Summary: Mrs X and Mrs Z complain about their mother’s care and treatment by Kirklees Metropolitan Borough Council and Locala. We found fault by the Council and Locala in relation to communication and parts of Mrs Y’s end of life care. As a result, Mrs X and Mrs Z were caused uncertainty, frustration and distress. We recommend the Council and Locala apologise, pay a total of £600 and make systemic improvements. We did not find fault with Mrs Y’s daily care and discharge planning.

The complaint

1. Mrs X and Mrs Z complain about their late mother, Mrs Y’s care and treatment in a rehabilitation placement at Moorland Grange Care Home (the Care Home). Kirklees Metropolitan Borough Council (the Council) managed the placement and Locala provided health and therapy services on behalf of the NHS. Mrs X complains about inadequate care, poor communication and inappropriate referrals. She also says the organisations failed to work together. Further, she says no one recognised their mother required end-of-life care or listened to the family’s concerns.
2. Mrs X says their mother did not receive the care she needed and was unnecessarily distressed when she died without end-of-life care in place. Mrs X says this has been deeply distressing for the family.
3. Mrs X and Mrs Z are seeking service improvements, staff training and financial redress.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A (1), as amended).
6. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again.
7. If we are satisfied with the actions or proposed actions of the organisations that are the subject of the complaint, we can complete our investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(1), as amended)

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How I considered this complaint

8. I considered evidence provided by Mrs X, the Council and Locala as well as relevant law, policy and guidance. I have carefully considered all the written and oral evidence submitted, even if it is not all mentioned within this decision statement.
9. Mrs X, Mrs Z, the Council and Locala had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

10. Mrs Y was an elderly woman with dementia. She lived at home independently and was supported by visits from a care agency.
11. In late December 2024, Mrs Y fell at home. She was admitted to hospital, where she was diagnosed with a fractured pelvis and displaced hip.
12. In hospital, Mrs Y was nursed in bed and transferred using a hoist as she had some difficulty following instructions to keep weight off her left leg.
13. On 15 January 2025, Mrs Y moved to the Care Home for a period of recovery and rehabilitation. Rehabilitation is a service designed to help a person regain or re-learn some capabilities where these capabilities have been lost due to illness. Mrs Y was placed on a Non-Weight Bearing pathway to allow her fracture to recover to move to partial weight bearing and gradually improve her mobility.
14. On 16 January 2025, a physiotherapist from Locala visited Mrs Y to assess her. The physiotherapist found Mrs Y was still struggling to follow instruction to keep weight off her left leg. She advised Mrs Y to continue to be transferred by hoist while she awaited further partial weight bearing assessment. She assessed Mrs Y as high risk of falls and advised sensor mats be put in place. The Care Home installed the sensor mats the same day.
15. Around 6am the next day, Mrs Y walked from her bed unaided and was found by staff in the bathroom. The staff returned Mrs Y to bed and reminded her to use the call bed if she needed help. A few minutes later, Mrs Y walked alone to the bathroom again. Mrs Y was not injured.
16. On 11 February 2025, a Community Assessment Support Officer (CASO) from the Council visited Mrs Y to assess her needs and explore discharge options. Mrs Y’s family raised concerns about her low food and fluid intake. They also raised concerns about Mrs Y’s swallow, having witnessed her choking on food that day. The family were concerned Mrs Y would be at risk of falls if she returned home and suggested a 24-hour residential care home placement.
17. On 14 February, the CASO visited Mrs Y again. The CASO felt Mrs Y was progressing well with her physiotherapy and would be suitable for further rehabilitation at another placement, with a view to returning home. The family were unhappy with this option, still preferring a long term care home placement.
18. The physiotherapist spoke with Mrs Y alone. Mrs Y said that she wanted to go to the further rehabilitation placement as she would ultimately like to return home. The physiotherapist spoke with the CASO. Both professionals agreed Mrs Y had the mental capacity to make this decision and would proceed with the referral.
19. On 18 February, the physiotherapist referred Mrs Y to the specialist rehabilitation placement.
20. On 21 February, a GP from Locala visited Mrs Y. The GP diagnosed a chest infection and prescribed a course of antibiotics.
21. On 26 February, a GP reviewed Mrs Y. The GP felt the infection had improved but prescribed a mucolytic (a medication to thin phlegm) as she was still struggling with phlegm.
22. On 28 February 2025, Mrs Y’s health deteriorated. Later that day, Mrs Y died.

