Summary: We will not investigate Mrs X’s complaint about discrepancies in the care home’s responses regarding how her mother-in-law fell. This is because an investigation would not lead to any different findings or outcomes.

The complaint

1. Mrs X complains about discrepancies in the care home’s responses regarding how her mother-in-law fell. She says they still do not know what exactly happened.

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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 an investigation if we decide:

• investigation would not lead to a different outcome, or
• there is no worthwhile outcome achievable by our investigation.

(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 and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Mrs X’s mother-in-law, Ms Z, was in a care home. In October 2023, Mrs X says she received a call from a nurse from the care home. She said the nurse informed her that Ms Z had been assisted to the toilet and given some privacy. Says Ms Z fell when she tried to get off the toilet.
6. The care provider said Ms Z’s care plan had identified she was at high risks of falls, but that Ms Z would mobilise unsupervised when in her room. The care provider also noted Ms Z could get herself in and out of bed and would take herself to the toilet.
7. The care provider said no staff had assisted Ms Z to the toilet, but that instead staff had heard Ms Z shouting for help. When staff attended, they found Ms Z on the floor. The care provider said it had spoken with the nurse that initially spoke with Mrs X and the nurse confirmed the information she had provided about Ms Z being assisted to the toilet was incorrect.
8. The care provider also acknowledged Ms Z had a sensor mat which had gone off. This was confirmed by a staff member who said she had heard the alert sound. However, the care provider could not give Mrs X a time for when the mat was triggered as the machine that printed the times the mat sensor goes off was faulty.
9. The care provider said a nurse completed a head-to-toe check on Ms Z and did not observe any bruising. However, it accepted staff failed to follow its post fall protocol by not recording Ms Z’s bruises once Mrs X reported them the next day.
10. The care provider said it had issued reminders to staff about the importance of following the guidance in its post fall protocol and the importance of recording any bruises, injuries, and skin changes. The care provider also confirmed it would arrange refresher training to staff around falls prevention and management.
11. As a personal remedy, the care provider offered Mrs X £300 to recognise the distress and upset caused by the incident.
12. The crux of the issue is the conflicting information Mrs X has been told regarding how Ms Z fell. I do not consider an investigation would lead to any further information being obtained which would help us determine how Ms Z fell. Therefore, an investigation is not justified as it would not lead to any new findings.
13. In terms of remedy, I am satisfied the care provider has implemented appropriate service improvements to address the faults identified. Further, the care provider’s financial remedy offer is in line with our guidance. Therefore, I do not consider an investigation would lead to any further outcomes.

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Final decision

14. We will not investigate Mrs X’s complaint because an investigation would not lead to any different findings or outcomes.

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Investigator's decision on behalf of the Ombudsman