Summary: We will not investigate Miss X’s complaint about how the Care Home responded to her father, Mr Y, becoming acutely unwell. This is because the Care Provider accepted it acted with fault, implemented service improvements to prevent a recurrence of fault and apologised to Miss X which was appropriate. We therefore could not add to its previous investigation.

The complaint

1. Miss X complained the Care Home attempted to resuscitate her late father, Mr Y, when he became unresponsive. She said this went against her father’s wishes and as a result, he sustained injuries to his ribs which affected his end-of-life care. Miss X said the matter caused her and the family distress. She wants the Care Provider to make service improvements to ensure it does not happen to other people.

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The Ombudsman’s role and powers

2. 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 we could not add to any previous investigation by the organisation.(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

3. I considered information provided by Miss X and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Mr Y lived in a care home. Mr Y had a DNAR (do not attempt resuscitation) as well as a RePECT form (recommended summary plan for emergency care and treatment). The latter is a document which emergency services can use to understand a person’s wishes and clinical recommendations.
6. In July 2025, staff were about to provide Mr Y with personal care however noticed he was unwell and unresponsive. Staff carried out observations and called the ambulance service to attend. Mr Y was breathing however, whilst waiting for the ambulance service to arrive, staff carried out CPR (cardiopulmonary resuscitation) in line with advice from the emergency services.
7. Upon arrival, the ambulance service asked the Care Home for Mr Y’s ReSPECT form and took Mr Y into hospital where he received end-of-life care and died several days later.
8. Miss X complained to the Care Provider. She said:
• staff should not have given Mr Y CPR. They should have been aware Mr Y had a DNAR in place;
• staff delayed providing the ambulance service with the ReSPECT form for approximately 30 minutes; and
• Mr Y had several injuries to his ribs following resuscitation. She said it made it difficult for him to breathe.
9. In her complaint to us, Miss X said the hospital did not transfer Mr Y into a hospice for end-of-life care due to his injuries. She said Mr Y’s final days were traumatic and he was denied a dignified and peaceful death.
10. The Care Provider investigated Miss X’s complaint. It recognised the Care Home had acted with fault in how it responded to Mr Y becoming acutely unwell. It apologised to Miss X for the distress caused. To reduce the risk of it happening again, the Care Provider said it had:
• carried out an audit of all critical documents to ensure they were correctly recorded onto its system and were accessible to staff;
• printed a list for staff which showed residents who have DNAR and ReSPECT documents in place;
• implemented discreet visual prompts in the rooms of residents which informed staff of how to assist residents in emergency situations;
• provided additional training to staff in relation to correctly recording on its system critical information regarding the residents; and
• reminded staff to share and record any updates in relation to care plans including clinical decisions.
11. We will not investigate Miss X’s complaint. This is because the Care Provider recognised the Care Home acted with fault in response to Mr Y becoming acutely unwell and made changes to its service to prevent it from happening again. These service improvements were appropriate and what we would expect the Care Provider to do. It also apologised to Miss X for the distress caused which was also appropriate. We therefore could not add to the Care Provider’s previous investigation.

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Final decision

12. We will not investigate Miss X’s complaint because we could not add to the Care Provider's previous investigation.

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Investigator's decision on behalf of the Ombudsman