Summary: We will not investigate Mr X’s complaint about the Care Home failing to correctly administer medication to his father, Mr Y. This is because we would not be able to add to the Care Provider’s investigation and we would not be able to achieve the outcome Mr X wants.

The complaint

1. Mr X complained the Care Provider’s Care Home failed to administer medication correctly to his father, Mr Y, as prescribed by his General Practitioner. He said the matter caused him and the family distress. Mr X wants the Care Provider to provide him and the family with a financial remedy for failing to provide his father with the correct level of care.

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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
• we cannot achieve the outcome someone wants.

(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 Mr X and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Mr Y resides in the Care Provider’s Care Home. Mr Y requires medication for his health needs which staff administer regularly. In 2025, the Care Home made two different medication errors when it administered Mr Y his medication.
6. In response to Mr X’s concerns, the Care Provider carried out an investigation. It accepted staff had failed to administer Mr Y his medication on those occasions and apologised to Mr X for the distress the matter had caused. It recognised the seriousness of the issue. In addition, the Care Provider said staff immediately sought medical advice from Mr Y’s GP, completed observations of Mr Y, informed Mr Y’s family and made a safeguarding referral to the Council.
7. The Care Provider also addressed the matter with its staff. It said:
• the staff member in question in relation to the first medication error completed a reflective practice exercise to understand how the medication error had occurred and the importance of safe medication administration. The Care Provider discussed the matter with the wider team;
• the agency worker in question in relation to the second medication error had completed their induction and was assessed as being qualified for the role however, senior staff had not signed off their full competency checklist. The Care Provider said going forward, all agency workers were required to complete a comprehensive checklist and a full medication competency checklist which senior staff would need to sign off before any commencement of shifts; and
• a handover was provided to the agency worker prior to their shift which included details of how to correctly administer medication to residents. Despite safeguards in place, an error had still occurred. The agency worker no longer worked at the Care Home since the medication error had occurred.
8. We will not investigate Mr X’s complaint. This is because the Care Provider accepted fault, took appropriate action when the medication errors occurred and thoroughly addressed the matter with staff to prevent a recurrence of fault. We could not add to the Care Provider’s investigation.
9. Furthermore, the Care Provider apologised to Mr X and the family for the distress the matter caused. This was appropriate and in line with our Guidance on Remedies. We would not recommend the Care Provider to offer a financial remedy to Mr X as it would not be appropriate and proportionate. Therefore, we cannot achieve the outcome Mr X wants.

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Final decision

10. We will not investigate Mr X’s complaint because we would not be able to add to the Care Provider’s investigation and we would not be able to achieve the outcome Mr X wants.

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Investigator's decision on behalf of the Ombudsman