Summary: The Council commissioned Care Home was at fault for the delay telling Mr X about his father’s condition deteriorating and that he was taken by ambulance to the hospital. The Care Home has apologised for the distress caused and made service improvements to prevent it happening again.

The complaint

1. Mr X complained the Council commissioned Care Home, Hillside Lodge, failed to take appropriate action when his late father, Mr F, became acutely unwell. He says it has caused him and the family distress. He wants the Care Provider to acknowledge it acted with fault.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended). As the Council commissioned the care home we consider it was acting on the Council’s behalf.
4. We may investigate complaints from the person affected by the complaint issues, or from someone else if they have given their consent. If the person affected cannot give their consent, we may investigate a complaint from a person we decide is a suitable representative. (section 26A or 34C, Local Government Act 1974)
5. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended) 
6. 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(1), as amended)

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How I considered this complaint

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

The Care Homes Procedures

9. The Care Home explained its procedure is to inform a resident’s family promptly when a resident’s health rapidly deteriorates, especially if staff call an ambulance.

What happened

10. I have summarised below the key events; this is not intended to be a detailed account.
11. Mr F was discharged from hospital to the Care Home in early April 2025. The care notes say Mr F seemed confused that evening.
12. The following day, the care notes say Mr F remained confused at times but he was eating and drinking and communicating.
13. The next day, the care notes said Mr F has a shower and ate well. The notes say there were no issues and he settled well and slept well overnight.
14. The care notes show the following day that Mr F had a quiet day without any issues. He ate and drank and settled well at night.
15. The following day, the care notes show Mr F appeared more ‘…confused than his “norm” at breakfast this morning.’ The nurse’s notes said he took his medication with assistance and had a drink. The carers’ notes said they gave Mr F breakfast, but he did not eat it.
16. At 10:50am, the care assistant noticed Mr F was ‘…finding it hard to talk and did not seem himself. Dropping everything. Breathing was not his normal.’ The carer alerted the nurse and said Mr F “seemed a lot worse” and “wasn’t right”. The nurse checked Mr F’s blood pressure and temperature and noted his “colour was very poor.” The care home called an ambulance at 11.05am.
17. The ambulance took Mr F to hospital at 11:40am.
18. The Care Home called Mr X at about 1pm to tell him the ambulance had taken his father to hospital. The Care Home advised Mr X to wait for further information from the hospital.
19. The hospital called Mr X about an hour later and asked him to come to the hospital immediately as his father was extremely ill. Mr X said his father was too ill to communicate by the time he arrived at the hospital.
20. Mr F died the following day.
21. Mr X complained to the Care Home in late June 2025.
22. The Care Home issued a stage one complaint response in early August. In its complaint response, the Care Home said it should have contacted Mr F’s family as soon as the nurse called the ambulance. It explained its primary concern was Mr F’s wellbeing. The Care Home apologised for the distress caused. It said it had emphasised the importance of contacting family as soon as an ambulance had been called with its staff.
23. The Care Home issued a stage two response in early (9) September 2025. It said the nurse took the correct action in the morning, at that time Mr F’s condition did not indicate need for medical intervention. When Mr F’s condition changed, the nurse responded appropriately and called the ambulance. The complaint response agreed the Care Home’s communication was ‘found wanting’ and stressed the importance of timely communication with families.
24. In response to my enquiries, the Council explained it had highlighted the importance of timely communication with families and reminded staff they must do so as soon as possible once they have called for an ambulance.

Analysis

Monitoring of Mr F

25. The care notes show the care staff observed Mr F every couple of hours, including the day he was taken to hospital. The notes show he was settled but sometimes confused since he returned from hospital. The notes from 9am on the day he went into hospital say Mr F refused breakfast and was more confused than normal, but there is nothing within the notes from the nurse to indicate Mr F’s condition was medically serious at this time. In conversation with Mr X, he was concerned the Care Home did not monitor his father more closely between 9am and 10:50am. While I understand Mr X’s distress, the notes show there was no medical reason to do so. The Care Home was not at fault.
26. The Care Home continued to monitor Mr F every couple of hours, as it had done in the previous 48 hours. Between 9am and 10:50am, the care notes show Mr F’s condition deteriorated to a point where he was finding it hard to talk, dropping things and his breathing had changed. The care notes show Mr F was responsive, but he “wasn’t right”. At this point, the care assistant requested support from the nurse and called an ambulance. The Care Home acted appropriately in seeking medical attention. It was not at fault.

Communication with the family

27. The Care Home’s procedure says staff must inform family promptly when a resident’s health deteriorates rapidly, and especially if they call an ambulance. The Care Home telephoned Mr X about two hours after staff raised concerns about Mr F’s health and called 999. This was delay, this was fault. Mr X felt he was robbed of the opportunity to talk to his father and provide comfort to him. The Care Home accepted in its complaint response that it should have told Mr X sooner and apologised for the distress caused.
28. The Care Home addressed the matter with staff and reminded them of the policy to contact family as soon as an ambulance is called. I do not need to make any further service improvements.

Summary of fault causing injustice

29. The Care Home was at fault for delay telling Mr X about his father’s condition deteriorating and delay telling him the ambulance took Mr F to hospital. This caused Mr X distress as his father’s condition worsened and he felt he did not get the opportunity to speak to him before he died.
30. The Council has already apologised to Mr X and made service improvements to prevent recurrence of the fault. There is nothing more we can achieve.

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Decision

31. I find fault causing injustice. The Council has already provided a remedy for the injustice.

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Investigator's decision on behalf of the Ombudsman