Analysis

Food and fluid intake

23. Mrs X complains about lack of action over Mrs Y’s food and fluid intake, weight loss and swallow difficulties. Mrs X says the family’s concerns were not listened to.
24. Historically, Mrs Y had a small appetite and had lost some weight during the months before her hospital admission. While in hospital, Mrs Y continued to eat small amounts and needed prompting to eat and drink. Mrs Y’s GP was involved and had prescribed nutritional shakes.
25. Mrs Y arrived at the Care Home with known concerns with her food and fluid intake. The Care Home’s care plan notes Mrs Y needed to be offered small, frequent and high calorie meals. It said she needed prompting with intake and to be encouraged to drink the nutritional shakes as she did not like them. The care plan said Mrs Y ate normal texture diet and had no difficulties chewing or swallowing. She was also noted to have low weight.
26. The Care Home’s daily care notes show Mrs Y was regularly offered multiple meals and snacks through the day. Despite encouragement, Mrs Y would sometimes decline meals or eat little. There is evidence the carers provided Mrs Y with drinks and snacks if she requested them, for example making her hot chocolate. This is in line with her care plan.
27. Mrs Y did not like the nutritional shakes and declined to drink them, saying they were too thick. Locala changed the shakes to a fortified juice instead, however Mrs Y still declined.
28. The Care Home’s food charts show Mrs Y initially ate reasonably well, although her intake fluctuated daily. Around mid-February, Mrs Y’s appetite became more variable, with low intake on some days. When Mrs Y developed a chest infection on 21 February, her food intake significantly reduced, although this is common when a person is unwell. The GP reviewed Mrs Y on 26 February, once her course of antibiotics had finished. The GP felt Mrs Y’s chest infection had improved. However, she was still feeling unwell and struggling with excess phlegm. Mrs Y refused all food on 26 to 28 February.
29. The Malnutrition Universal Screening Tool (MUST) is a flow chart consisting of five steps, which are used to identify adults who are malnourished, at risk of malnutrition or obese. MUST also contains management guidelines for use in developing care plans to ensure nutritional needs are met.
30. On arrival, the Care Home assessed Mrs Y’s MUST score which put her at Medium risk of weight loss. As a result, Mrs Y’s intake was observed and she was weighed fortnightly, in line with MUST guidance.
31. Mrs Y maintained her weight at all weigh ins up to and including 12 February. At the next weigh in, on 26 February, Mrs Y had lost 3kg. We cannot know exactly when Mrs Y began to lose weight during those two weeks. However, Mrs Y’s food and fluid intake notably reduced during her chest infection and this likely contributed to her weight loss at that time. The GP was contacted, who advised continuing to observe and increase weigh ins to weekly. As I have explained above, the GP also reviewed Mrs Y that day due to her chest infection.
32. I have not found fault in relation to Mrs Y’s food intake. The Care Home assessed Mrs Y’s MUST score and acted in line with the relevant guidance. The care plan put steps in place to encourage Mrs Y to eat and the staff followed the care plan. When Mrs Y lost weight, the Care Home escalated this to the GP, who increased monitoring of her weight. The GP also changed Mrs Y’s nutritional supplements to encourage her to accept them. Overall, I am satisfied the professionals caring for Mrs Y took multiple steps to support her nutritional intake.
33. Mrs X complains that the CASO and physiotherapist failed to act on the family’s concerns about Mrs Y’s swallow. She says Speech and Language Therapy (SALT) input should have been sought.
34. On 11 February, the family raised concerns with the CASO that Mrs Y had choked on food that day. The CASO said she would raise this with the therapy team. The physiotherapist asked the Care Home about Mrs Y’s swallow. The Care Home said Mrs Y was on normal texture diet, had a low intake but they were not aware of any problems chewing and swallowing. The physiotherapist advised the Care Home to monitor any difficulties.
35. On 21 February, the physiotherapist spoke with the family, who raised concerns about Mrs Y’s swallow again. The physiotherapist spoke with the Care Home again, who said staff had not seen any choking incidents but said Mrs Y needed lots of prompting to eat and would sometimes fall asleep while eating.
36. The next day, the physiotherapist submitted a referral to SALT.
37. I have not found evidence of any delay with the SALT referral. The physiotherapist acted on the family’s concerns by making enquiries with the Care Home and asking them to monitor any issues. When the family raised further concerns, the physiotherapist referred Mrs Y to SALT.
38. In the meantime, the Care Home could have acted on the family’s concerns that some meals were too dry for Mrs Y. The Council has already acknowledged appropriate sauce should have been offered to moisten Mrs Y’s food. The Council has apologised to the family. Further, the Council has reviewed nutrition and hydration training for staff and is actively ensuring all relevant staff complete this. The Council has provided evidence of training progress and confirmed discussing swallow concerns is now a standing item at staff meetings. The Council has taken sufficient steps to remedy this fault.
39. Mrs Y’s care plan recognised that she needed regular prompting with fluids. However, Mrs Y’s fluid intake remained variable despite encouragement. Mrs Y was offered high liquid food such as soup, but she did not always accept this.
40. On 10 February 2025, the Care Home put a fluid monitoring chart in place. Mrs Y’s fluid intake fluctuated, reducing noticeably when she became unwell with a chest infection. Mrs Y was always offered more fluid than she accepted. The Care Home was actively encouraging her to drink more.
41. I have considered whether a fluid chart should have been implemented sooner. While this could have been done, the staff were already prompting her to drink and I am not persuaded the chart would have significantly increased her fluid intake.
42. Mrs X asks why Mrs Y was not taken to hospital to be put on a fluid drip. Mrs Y had been reviewed by medical professionals in late February, who were aware of Mrs Y’s low fluid intake. There is nothing to suggest the medical staff felt rehydration via a drip was necessary.
43. Care Home staff were aware of Mrs Y’s reduced fluid intake, monitoring it and encouraging her. While Mrs Y’s fluid intake was low, Care Home staff took sufficient steps to increase this. I have not found fault on this point.

