London Borough of Lewisham (25 003 265)
Category : Adult care services > Residential care
Decision : Closed after initial enquiries
Decision date : 17 Sep 2025
The Ombudsman's final decision:
Summary: We will not investigate this complaint about the actions of the Council-commissioned Care Provider at this time. There is an ongoing coroner’s inquest. Until the inquest is complete, we could not come to sound conclusions or achieve a meaningful outcome.
The complaint
- Mr and Mrs X complained about Mr X’s mother’s (Mrs Y’s) care in a Council-commissioned care home. They said the Care Provider did not properly manage Mrs Y’s blood sugars, and they are concerned she died due to neglect. Mr and Mrs X also raised concerns about poor communication, and inconsistent information around Mrs Y’s health and whether she was considered end of life.
- Mr and Mrs X said the matter caused distress for the family, and Mrs Y died in a way that was not in line with her wishes. They believed Mrs Y’s death could have been prevented. They wanted acknowledgement of fault and service improvements.
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 there is no worthwhile outcome achievable by our investigation. (Local Government Act 1974, section 24A(6), as amended, section 34(B))
How I considered this complaint
- I considered information provided by the complainant.
- I considered the Ombudsman’s Assessment Code.
My assessment
- The coroner is currently investigating the circumstances around Mrs Y’s death. We could not make a causal link between any failings by the Care Provider and Mrs Y’s death. Only the coroner could do so. The outcome of the coroner’s inquest is relevant to any investigation we could carry out, and we could not come to sound conclusions until that process has completed.
- We will not investigate this complaint at this time. We could not achieve any worthwhile outcome if we investigated now given the ongoing consideration by the coroner’s office.
- It is open to Mr and Mrs X to submit a new complaint to us after that process has finished, at which time we can consider whether there is anything further investigation by us could achieve.
Final decision
- We will not investigate Mr and Mrs X’s complaint because we could not achieve anything worthwhile by doing so at this time.
Investigator's decision on behalf of the Ombudsman