Summary: We will not investigate Ms B’s complaint about the Council’s safeguarding investigation into the care her late father, Mr C received. This is because any further investigation by the Ombudsman is unlikely to make a different finding to that already uncovered by the investigation or provide Ms B with the outcome she wants. Sadly, Mr C is now deceased so any injustice caused to him by his care provider cannot be remedied.

The complaint

1. Ms B complained to the Council about its safeguarding investigation into concerns she raised about her late father, Mr C. Ms B says Mr C was not properly cared for, some of his clothes were missing, he was not dressed and his nails were dirty. Ms B was concerned about bruising she saw on Mr C’s face in August 2019 and very concerned following a safeguarding investigation to find there had been another safeguarding alert raised in July 2019 when a carer discovered a rat jumping off his bed and found Mr C with blood coming from his ear. Ms B says the care provider sent Mr C to hospital in a tee shirt and pad, was told to clear his room, was not offered condolences and no-one from the home attended his funeral following his death.

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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’. 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 could add to any previous investigation by the Council, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, section 24A(6), as amended)

3. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)

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How I considered this complaint

4. I considered the information and documentation Ms B and the Council provided. I sent Ms B a copy of my draft decision and considered her comments on it.

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What I found

5. Mr C lived in the care home between November 2017 and September 2019. Sadly Mr C died on 3 October 2019.
6. Ms C raised concerns with Mr C’s care provider in August 2019 when she found Mr C with bruising to his face. The care provider could not say how this had occurred and reported it to the Council as lead authority for safeguarding vulnerable adults. The Council says it investigated but could not determine how the bruising had occurred.
7. Ms B contacted the Council in January 2020 as she felt the explanation given was not adequate. Ms B provided additional photographs of the bruising to Mr C’s face and was concerned about missing clothing and poor hygiene/care he received. The Council investigated Ms B’s concerns. It responded in September 2020 and apologised for the delay.
8. The Council said there had been two safeguarding alerts raised regarding Mr C. in July 2019 a carer found a rat jumping off Mr C’s bed and noticed a little blood on his right ear lobe. A GP was called who examined Mr C and advised the blood was because of Mr C scratching his ear, but as a precaution he was given a tetanus injection. The care provider called in a pest control inspector who found no evidence of rats on his visit. The pest control inspector said the rat may have got in through an open patio door as it was a hot day. The Council said it attempted to speak to the person managing the premises at the time but was unable to do this as they had left. It spoke to the current Manager who was concerned Ms B had not been informed of this incident at the time and apologised this was the case. The Manager also apologised that no one had attended Mr C’s funeral and for failing to contact Ms B afterwards to explain this oversight.
9. The second safeguarding alert raised on 16 August was regarding a visit Ms B made on 2 August and found bruising to Mr C’s face which had occurred sometime between 31 July when she had last visited him. The Council says it contacted the home who interviewed staff on duty over the period. It completed an enquiry report but could not determine how the bruising had occurred but thought it might be because Mr C had rested his hand heavily on his glasses.
10. Ms C was unhappy with this explanation and showed the Council additional photographs of the bruising which were more substantial than those produced by the care provider. The Council says it shared the photographs with the police who decided there was not enough evidence to take the matter further. Ms B thought the hoist may have accidentally hit Mr C in the face, but the Council and police said if this was the case, the bruising would have been more pronounced.
11. The Council discussed Ms B’s complaint about missing clothing and poor hygiene with the care provider. It apologised Mr B did not receive a good standard of care and advised it is reviewing processes regarding the labelling of clothing.
12. Ms B says the care provider should reimburse her for losing the new clothing she had purchased for Mr C. We could not make a finding on what happened to Mr C’s missing clothing or says the care provider is liable. Only a court can make a finding of liability and it would be reasonable for Ms B to ask the small claims court to consider whether Mr C’s care provider is liable for the missing clothing and reimburse her the costs. Information about the small claims court can be found on the website below.

Make a court claim for money - GOV.UK (www.gov.uk)

13. While Ms B has not had answers to all her questions about what happened to Mr C we would not be able to make any different finding or provide a different outcome to that already given to Ms B even if we investigated. We recognise the concerns Ms B raised as safeguarding matters may have caused Mr C some injustice at the time but sadly as he is now deceased we cannot provide him with a remedy. The care provider and Council has apologised to Ms B and advised of new procedures in place in the home to ensure residents receive good care and clothes are clearly labelled. We could achieve no more than this.

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Final decision

14. We will not investigate this complaint. This is because any further investigation by the Ombudsman is unlikely to make a different finding to that already uncovered by the investigation or provide Ms B with the outcome she wants. Sadly Mr C is now deceased so any injustice caused to him by his care provider cannot be remedied.

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Investigator's decision on behalf of the Ombudsman