Summary: We will not investigate this complaint about an incident that occurred when Mr Z was in a care home. Further investigation by the Ombudsman would not achieve any further meaningful outcome.

The complaint

1. Miss X (Mr Z’s niece) and Ms Y (Mr Z’s sister) complained about unsatisfactory care and an incident when Mr Z was in a care home, commissioned by the Council. They said record-keeping was poor and the Care Provider shared misleading and inaccurate information, with changing explanations about what happened. They said the complaint handling failed to consider the matter thoroughly and provide answers, and they say the Care Provider failed to respond to other matters including quality of care concerns.
2. Miss X and Ms Y said they believed the incident contributed to Mr Z’s death some weeks later. They said the matter caused significant distress and the family have not been able to grieve properly. They wanted the Care Provider to make service improvements.

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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 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:

• any fault has not caused injustice to the person who complained, or
• we could not add to any previous investigation by the organisation, or
• further 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))

4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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My assessment

5. Mr Z suffered a fall in the care home he lived in. The Care Provider telephoned Miss X and said Mr Z had fallen from a hoist. However, when the Care Provider considered the matter via its complaints process it clarified Mr Z had slipped from his wheelchair. Miss X was not satisfied the Care Provider had taken the matter seriously and she was concerned due to its explanation having changed.
6. I have considered the Care Provider’s records, including the contemporaneous evidence from the day of the incident. This confirms Mr Z slipped from his wheelchair, and not a hoist. The Care Provider apologised during the complaints process for having communicated inaccurate information on the day of the event.
7. The Care Provider has considered what happened and identified Mr Z’s footplates had not been put down. It also identified the record-keeping had not been to an acceptable standard. It therefore took steps to discuss the matters of record-keeping and moving and handling with the relevant staff.
8. Parts of Miss X and Ms Y’s complaint stemmed from the belief Mr Z had fallen from a hoist. For example, they were concerned an ambulance had not been called for Mr Z on the day of the incident. Mr Z instead slipped from his wheelchair, and care home staff checked Mr Z for any injury and pain. They decided Mr Z did not require an ambulance. I will not further consider parts of the complaint that rely on the presumption Mr Z fell from a hoist.
9. Miss X raised other issues in her complaint to the Care Provider, for example issues relating to Mr Z’s possessions, and the Care Provider calling from an unknown number. There is insufficient evidence any fault in these areas caused injustice to Miss X and Ms Y and we will not consider these issues further.
10. Miss X and Ms Y requested information from the Care Provider, but it refused their request. It is open to them to escalate that matter to the Information Commissioner, as the body that considers complaints about how organisations respond to information requests.
11. We will not normally investigate a complaint unless we are likely to be able to achieve a meaningful outcome by doing so. In this case, I do not believe further investigation by the Ombudsman would achieve anything of value.
12. We could not say the incident contributed to Mr Z’s death, as this is a decision only the coroner could have made. We also could not remedy any injustice
    Mr Z himself experienced, because he has died. Complaints Miss X and Ms Y raised relating to quality of care related to events that occurred more than 12 months before they came to the Ombudsman so would be late. In any event, there is no meaningful outcome we could achieve for the same reason.
13. Miss X and Ms Y sought service improvements from the Care Provider. If we investigated, it is unlikely we would recommend further service improvement action, because there is insufficient evidence of any wider systemic issue that would warrant further actions to prevent similar incidents in the future.

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Final decision

14. We will not investigate Miss X and Ms Y’s complaint because we could not achieve a meaningful outcome.

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Investigator's decision on behalf of the Ombudsman