Summary: The Ombudsman will not investigate this complaint about care provided to a woman by a care home, or the safeguarding investigation undertaken by a local authority. This is because it is unlikely an investigation by the Ombudsman would add anything to the investigations that have already been carried out by the organisations involved and other relevant agencies.

The complaint

1. The complainant, who I will call Ms G, is complaining about the care and treatment provided to her mother, Mrs H, in 2017 when she was resident in a care home placement funded by Bournemouth, Christchurch and Poole Council (BCPC). She is also complaining about the handling of a subsequent safeguarding investigation by North Yorkshire County Council (NYCC).

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word ‘fault’ to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’.
3. 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 if it is unlikely we could add to any investigations that have already been undertaken. (Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

4. In reaching this final decision, I considered information provided by Ms G. This included complaints correspondence and extracts from the care records. I also discussed the complaint with Ms G. I also considered Ms G’s comments on my draft decision statement.

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What I found

Key facts

5. Mrs H was resident in a care home in 2017. This placement was funded by BCPC.
6. On 11 September 2017, Mrs H was admitted to hospital with a suspected chest infection. While awaiting treatment, Mrs H fell from her bed. A doctor examined her and found no significant injuries.
7. Mrs H was discharged back to the care home the following day, where she rolled from her bed. Ms G, who was visiting Mrs H, helped her up.
8. Mrs H was complaining of pain and was seen by a GP on 15 September 2017.The GP prescribed pain relief medication and recommended care home staff continue to monitor Mrs H.
9. On 16 September 2017, Mrs H suffered another fall and sustained bruising to her head. She also seemed to be experiencing pain in her chest.
10. Mrs H was admitted to hospital and further examination revealed she had broken her hip. She underwent surgery to repair the hip on 18 September 2017.
11. Mrs H’s condition deteriorated following the surgery and she died in hospital on 20 September 2017.

Analysis

Care Home (BCPC)

12. Ms G complained about many aspects of the care provided to Mrs H during her time as a resident in the care home in late 2017. Ms G said the care home failed to safeguard Mrs H from another resident with behavioural problems. She said the care home took no action to manage Mrs H’s risk of falls. Furthermore, Ms G said the care home allowed Mrs H to become dehydrated and failed to administer her medication as prescribed.
13. The circumstances leading to Mrs H’s death were the subject of a Coroner’s Inquest. The Coroner concluded that Mrs H had experienced a number of preventable falls.
14. The Coroner passed his concerns about the standard of care provided by the care home to the Care Quality Commission (CQC). The CQC is the regulator for health and social care services in England. It is responsible for inspecting and monitoring care providers and services.
15. The CQC carried out an unannounced inspection of the care home in October 2017. The inspection found the care home did not have robust risk assessment and management procedures in place. The inspection also found the care home did not manage medicines safely and that staff knowledge of risk management around nutrition and hydration was poor. The CQC gave the care home a ‘requires improvement’ rating.
16. The CQC carried out a further inspection in April 2018. This found the care home had made some improvements to its staffing levels and to its processes for monitoring and managing risk to residents. However, the CQC concluded these improvements were newly established and would require further time to embed into practice.
17. In the meantime, NYCC also carried out a safeguarding investigation to determine whether Mrs H’s falls had been a result of neglect by the hospital and care home. The conclusion of the investigation was delayed until November 2018 as the matter was still under consideration by the Coroner. The outcome of the safeguarding investigation was inconclusive. This was because the investigation could not determine conclusively where or when Mrs H had sustained her injuries.
18. Nevertheless, NYCC made several recommendations to both the hospital and care home to improve their services. NYCC recommended the care home review its falls policy and procedure, properly maintain equipment all equipment and ensure staff accurately record falls of injuries in the records.
19. The CQC carried out an additional inspection in February 2019 to monitor the care home’s progress. The CQC found the care home had made significant improvements to its services. These included improvements to safeguarding, falls risk management, medicines management and record keeping. The CQC allocated a ‘good’ rating in all areas of care.
20. It is clear from the investigations undertaken by NYCC and the Coroner that there were significant failings in the care provided to Mrs H by the care home. This was acknowledged by the care home and addressed in the recommendations arising from the safeguarding investigation. Furthermore, the CQC monitored the care home to ensure it had made the necessary improvements.
21. I am satisfied, therefore, that suitable action has been taken to improve the services provided by the care home.
22. I appreciate Ms G feels she has not received a full explanation for the failings in Mrs H’s care. I also understand she is strongly of the view that the records and complaint responses do not accurately reflect what took place and contain discrepancies and inconsistencies.
23. However, Mrs H’s care has already been subject to considerable independent scrutiny by the Coroner, CQC and NYCC. These investigations found that, while there had been clear failings in Mrs H’s care, it was not possible to provide conclusive answers around exactly how and when she had sustained her injuries.
24. In the absence of any additional independent evidence to assist us, we would be similarly unable to reach a robust view on what took place. On this basis, an investigation by the Ombudsman would be unlikely to add anything further to the investigations that have already been undertaken in this case.

Safeguarding (NYCC)

25. Ms G said she offered numerous amendments to the draft minutes of NYCC’s safeguarding meeting of November 2018. However, Ms G complained that NYCC made only minor amendments and did not incorporate her other proposed amendments.
26. I appreciate Ms G found this frustrating. However, I do consider this to be a sufficiently significant issue to warrant investigation by the Ombudsman. Although NYCC did not make all of the amendments suggested by Ms G, it agreed to keep a copy of her proposed amendments appended to the safeguarding documentation. In my view, this was a reasonable and sensible approach.
27. The documentation I have seen suggests the safeguarding investigation was robust and made appropriate recommendations to address the failings it identified.
28. Taking everything into account, I do not consider an investigation by the Ombudsman would be likely to identify significant fault by NYCC.

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Final decision

29. The Ombudsman will not investigate Ms G’s complaint about the care provided by the care home on behalf of BCPC and the handling of the subsequent safeguarding investigation by NYCC. This is because it is unlikely an investigation by the Ombudsman could add anything further to the investigations that have already been undertaken by NYCC, the CQC and the Coroner.
30. I have now closed the case on that basis.

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Investigator's decision on behalf of the Ombudsman