Summary: We will not investigate this complaint about end-of-life care in a residential care home. This is because it is unlikely we would add to investigations already completed by other organisations or reach a different or worthwhile outcome to justify our resource.

The complaint

1. Ms E says the care provider acting for the Council failed to follow the end-of-life plan for her relative Mr F. Ms E says the care provider failed to regularly give medication and Mr F spent time at the end of his life in pain, and Ms E witnessed him die in pain. Ms E is traumatised and will never get over it.

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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:

• there is not enough evidence of fault to justify investigating, or
• we could not add to any previous investigation by the organisation or other bodies, 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))

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How I considered this complaint

3. I considered information provided by the complainant and the Council.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. The Council was responsible to meet Mr F’s adult social care needs, it did this by arranging his care in a residential care home (the care provider).
6. Ms E complains about the care Mr F received at the end of his life. As Mr F has died the Ombudsman could provide him with no remedy if we found fault causing injustice. It would undoubtedly be upsetting for Ms E seeing Mr F’s decline in health. It would be difficult to say how much was caused by the care provider’s actions.
7. Ms E says the care provider failed to regularly give Mr F pain medication; Ms E may be under the impression the provider should have given it to Mr F every four hours. The records show the medication was to be given as and when required, and the care provider used its judgement on that. It referred to senior staff or medical professionals when it felt it was needed. It contacted the district nurses when it noted Mr F was in pain. When the district nurses came out Mr F was asleep and settled so the district nurses did not give the pain relief on those occasions.
8. The Council’s team which oversees its contracts with care providers investigated the medication management at the care home, and the Council’s safeguarding team carried out an enquiry. The Care Quality Commission who regulates care providers also completed an investigation. None of these independent investigations resulted in findings against the provider or any action taken. It is unlikely that an Ombudsman investigation could add anything further after considering the same evidence.

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Final decision

9. We will not investigate Ms E’s complaint because it is unlikely we would add to investigations already undertaken by other bodies, or that we would achieve a different outcome. We could provide no remedy for Mr F so there is no worthwhile outcome achievable.

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Investigator's decision on behalf of the Ombudsman