Fall risk

44. Mrs X complains about delay putting sensor mats in place. She says this allowed Mrs Y to walk to the bathroom unsupervised when she should have been Non-Weight Bearing.
45. As mentioned above, the physiotherapist visited on 16 January 2026 and advised sensor mats be put in place due to Mrs Y’s high fall risk. Mrs Y was reminded to use the call bell for staff attention if she needed to go to the toilet. At the time, Mrs Y understood the risks of moving alone.
46. The daily care records show the sensor mats were put in place on 16 January, before Mrs Y walked to the bathroom the next morning. I have not found any evidence of delay.
47. It is unclear how Mrs Y managed to walk to the bathroom without triggering the sensor mat alarm. Mrs Y should not have been walking around unsupported, and this was understandably concerning for her family. However, I have not found any evidence that this incident occurred due to fault by the Care Home.

Moving and handling

48. Mrs X complains about an incident on 23 February, when she says a member of staff moved Mrs Y inappropriately. Mrs X complains a staff member pulled Mrs Y up by her trousers, when struggling to reposition Mrs Y by herself. Mrs X says this was particularly inappropriate, given Mrs Y’s fractured hip.
49. The Council’s complaint response says the family did not report the incident on the day, so it could not be addressed at the time. The staff member refutes the allegation.
50. The daily care records record Mrs Y being repositioned regularly through the day but does not mention any difficulties. By that date, Mrs Y had been assessed as being able to move with the assistance of one staff member.
51. I cannot say what happened. There are conflicting accounts of the incident and no independent evidence to confirm either account. As such, there is insufficient evidence to make a finding on this point.
52. The Council has reminded staff of the importance of moving and handing in line with training. Any further investigation by us is unlikely to achieve more.

Isolation

53. Mrs X complains Mrs Y was left alone in her room, without access to social areas and other residents.
54. The Council has explained Mrs Y was placed in her room due to limited availability of other room options. The Council says Mrs Y was encouraged to leave her room but declined.
55. The daily care records show that, when Mrs Y first arrived, she was taken to the dining room on several occasions for her meals. However, Mrs Y later began to decline offers to leave her room.
56. I have not found fault on this point. Mrs Y appears to have preferred remaining in her room, and the staff were acting in line with her wishes. The daily care records note Mrs Y often enjoyed chatting with staff during personal care.

Delayed assessment by Council

57. Mrs X complains about delays by the Council completing Mrs Y’s assessment in the Care Home. She believed Mrs Y would be assessed within a week, but says the Council took six weeks. Mrs X says this impacted on the family finding suitable long term care options, where Mrs Y could have been settled before she died.
58. Rehabilitation placements are usually funded for up to six weeks. This allows time for a person to settle in the temporary placement, engage with therapy and see how they are progressing. It would be unusual for a person to be assessed within one week, as this is unlikely to be long enough to see any improvements. I cannot say why Mrs X was unclear on the timescales.
59. The CASO visited Mrs X on 11 and 14 February, around four weeks after she arrived in the Care Home. The CASO did not complete the assessment as the plan was for Mrs Y to move to a specialist rehabilitation placement, after which she would be further assessed. The CASO discussed the decision with the family on 16 February. This is within the usual expected time frame and I have not seen any evidence of delay.
60. This decision later changed when Mrs Y’s health deteriorated. However, this was due to a change in circumstances, not delay.

