Summary: We will not investigate Miss X’s complaint, made on behalf of the late Mr Y, about the Care Provider’s delay in using a pain relief medicine during Mr Y’s end-of-life care. There is not enough evidence the Care Provider’s actions led to the injustices complained of to warrant us investigating.

The complaint

1. Miss X is the late Mr Y’s relative. Mr Y was receiving end-of-life provision at a home run by the Care Provider in spring 2025. Complains the care home delayed in using a syringe driver to give end-of-life pain relief to Mr Y.
2. Miss X says Mr Y was in visible pain and distress and received insufficient pain relief in his last days. She feels Mr Y was let down and his family feels guilty.

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The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe the action has not caused injustice to the person who complained. (Local Government Act 1974, sections 34B(8) and (9))

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How I considered this complaint

5. I considered information from Miss X and the Ombudsman’s Assessment Code.

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My assessment

6. Miss X complains the Care Provider delayed in putting in place a syringe driver to give Mr Y pain relief medication. She says the GP prescribed the medication but the Care Provider did not start to use it until many hours later, leaving Mr Y in avoidable pain which she and other family members witnessed.
7. The Care Provider says the GP’s the initial Direction to Administer (DTA) was insufficiently detailed to allow their staff to give Mr Y the pain medication. It says the DTA gave a list of medicines which may have been required, with variable dosage amounts. The Care Provider says staff had to seek clarification of the specific type and dose before they could give it to Mr Y. It says Mr Y’s pain was managed with previously prescribed medicines while they sought clear information about the syringe driver medication. Once another GP provided that specific information the new medication was agreed and in place for when Mr Y needed it.
8. As the employer of staff who are not prescribers but who administer medication, the Care Provider required specific details of the type and size of dose to be given to Mr X. A GP provided this further information to the home’s staff after their request. This indicates the medical prescriber recognised the initial prescription and information was not sufficiently clear for the care home staff to act upon. There is not enough evidence of fault in the Care Provider’s actions here regarding the pain relief medication leading to the injustice complained of to warrant us investigating.
9. We recognise Miss X and other members of Mr Y’s family would have been caused distress by witnessing this pain relief issue during his end-of-life care. But we cannot say that injustice of their upset was directly caused or worsened by the actions or inactions of the Care Provider. The primary injustice stemming from the matter complained of would have been to the late Mr Y. Even if we had found the Care Provider to be at fault here, we could not remedy Mr Y’s injustice because he has died.

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Final decision

10. We will not investigate Miss X’s complaint because there is not enough evidence of fault in the Care Provider’s actions leading to the injustice complained of to warrant us investigating.

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Investigator's decision on behalf of the Ombudsman