Summary: We will not investigate this complaint about the care provider’s actions leading up to, and following, Miss X’s son’s death. The coroner made a decision about the cause of his death, and we have no power to investigate the matter or change that decision.

The complaint

1. Miss X complained about the care provider (commissioned by the Council) that her son (Mr Y) resided with before his death in 2021. Her complaints include that the care provider:
• Did not adhere to the Speech and Language Therapy instructions, and allowed Mr Y to have solid food in bed, unsupervised;
• Did not call an ambulance until between two and four hours after Mr Y had died; and
• Lied to the coroner about how Mr Y had died.
2. Miss X says the Council conducted a safeguarding enquiry but did not hold the care provider accountable. She says the Care Quality Commission has also not taken action. She says the care provider's negligence caused her son’s death, and its lack of transparency led to the coroner coming to the wrong decision about the cause of death. She wants the care provider to be held accountable.

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The Ombudsman’s role and powers

3. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
4. We have the power to start or end an investigation into a complaint about actions the law allows us to investigate. We may decide not to start or continue with an investigation if we think the issues could reasonably be, or have been mentioned as part of the legal proceedings regarding a closely related matter. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended, section 34(B))

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How I considered this complaint

5. I considered information provided by the complainant and the care provider.
6. I considered the Ombudsman’s Assessment Code.

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My assessment

7. Miss X’s complaint relates to the actions of the care provider, which she believes caused her son’s death. The matter was considered in the coroner’s court. The decision resulting from this was inconclusive.
8. We are prevented in law from considering what information the care provider presented to the coroner, because we cannot investigate what happens in court. We are also prevented in law from investigating the coroner’s decision.
9. Miss X had the opportunity during the coroner’s inquest to raise the concerns she has brought to the Ombudsman. We could not change the coroner’s decision, and the only route for this would be via judicial review. We could not say the care provider caused Mr Y’s death, and only the courts could provide the outcomes Miss X seeks.

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Final decision

10. We will not investigate Miss X’s complaint because it is about matters that have been subject to a coroner’s inquest, which is a court process. All matters raised in the complaint could have been raised as part of that process, or via judicial review.

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Investigator's decision on behalf of the Ombudsman