Record keeping

61. Mrs X complains about poor record keeping by the CASO, for example, not keeping discharge meeting minutes.
62. The Council’s complaint response says there were no meetings, only assessments. Therefore, there were no meeting minutes.
63. I have not found fault with the CASO’s record keeping. The Council’s records sufficiently document the CASO’s assessment, including discussions with Mrs Y, her family and other professionals. The CASO and physiotherapist’s records contain a consistent recollection of these discussions. I have not found any significant gaps in the records.

Physiotherapy

64. Mrs X complains that the Council and physiotherapist tried to move Mrs Y to an inappropriate placement for further rehabilitation, against the family’s wishes. Mrs X says the family’s concerns about Mrs Y’s safety at home were ignored. While Mrs Y agreed to the placement, Mrs X says Mrs Y had dementia and likely lacked the mental capacity to make such a decision.
65. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
66. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
67. During her time in the Care Home, the physiotherapist carried out several cognitive tests and considerations of Mrs Y's capacity. Multiple urine tests were also carried out to check for Urinary Tract Infections; however no treatment was required. Mrs Y was confused at times and there was evidence of some cognitive impairment. However, she retained capacity to make daily decisions about her care and to engage in physiotherapy. The physiotherapist’s records show Mrs Y’s cognition fluctuated.
68. Mental capacity assessments look at whether a person can make a specific decision, at the specific time they are being asked. When the physiotherapist spoke with Mrs Y alone, she was clear that she wanted to engage in further therapy at another placement with the goal of returning home. The physiotherapist had completed multiple therapy sessions with Mrs Y by this point and was familiar with her cognitive difficulties. The physiotherapist records Mrs Y was alert and orientated at the time of the discussion. The physiotherapist considered Mrs Y was aware of her present mobility limitations and need for support. She recorded Mrs Y demonstrated reasoning and understanding, and concluded Mrs Y retained mental capacity to make the decision. The physiotherapist spoke with the CASO, who also agreed. Both professionals felt Mrs Y was progressing well with her therapy and further goals were achievable.
69. I acknowledge the family’s concerns about Mrs Y’s cognition and safety, and I appreciate how these concerns arose. Professionals need to consider the views of both a person and their family. Where those views do not align, it can be a difficult balance to strike.
70. The physiotherapist and CASO properly considered Mrs Y’s capacity and acted in line with her wishes. The family’s concerns were not ignored. The professionals considered all the information available then used their professional judgment to reach a different decision, which they were entitled to do. I have not found fault on this point.
71. Further, the decision was not about whether to send Mrs Y home. The decision was whether to refer her to another rehabilitation placement. Here she would have been supervised while continuing her therapy. Following this, there would have been a fresh assessment of her ability to return home safely.
72. Mrs X complains about confusion and delay completing the rehabilitation referral. It seems Mrs X did not always receive clear communication around this. However, the physiotherapist submitted the referral on 18 February, therefore I have seen no evidence of delay.
73. A few days later, the GP diagnosed Mrs Y with a chest infection. In the following days, Mrs Y’s food and drink intake reduced, and she became less compliant with therapy. Records show her cognition declined rapidly over the next few days. On 25 February, the physiotherapist noted that Mrs Y had deteriorated since the chest infection, was significantly more confused and had stopped engaging in therapy. The physiotherapist advised the CASO that Mrs Y was no longer suitable for further therapy. The physiotherapist took new evidence into account and updated her recommendation, based on the current circumstances.

