Summary: We will not investigate Miss X’s complaint about the Council’s commissioned Nursing Home and the poor care it provided to her late relative. This is because we could not add to the Council’s previous investigation and a further investigation would not lead to a different outcome.

The complaint

1. Miss X complained the Council’s commissioned Nursing Home, provided poor care to her late relative, Miss Y, towards the end of her life. The matter caused Miss X distress. Miss X wants the Council to acknowledge it acted with fault and provide her with an apology for the injustice caused.

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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, 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

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

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My assessment

5. Miss Y was a resident at the Council’s commissioned Nursing Home.
6. Miss Y had a fall. She was admitted into hospital following her fall and then discharged back to the Nursing Home. At this point, Miss Y was towards the end of her life. She required pain relief medication as needed. Shortly after being back at the Nursing Home, Miss Y died.
7. Miss X complained to the Council. As part of her complaint, Miss X said:
• there were inconsistencies in where Miss Y had fallen. She also said care workers had decided to move Miss Y from the floor and onto her bed which caused her more distress;
• Miss Y had bruising on her upper arms which had not been recorded;
• care workers had falsified medication records, observation records and that Miss Y had spent time with an activity worker; and
• the Nursing Home had poorly planned Miss Y’s care in relation to her medication towards the end of her life.
8. The Council investigated Miss X’s complaint. It reviewed Miss Y’s records, witness statements and spoke with the staff at the Nursing Home. In response, the Council said:
• care workers had found Miss Y by the bathroom door. It could not explain why the paramedics and hospital staff said she was found at another location in her room;
• care workers had decided to move Miss Y from the floor to her bed whilst they waited for the paramedics to arrive as they had observed Miss Y as being distressed. On reflection, the Council said it was not standard practice to move someone following a fall and said it would address this with the Nursing Home;
• it could not explain Miss Y’s bruising on her upper arms. Care workers had recorded injury to her lower arms. However, the Council said it was working with the Nursing Home to ensure all staff were up to date with moving and handling training. It also said it had found in a recent visit, there were gaps in care records and so was working with the Nursing Home to improve how staff recorded injuries;
• its records showed care workers had administered medication to Miss Y, observation checks were completed and Miss Y had spent some time with the activity worker. It therefore could not conclude whether the records were falsified. However, the Council noted there was a discrepancy in the observation checks record which a care worker had noted Miss Y was sleeping but another care worker had noted Miss Y was awake. The Council said going forward, it would simplify recording observation checks to prevent a mistake from happening again;
• it accepted Miss Y’s end of life care had been poorly planned. Miss Y did not have an end-of-life care plan which informed care workers how to support her, how to manage the syringe driver and Miss Y’s pain relief. The Council said it had since made changes to prevent a recurrence of fault which included providing all nursing staff with training; and
• it was sorry Miss X and the family did not have the experience they should have had in Miss Y’s final days.
9. We will not investigate Miss X’s complaint because the Council has already addressed her concerns appropriately. The Council acknowledged its errors, explained the preventative steps it will take to avoid further fault and issued an apology to Miss X and her family. Subsequently, we cannot add further value to the Council’s existing investigation and a further investigation would not lead to a different outcome.

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Final decision

10. We will not investigate Miss X’s complaint because we could not add to the Council’s previous investigation and a further investigation would not lead to a different outcome.

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Investigator's decision on behalf of the Ombudsman