Summary: Mr X complained about the way staff at a care home dealt with the death of his father, Mr Y. He said they failed to tell him Mr Y was close to death and have misrepresented matters about Mr Y’s passing, causing uncertainty about the care Mr Y received. We have found no evidence of fault in the actions of the care home, and so the Council was not at fault.

The complaint

1. Mr X’s father Mr Y lived in a care home (the Home), a placement commissioned by the Council. Mr Y died at the home in 2024. Mr X complains:
1. the care home staff failed to tell him and his wife that Mr Y was close to death;
2. the staff offered no dignity, respect or compassion over Mr Y’s death;
3. the version of events on the night of Mr Y’s death given by staff do not tally with the electronic records;
4. the home provided inadequate care, did not do regular checks on Mr Y on the night of his death, and have not taken accountability;
5. the home did not suspend the staff involved while the matter was investigated;
6. the home has misrepresented matters in its response.
2. Mr X says Mr Y’s wish was that his family should be with him in his final hours of life, a wish the Home prevented by not informing him and his wife of Mr Y’s impending demise. Mr X’s complaint says he wants Home staff involved to be reprimanded.

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The Ombudsman’s role and powers

3. Part 3 and Part 3A of the Local Government Act 1974 give us our powers to investigate adult social care complaints. Part 3 is for complaints where local councils provide services themselves. It also applies where a council arranges or commissions care services from a provider, even if the council charges the person receiving the care. In these cases, we treat the provider’s actions as if they were council actions.
4. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by their personal representative (if they have one), or someone we consider to be suitable (Local Government Act 1974, section 26A(2), as amended).
5. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

6. I considered evidence provided by Mr X, the Council and the Care Provider as well as relevant law, policy and guidance.
7. Mr X, the Council and the Care Provider 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

Relevant guidance and legislation

Fundamental Standards of Care

8. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (the 2014 Regulations) set out the requirements for safety and quality in care provision.
9. Regulation 9 of the 2014 Regulations requires care and treatment to be appropriate, to meet a person’s needs and to reflect their preferences. Care providers should carry out an assessment of needs and preferences and design a care plan to meet needs and preferences.
10. Regulation 17 of the 2014 Regulations says providers must securely maintain accurate, complete, and detailed records in respect of each person using the service.

Safeguarding

11. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

What happened

12. Mr Y was an older man, who needed 1-1 care and support from 8am to 8pm daily, and lived at the Home from April 2023 until his death in November 2024.
13. After Mr Y’s death, Mr X complained to the care provider, running the Home. He said:
• a manager at the Home had told another member of staff Mr Y would not last through the night;
• he had rung the care home at 00:15am. When he was called back was told ‘he’ has passed; and
• staff were not professional when Mr X arrived at the care home and they had prevented Mr Y’s wish to have his family with him in his last hours.
14. In December 2024 a meeting was held between Mr X and the care provider. The care provider gave its complaint response in January 2025, it said:
• staff are not medical professionals and cannot give prognosis;
• it understood the frustration of being told he would be called back and apologised for Mr Y’s name not being used when the message of his death was delivered. It had reminded staff regarding clear communication;
• staff had offered condolences and bespoke training had been offered to the member of staff in Mr X’s complaint.
• Mr X had spoken directly to the paramedic staff about his Mr Y;
• Mr Y had been regularly checked up to the time of his death; and
• it would review all end of life plans in the home and use the lessons learned to change how it communicated and provided end of life care.
15. In February 2025 Mr X raised a safeguarding concern with the Council, he said:
• he had made numerous complaints to the care provider with no response and it would not provide electronic records relating to Mr Y’s death;
• in a meeting the care provider had advised staff were not medically trained so questioned how had they been able to determine Mr Y’s death without contacting emergency services; and
• no independent witness statements or investigation had been carried out by the care provider.
16. A safeguarding enquiry was conducted and unsubstantiated in June 2025. It said:
• At approximately 20:00 on the evening prior to his death, Mr Y received medical treatment for a blocked catheter. Urine was not passing, Mr Y had a swollen abdomen and was presenting as pale. Staff were advised to call Mr Y’s GP. A member of staff was seen calling 999.
• Paramedics attended to Mr Y at 21:09. Pain relief was administered and a palliative nurse visit requested via the district nursing team for the following day. Staff were advised to contact the district nursing team for pain relief over night or call 999 if symptoms worsened. Paramedics spoke with Mr X regarding Mr Y’s care. Mr X advised he did not want Mr Y taking to hospital. Paramedics discharged Mr Y and left the home at 22:20.
• Staff were advised to carry 30-minute checks of Mr Y after the paramedics had left. Four checks were completed, three within this time frame and the final after 40 minutes.
• The final check at 00:20, recorded Mr Y as appearing not to be breathing and medical assistance was requested at 00:38 to confirm his death. His doctor was told Mr Y was found presumed deceased at 00:15 and Mr X was contacted. A doctor confirmed Mr Y’s death at 04:15.
• The home had sought appropriate support from health professionals and there had been no record that these professionals anticipated Mr Y’s death, only a palliative review for the following day. The only discrepancy found being a period of five minutes for the last reported check between written and electronic records but his did not constitute as neglect.
17. Mr X agreed that his concerns were not specific to safeguarding and for the closure of the safeguarding enquiry.
18. Mr X remained concerned that the care provider had not taken accountability for its actions relating to Mr Y’s death, specifically:
• respecting Mr Y’s wishes to have family with him,
• a lack of proper internal investigation,
• irregularities in the records, including the gap between the paramedics leaving and Mr X being notified of Mr Y’s death; and
• comments by Mr Y’s carer that a home manager had said they did not think Mr Y would last the night.
19. Consequently, Mr X asked the Ombudsman to investigate.

Analysis

20. When a council commissions or arranges for another organisation to provide services we treat actions taken by or on behalf of that organisation as actions taken on behalf of the council and in the exercise of the council’s functions.
21. Mr X’s desire to know more about what happened and the Home’s actions at the time of Mr Y’s death and the frustration of not being with Mr Y when he passed away. It is however not part of our role to determine the cause or time of Mr X’s death or whether the Care Provider’s quality of care contributed to this.
22. It is our role to look at whether the Home took reasonable steps to identify Mr Y’s deterioration and respond to it. It is apparent that Mr Y’s deterioration was more rapid than anticipated on the evening of his death, with palliative care appointments arranged for the next day and no indication given directly to Mr X by attending paramedics.
23. The evidence shows the Home took appropriate action by seeking clinical input, advice from out-of-hours services and carried out regular observations of Mr Y leading up to his death. In addition, the safeguarding enquiry was unsubstantiated, a finding which Mr X agreed to.

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Decision

24. I find no fault.

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Investigator's decision on behalf of the Ombudsman