End of Life care

74. Mrs X complains that the Care Home and Locala jointly failed to recognise Mrs Y was approaching the end of her life. Mrs X says this prevented Mrs Y from being put on an End-of-Life pathway, meaning she was unable to access medication which would have made her more comfortable. Mrs X says Mrs Y’s death was unnecessarily distressing.
75. Mrs X says on Mrs Y’s last day, the Care Home only took her observations once and did not escalate matters when the medics hadn’t arrived. Mrs X questions what the Care Home management did to support Mrs Y.
76. On 21 February 2025, a Locala GP diagnosed Mrs Y with a chest infection and prescribed a course of antibiotics. The GP noted her low oral intake. On 26 February, the GP reviewed Mrs Y and found the infection had improved. Mrs Y was still struggling with excess phlegm, so the GP prescribed a mucus thinning medication to help. The GP planned to review Mrs Y in a week.
77. On 26 to 28 February, Mrs Y declined all food. Her fluid intake was also very low. Around 11am on 28 February, Mrs Y’s family raised concerns with the Care Home management about Mrs Y’s wellbeing. They said Mrs Y was agitated and her breathing was laboured. The Deputy Manager visited Mrs Y, who was uncomfortable but alert. The Deputy Manager reassured the family that Mrs Y had been reviewed by a GP on 26 February. The Deputy Manager said they would task the medical team. However, this was not done until 12.49pm.
78. At 12pm, the family spoke with the physiotherapist. The physiotherapist spoke with the Deputy Manager, who said they were taking Mrs Y’s observations and liaising with the medical team.
79. At 12.40pm, a Deputy Manager visited Mrs Y and took her observations, which were all within range although they were unable to read her oxygen saturation levels. Locala’s records show the Deputy Manager contacted the medical team at 12.49pm. They provided Mrs Y’s observations and explained she was agitated and had low intake. Mrs X says action should have been taken when Mrs Y’s oxygen saturation levels could not be read. The Care Home says it’s not unusual for oxygen saturation levels to be difficult to pick up at times. The Care Home took action by advising the medical team that Mrs Y’s oxygen levels could not be read, when contacting them.
80. At 13.45pm, the physiotherapist followed up with the Deputy Managers and medical team to check that the nurse was still coming. Locala confirmed the nurse was on his way. Locala says it is at least a 30 minute journey to the Care Home.
81. At 14.45pm, the physiotherapist decided to call 999, as Mrs Y’s breathing had deteriorated. The nurse arrived a few minutes later, while the physiotherapist was still on the phone. The nurse decided to cancel the ambulance as Mrs Y’s breathing indicated she was dying. The nurse contacted the GP to visit and prescribe anticipatory medication. Sadly, Mrs Y died shortly before the GP arrived.
82. In response to my enquiries, Locala said Mrs Y was being actively assessed and treated by multiple healthcare professionals and at no point did her clinical presentation prompt professionals to consider end of life care. Locala said Mrs Y’s presentation fluctuated, which suggested her condition was reversible rather than permanently declining towards end of life. Locala said it cannot predict when a person will die.
83. However, Locala also accepted that the family raised concerns that Mrs Y may be reaching her end of life and asked for her to be nursed in bed. The team was still hoping Mrs Y could be rehabilitated, but Locala accepts greater weight could have been given to the family’s concerns. The family did not feel heard and this has been distressing for them.
84. I acknowledge the family’s strong views that there were missed opportunities to recognise Mrs Y was approaching the end of her life and appropriately plan for that. However, it is clear from the records that none of the professionals from the Council, Locala or the Care Home considered Mrs Y to be end of life. They were planning for Mrs Y’s discharge and believed her poor presentation was temporary and related to the chest infection, which she appeared to be recovering from. On 26 February, Mrs X was arranging for a care home to assess Mrs Y, therefore she was also planning for Mrs Y’s discharge. While Mrs Y was quite unwell over her last few days, it was not clear that she was reaching the end of her life.
85. The physiotherapist appropriately monitored Mrs Y, escalated concerns to the Care Home management, the medical team and 999 and actively followed up to check when the medics would be arriving.
86. However, there are some indications that the Care Home could have acted sooner than it did. The Care Home did not contact the medical team on 27 February when Mrs Y continued to refuse all food. Further, there is no evidence the Care Home contacted Locala when the family raised concerns at 11am on 28 February despite this being the third day Mrs Y had refused almost all oral intake. It appears the Deputy Manager only contacted Locala’s medical team at 12.49pm, after further concerns were raised by the physiotherapist. This was almost two hours after the family first raised concerns. There is no clear reason for this delay.
87. It then took two further hours for the nurse to arrive. Nevertheless, I acknowledge the nurse would have been visiting other patients and needed time to travel to the Care Home.
88. I cannot say whether the Care Home contacting Locala earlier would have led to a different outcome. We cannot know, had a GP been contacted on 27 February, whether her presentation would have been deemed end of life, given that her presentation was similar to when the GP reviewed her the day before. I also cannot say whether Mrs Y would have received anticipatory medications in time, even if the medical staff arrived earlier on 28 February. This is because it can still take some time to prescribe, obtain and administer the medication.
89. However, these questions have left Mrs Y’s family with significant uncertainty and distress about whether Mrs Y’s final hours might have been more comfortable if their concerns had been handled differently.

