to ensure the care provider improves its processes and procedures to ensure a good standard of care to its care home residents.

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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 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 continue an investigation if we decide:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

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

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My assessment

5. In response to Ms X’s complaint, the Council completed a posthumous safeguarding investigation to consider Ms X’s concerns. The investigation considered information from Council and care home records, communications between Ms X and the care home, and information gathered from the hospital and ambulance service.
6. The investigation concluded there was evidence to substantiate:
• poor communication by the care home with the family and a lack of transparency during Ms Y’s hospital admission
• episodes of medicine mis-administration – medication sometimes being administered late or not at all by care home staff
• care home staff having an unwelcome attitude and making antagonistic comments to Ms Y
7. The investigation also considered whether there was evidence of neglect by the care home, in particular, whether poor care caused Ms Y to be dehydrated and led to her hospital admission. The investigation considered multiple sources of information including the ambulance service records which did not list dehydration as the reason for admission. It found insufficient evidence to substantiate this claim.
8. The investigating officer made a series of recommendations for the Council to implement with the care home to improve the standard of care provided.
9. We will not investigate this complaint as it is unlikely further investigation would lead to a different outcome or achieve what Ms X wants. The Council has considered relevant evidence and decided there is insufficient evidence to substantiate a claim of neglect. Although I accept Ms X disagrees with this conclusion, an investigation by us would be unlikely to reach a different finding or conclude that the care home’s actions contributed to Ms Y’s death.
10. In relation to the substantiated concerns, the safeguarding investigation made recommendations to improve the service provided by the care home. This is what we would expect. Further investigation would not achieve more than this or lead to a different outcome.

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Final decision

11. We will not investigate Ms X’s complaint because further investigation would not lead to a different outcome or achieve what Ms X wants.

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Investigator's decision on behalf of the Ombudsman