Hertfordshire County Council (25 022 228)

Category : Adult care services > Residential care

Decision : Closed after initial enquiries

Decision date : 27 Jul 2026

The Ombudsman's final decision:

Summary: We will not investigate Miss X’s complaint about a care home not taking a urine sample from her mother, Mrs Y, prior to her operation. This is because an investigation would not achieve a worthwhile outcome.

The complaint

  1. Miss X complains that care home staff failed to take a urine sample from her mother, Mrs Y, in readiness for an operation. She says this contributed to Mrs Y’s death.

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The Ombudsman’s role and powers

  1. 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 there is no worthwhile outcome achievable by our investigation. (Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

  1. I considered information provided by the complainant and the Council.
  2. I considered the Ombudsman’s Assessment Code.

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My assessment

  1. Mrs Y died in late 2023, following an operation. In February 2025, an inquest concluded a lack of infection screening contributed to her death.
  2. Miss X complained to the Care Provider it should have taken a urine sample. The Care Provider said there was no evidence Mrs Y had an infection before her admission. It said it closely monitored Mrs Y due to her medical history, and she was under the care of NHS medical specialists.
  3. I will not investigate this complaint because there is no worthwhile outcome we can achieve. Mrs Y was under the care of a specialist medical team, who assessed her before deciding to do the operation. Therefore, I cannot find the Care Provider at fault for not doing the sample.
  4. During its investigation, the Care Provider found inaccurate records and provided training for its staff on the importance of accurate recording.

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Final decision

  1. We will not investigate Miss X’s complaint because no worthwhile outcome could be achieved by our investigation.

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Investigator's decision on behalf of the Ombudsman

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