Summary: We will not investigate this complaint about poor care provided to the late Mr B. This is because further investigation by us could not add to the Care Provider’s response. We could not achieve a remedy for Mr B as he has now passed away.

The complaint

1. Mrs C complained about the care her late father, Mr B, received from his care provider during the time he was receiving respite care. Mrs C complained:

• Mr B was found in his room, curtains closed, and his door shut on a hot day.
• Mr B had an unwitnessed fall, family members were not told until after the incident, no one could say how long he was left unattended.
• Staff did not request medical intervention or assistance when Mr B was found to be unresponsive, staff assumed he was asleep. Mrs C says an ambulance should have been called five hours sooner.
• Nursing staff were observed crushing medication to add to Mr B’s yoghurt.
• Mr B was not given personal care, he was not showered, was unshaven, left partially dressed, his teeth were not cleaned, and he was left to sleep with his teeth in.

2. Mrs C is concerned she has not had all the answers to her questions, there are discrepancies with the Care Provider’s account of what happened and there is a lack of accountability for staff. Mrs C wants the Ombudsman to investigate.

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The Ombudsman’s role and powers

3. 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 do not start an investigation if we decide the tests set out in our Assessment Code are not met. (Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

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

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My assessment

6. Mr B received care provided by a residential care provider on behalf of the Council.
7. Mrs C complained to the Care Provider who responded to her concerns. It acknowledged the failings in this case. It said there was a lack of communication with Mr B’s family about his refusal to accept personal care, acknowledged staff could have been more sensitive and that there were discrepancies with the timings of Mr B’s unwitnessed fall. It said it was satisfied Mr B had been assisted 5 minutes after he fell. It acknowledged a lack of proactivity when concerns were raised about Mr B’s wellbeing and said it would have expected someone to act sooner to assess Mr B and seek further medical assistance.
8. The Care Provider acknowledged that wrong information was recorded on the electronic system and said it believed this was caused by staff selecting the wrong information tile on the electronic system. It apologised for the mistake. The Care Provider said after further consideration, it found the statement given by the agency nursing staff member to be incorrect and advised of the actions it has taken to ensure the agency is aware of the concerns.
9. The Care Provider apologised for its shortcomings in this case. It advised that it has spoken to staff, implemented internal HR measures where necessary with specific staff members, which will be followed up in supervision. The Care Provider said it will be actioning learning from the complaint in order to improve future services. We could achieve no more than this even if we investigated. Sadly, we could not now provide a remedy to Mr B for the injustice caused to him by the faults even if we investigated as he has passed away.
10. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC). As the regulator of Care Providers, the CQC can ensure the lessons learned identified by the Care Provider have been actioned.

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Final decision

11. We will not investigate Mrs C’s complaint because we could achieve no more than identified by the Care Provider.

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Investigator's decision on behalf of the Ombudsman