Summary: We will not investigate this complaint about poor quality of care in a care home before Mrs Y’s death. The Council has carried out a Serious Incident Practice Review and it will share its report with Mrs X when it is completed. It is unlikely our involvement would add to the Council’s investigation or lead to a different outcome at this time.

The complaint

1. Mrs X complained about poor care her mother, Mrs Y, received in a care home. She said:
• Mrs Y was not provided sufficient food and fluid for a three-month period, leading to her death.
• The Council could not access the records it needed from the care home. The care home changed its explanation of the reasons for Mrs Y’s hospital admission and important records were missing. This casted doubt on events.
• The family have been traumatised.

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The Ombudsman’s role and powers

2. The Ombudsman investigates 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 may decide not to continue with 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))

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How I considered this complaint

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

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My assessment

5. Mrs X says Mrs Y lost six kilograms in weight in a three-month period at the care home. Mrs Y was admitted to hospital and Mrs X says a doctor expressed concern about her emaciated state. Mrs Y tested positive for Covid-19 three days after being admitted to hospital and passed away. Covid-19 was stated as the cause of death on her death certificate.
6. The Council apologised to the family. It has carried out a Serious Incident Practice Review and put together a plan of action it expects the care provider to take, as it found improvements were necessary. It intends to meet with the care provider to complete this. However, there has been unavoidable delay. The Council will complete its report as soon as this is resolved, and it will share the report with Mrs X.
7. Investigation by the Ombudsman will not uncover further information about what happened. It is also unlikely it would lead to a different outcome, because the Council has taken steps to ensure learning takes place. When Mrs X complained to us, the outcome she sought was procedural review to protect other families from experiencing the same issues. The Council’s Serious Incident Practice Review should achieve this. However, should there be significant further delay in the report being shared with Mrs X, it is open to her to bring her complaint back to the Ombudsman.

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Final decision

8. We will not investigate Mrs X’s complaint because it is unlikely our involvement would add to the Council's investigation or lead to a different outcome at this time.

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Investigator's decision on behalf of the Ombudsman