North East Lincolnshire Council (25 001 227)
Category : Adult care services > Residential care
Decision : Closed after initial enquiries
Decision date : 20 Aug 2025
The Ombudsman's final decision:
Summary: We will not investigate Miss X’s complaint about the care her late father Mr Y received from a Council-commissioned care provider. The Care Provider has investigated Miss X’s concerns, upheld parts of her complaint, apologised and taken action to improve. We could not add anything to the Care Provider’s response or achieve the outcome Miss X wants.
The complaint
- Miss X complains the Council-commissioned care provider (Company Z) failed to properly look after her father, Mr Y, before he died in early 2025. Miss X complains about:
- frequent changes in staff and heavy reliance on agency workers who were not properly briefed;
- Mr Y’s clothes and possessions being filthy;
- not monitoring Mr Y’s blood pressure;
- not calling an ambulance when Mr Y was having an heart attack and instead taking him to hospital by car;
- there being two recent deaths of residents at Mr Y’s supported accommodation (including Mr Y); and,
- Mr Y needing support from two staff members but only getting help from one.
- Miss X says this has caused her and Mr Y’s family significant distress. She wants explanations for what went wrong.
The Ombudsman’s role and powers
- 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, or
- we cannot achieve the outcome someone wants. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
How I considered this complaint
- I considered information provided by the complainant and the Council.
- I considered the Ombudsman’s Assessment Code.
My assessment
- Company Z has responded to Miss X’s complaints as summarised in paragraph 1 above. It upheld complaints about the cleanliness of Mr Y’s room, clothing and other possessions and when staff interaction with Mr Y’s family should have been better. It has apologised to Miss Y for the distress caused. Company Z has also provided a detailed summary of events leading to Mr Y’s admission to hospital shortly before his death. It explained it acted on Mr Y’s request to be driven to hospital rather than wait more than an hour for an ambulance. It has also confirmed Mr Y’s care and support plan specified one to one rather than two to one support to meet his needs.
- Although Mr Y lacked capacity to manage his financial affairs, I have seen evidence which shows he was capable of expressing his wishes and making routine decisions about day-to-day matters such as what he wanted to eat and how he wished to travel or what he wanted to wear.
- I appreciate Miss X and her family are still grieving Mr Y’s death and wish for some sort of closure. I also understand why Miss X might remain dissatisfied with how Company Z has handled her concerns and wants to know whether her father’s death could have been avoided. We could not likely say these would have been significantly different but for something Company Z might have done or not, and that its actions caused significant avoidable injustice. We also have no role in determining the cause of Mr Y’s death as that would be a matter for the coroner.
- The core complaint issue is about the standard of care Mr Y received from Company Z prior to his death. The main impact of these issues was on Mr Y. We focus our investigations on matters where there has been significant personal injustice, but also where we can then provide outcomes for the recipient of the service. We cannot provide such outcomes where the service user has died. We are unable to provide a remedy for the late Mr Y so will not investigate.
- We will not normally investigate a complaint which the Council or commissioned care provider has already comprehensively investigated and responded to. It is not a good use of public money to do so. In this case, the question for us is whether our intervention would add anything to the investigation Company Z has carried out. There is nothing to suggest that it would do so.
Final decision
- We will not investigate Miss X’s complaint because further investigation could add to the Care Provider’s responses and we cannot achieve the outcome the complainant wants.
Investigator's decision on behalf of the Ombudsman