Communication with family

90. Mrs X complains about poor communication with the family. Mrs X feels the family’s concerns were ignored and they were not properly involved in decisions. Mrs X also complains about a lack of interest and empathy by the Care Home staff on the day Mrs Y died.
91. I have addressed some of these points above, in relation to Mrs Y’s food and fluid intake and discharge planning.
92. It appears Mrs X may have received conflicting information about whether Mrs Y had been referred for further rehabilitation.
93. In the joint complaint response, both the Council and Locala acknowledged poor communication around Mrs Y’s last days. The family raised concerns that Mrs Y could be reaching the end of her life, however all professionals involved maintained the view she was able to receive active treatment. In response to my enquiries, Locala said “in hindsight, it is recognised that greater weight could have been given to the family’s concerns”.
94. We cannot know whether, or to what extent, Mrs Y’s end of life care may have been different, if the family’s concerns had been handled differently. However, the family did not feel heard and this has caused them significant uncertainty and frustration.
95. Regarding the actions of the Care Home staff, the Deputy Managers visited Mrs Y and took her observations after the family raised concerns. The physiotherapists arrived shortly after and spoke with the Deputy Managers. The physiotherapists told the Deputy Mangers that they would support Mrs Y. It does not appear this was communicated to the family. The Deputy Manager recalls trying to visit later in the day but explained the family were upset and wished to be left alone with Mrs Y. The Deputy Manager says they gave condolences to the family after Mrs Y died.
96. There are some conflicting accounts regarding this period, which I cannot resolve. However, there is evidence that the family was not clearly informed that the physiotherapists were taking responsibility for supporting Mrs Y. This created the impression that the Care Home management was disinterested in Mrs Y’s wellbeing.
97. Overall, there is evidence of some poor communication with Mrs Y’s family, particularly in relation to her final days. This caused her family frustration and distress during a deeply upsetting time.

Failure to work together

98. Mrs X complains about multi organisational failings by the Council, the Care Home and Locala to work together. Mrs X says she was given conflicting information.
99. As noted above, it is unclear why Mrs X appears to have been told no referral had been made to the further rehabilitation placement. The physiotherapist made the referral on 18 February, then a week later decided this was no longer a suitable option.
100. Both the Council and Locala records show multiple contact between the CASO, medical professionals, therapists and Care Home staff. Generally, the records align. Where the family raised concerns with one professional, these were promptly discussed with other relevant professionals. I have found no evidence of failure to work together.

Death certificate

101. Mrs X complains about delays receiving Mrs Y’s death certificate, due to administrative problems.
102. Locala has already acknowledged the delay. Locala explains this was due to a technical issue between Locala and Mrs Y’s usual GP’s different computer systems. This caused additional frustration for the family, at a distressing time.
103. Locala has apologised to the family. Local has also provided evidence of changes to the process to prevent this happening again. I am satisfied that Locala has taken sufficient steps to put things right.

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Action

Council

104. Within one month of my final decision statement, the Council will:
• apologise to Mrs X and Mrs Z for communication failures and delays responding to the family's concerns on Mrs Y’s last day; and
• pay £150 each to Mrs X and Mrs Z for uncertainty, frustration and distress
105. Within three months of my final decision statement, the Council will explain what action they will take to
• ensure the Care Home recognises the importance of robust communication with residents, families and carers; and
• ensure concerns about a person’s wellbeing are escalated in a timely manner.
106. The Council should provide us with evidence it has complied with the above actions.

Locala

107. Within one month of my final decision statement, Locala will:
• apologise to Mrs X and Mrs Z for communication failures and failure to give sufficient weight to the family's concerns; and
• pay £150 each to Mrs X and Mrs Z for uncertainty, frustration and distress
108. Within three months of my final decision statement, Locala will explain what action they have taken or will take to
• ensure staff properly consider and record concerns raised by residents, families and carers.
109. Locala should provide us with evidence it has complied with the above actions.

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Decision

110. I have found fault by the Council and Locala in relation to communication with Mrs Y’s family, particularly around her end-of-life care and failure to respond properly to the family’s concerns. I have also found delays by the Council escalating concerns to the medical team on Mrs Y’s last day. As a result, Mrs X and Mrs Z have been caused uncertainty, frustration and distress.
111. I have not found fault with Mrs Y’s daily care and discharge planning.
112. I have now completed my investigation.

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Investigator's decision on behalf of the Ombudsman