Summary: We will not investigate this complaint about a fall Mrs Y suffered while in respite care because further investigation would be unlikely to lead to a different outcome.

The complaint

1. Mr X complains on behalf of his late mother, Mrs Y, who suffered a serious fall while staying in respite care. Mr X says Mrs Y left her room and fell down a staircase. He says the Care Provider had not provided adequate safety measures, including lighting, a pressure mat and a safety gate. Staff found Mrs Y shortly afterwards and called an ambulance.
2. Mr X says the hospital, rather than the Care Provider, informed him about the incident. He says Mrs Y sustained multiple injuries and could no longer return home, resulting in her moving to a nursing home. Mr X says the incident caused him significant distress and led him to lose trust in care services. He would like the Care Provider to install pressure mats and safety gates and carry out hourly checks on residents.

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The Ombudsman’s role and powers

3. 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, or
• further investigation would not lead to a different outcome. (Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

4. I considered information provided by the complainant and the Care Provider.
5. I considered the Ombudsman’s Assessment Code.

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My assessment

6. The Care Provider investigated the complaint and found that, although a call bell was available to Mrs Y, there was no call mat in her room. The Care Provider acknowledged that, had a call mat been in place, it may have alerted staff that Mrs Y was out of bed, and the fall may have been prevented.
7. The Care Provider expressed its sincere apologies for the incident and following the incident implemented several service improvements, including enhanced staircase safety measures, increased monitoring and overnight checks, new alarm systems, additional risk assessments, increased staffing levels, and refresher training for staff.
8. Sadly, Mrs Y has since passed away so we could not provide a remedy for any injustice caused to her by the action of the Care Provider even if we investigated and found evidence of fault. The Care Provider has apologised and advised of the actions it has taken to minimise the risk of a similar occurrence. We could achieve no more than this.
9. We will not investigate this complaint because further investigation would be unlikely to lead to a different outcome.

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Final decision

10. We will not investigate Mr X’s complaint because further investigation would be unlikely to lead to a different outcome.

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Investigator's decision on behalf of the Ombudsman