Summary: We will not investigate Mrs X’s complaint about the standard of care her mother received just before she died. The Care Provider has investigated Mrs X’s concerns, upheld parts of her complaint, apologised and taken action to improve. We could not add to the Care Provider’s response by investigating the matter further.

The complaint

1. Mrs X complains the Care Provider failed to contact her and another person when her mother, Mrs Y, was in the process of dying. Mrs X complains carers were not with her mother, providing comfort in her final moments. She also complains about the overall quality of care her mother received and the lack of cleanliness in the Care Home. She wants to ensure other families and residents do not experience the same distress as her mother and her family have.

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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. (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.

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My assessment

4. The Care Provider has responded to the elements of Mrs X’s complaint summarised above. It has explained that staff briefly stepped out of Mrs Y’s room just before she passed away but were present as she took her last breath. The Care Provider’s End of Life Adviser has reviewed its handling and identified areas for learning and improvement. The Care Provider has apologised to Mrs X that it did not contact her and the other person sooner. It has also explained the other action it has taken to improve cleanliness in the Care Home and the work it undertakes to ensure it is adequately staffed.
5. Mrs Y sadly passed away at the end of last year. We could not provide a remedy for any injustice caused to her by the Care Provider’s actions, even if we investigated and found evidence of fault. Mrs X is understandably upset at events leading up to her mother passing away. We could not likely say these would have been significantly different but for something the Care Provider might have done or not, and that its actions caused significant avoidable injustice.

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Final decision

6. We will not investigate Mrs X’s complaint because further investigation could not add to the responses the Care Provided has already provided.

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Investigator's decision on behalf of the Ombudsman