Summary: We will not investigate Ms H’s complaint about the care her late partner Mr O received at a care home, including issues relating to falls and pressure area care. We are unlikely to find fault by the care home on the key issues. Also, some of the complaints are about old events and we are unlikely to be able to reach reliable conclusions about them now.

The complaint

1. Ms H complained to the Ombudsmen about the care her late partner Mr O received at Birch Abbey Care Home (the care home), between 2023 and late 2025. Her complaints included:
• events surrounding Mr O’s fall in October 2025
• management of his pressure areas
• management of medications
• continence and personal care
• management of fluids
2. Ms H said she believed poor care and neglect led to Mr O’s premature death. She said Mr O suffered avoidable pain and distress because of the poor care, and this also caused her distress. Ms H said she wanted the care home to acknowledge the failings in Mr O’s care, and to make changes to improve the care for other residents in future.

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The Ombudsmen’s role and powers

3. The Local Government and Social Care Ombudsman and Health Service Ombudsman have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
4. We investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, we consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• the injustice is not significant enough to justify their involvement, or
• it is unlikely we could add to any previous investigation by the organisations

6. When someone complains on behalf of a person who lacks mental capacity, we may decide not to investigate because the events happened too long ago, meaning we are unlikely to be able to reach reliable conclusions or unlikely to achieve meaningful outcomes. (Local Government Act 1974, sections 24A(6) and 34B(8), as amended).
7. Mr O’s placement at the care home was the joint responsibility of the council and the NHS, as his care was jointly funded. We consider the council as the responsible organisation for Mr O’s social care at the care home. When a council commissions or arranges for another organisation to provide services, we treat actions taken by that organisation as actions taken on behalf of the council. In terms of the NHS-funded elements of Mr O’s care, following the approach of the Health Service Ombudsman we consider the care home to be the responsible organisation for this.

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How I considered this complaint

8. I considered evidence from Ms H, the council and the care home. I also considered the Ombudsman’s Assessment Code, and relevant law, policy and guidance. I gave Ms H the opportunity to comment on my draft decision.

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What I found

What happened

9. Mr O was a resident at the care home. His medical conditions included vascular dementia, cellulitis, and psychosis. He also had repeated urinary tract infections. Mr O needed assistance from staff with his mobility and had a history of falls. He also needed assistance with continence care, and care of his skin, and was at high risk of developing pressure sores.
10. In late October 2025 Mr O had an unwitnessed fall in his room. Staff called an ambulance and he was taken to hospital. Once in hospital Mr O was diagnosed with urosepsis (a condition where a urinary tract infection spreads and triggers sepsis, a life-threatening condition). Mr O remained in hospital for around ten days until he sadly died.
11. Ms H complained about Mr O’s care at the care home and at the hospital. Our consideration of the complaint has looked at the care home complaint. Ms H said she is going to pursue her complaints about the hospital with the Parliamentary and Health Service Ombudsman (PHSO).

Analysis

Fall in October 2025

12. Ms H said that when she arrived at the home and went to Mr O’s room, she heard him screaming in pain, and saw him being manhandled by staff on the floor while they tried to shove a crash mat under him. She said Mr O was complaining of pain in his hip, back and legs but staff were talking about trying to hoist him onto the bed. Ms H said the nursing staff did not do enough to manage Mr O’s pain and his high temperature while waiting for an ambulance.
13. The care home said its records of the fall confirm that Mr O landed on the crash mat. It did not comment any further on how the fall was managed or how Mr O was cared for until the ambulance arrived.
14. I have reviewed the care home’s records about the fall. These say that Mr O fell from his low-level bed onto the crash mat which caused the sensor alarm to sound, alerting staff. The records also say that a nurse carried out a full assessment, that Mr O was given paracetamol for pain, and that he was not to be moved while waiting for the ambulance.
15. I appreciate that Ms H’s account of events differs from what is documented in Mr O’s care records. Based on the evidence I have seen, I consider we are unlikely to be able to resolve the conflicting accounts about what happened, and are unlikely to find fault by the care home if we investigated.

Management of pressure areas

16. Ms H said that after Mr O arrived at hospital, staff found he had extensive bruising on his hips, back and legs. They also found he had serious pressure sores on his bottom. Ms H complained the home’s management of Mr O’s pressure areas was poor. She also complained to the hospital about how it documented Mr O’s pressure areas and managed his risk.
17. The care home said when Mr O left its care, he did not have any open pressure wounds. It said Mr O had remained on a trolley in the emergency department for an extended time without a pressure relieving mattress, and this had been raised with the hospital.
18. The hospital acknowledged that Mr O waited a long time on a trolley due to demand pressures. It also acknowledged and apologised that there was no documentation about Mr O’s skin integrity while he was in the emergency department.
19. The care home’s records show that Mr O was known to be at very high risk of developing pressure sores. They show him being repositioned regularly by staff to avoid pressure damage to his skin, and other care measures in place including an airflow mattress. The Body Maps completed three days before Mr O’s admission to hospital do not document any open pressure sores, and nor do his daily care records.
20. When someone is at very high risk of developing pressure sores, they can develop within a matter of hours if pressure is not relieved. We are unlikely to be able to determine when or where Mr O’s open pressure sores developed. However, having reviewed the available evidence, we are unlikely to find fault in how the care home managed Mr O’s pressure areas.

Other complaints and late complaints

21. Ms H raised several other complaints about Mr O’s care, going back to 2023. These included matters like leaving him soiled while staff were serving dinner, poor management of his cellulitis, failing to answer call bells, not following correct medication management procedures, inadequate staffing levels, and not following up hospital appointments.
22. It is difficult to investigate complaints about care over a long period where there are no specific dates or examples of the poor care complained about. Without this information, we are unlikely to be able to reach reliable or robust findings.
23. The Care Quality Commission (CQC) regulates care providers in England. The CQC can consider issues such as staffing levels, medication administration, care planning and record keeping, to improve services in the wider public interest. The CQC treats information from service users and relatives as evidence, which it considers during risk identification and inspection planning. Ms H has already raised some of her concerns with the CQC.
24. In addition, some of Ms H’s complaints date back to 2023. Ms H said she did not raise these issues as a formal complaint with the home until after Mr O had died, but that she had regularly raised issues with the care home informally, and had met with them to discuss concerns.
25. I have taken this into account. However, it is my view that it would have been reasonable to raise these issues as formal complaints sooner, if Ms H was sufficiently concerned about them. The amount of time that has passed impacts on our ability to investigate a complaint fairly and effectively. We are unlikely to be able to reach reliable conclusions about these issues if we investigated them now.

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Final decision

26. We will not investigate Ms H’s complaint. We are unlikely to find fault by the care home on the key issues, and some of the complaints are about old events and we are unlikely to be able to reach reliable conclusions about them now.

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Investigator's decision on behalf of the Ombudsman