Summary: We will not investigate Mr B’s complaint about the Council’s safeguarding investigations into his late mother’s, Mrs C’s care. This is because further investigation by us could not make a different finding or provide Mr B with the answers he wants.

The complaint

1. Mr B complained about the Council’s initial safeguarding investigation and review into care his late mother, Mrs C, received from her domiciliary care provider in 2019. Mr B says care staff missed giving Mrs C three elements of her medication over a two-week period. Mr B says the care provider was deemed inadequate by the Care Quality Commission (CQC) and should not have been commissioned to deliver care to Mrs C. Mr B says the Council has undertaken three separate safeguarding investigations into what happened but none of them have answered the questions he has. Mr B wants the Council to conduct an internal investigation what happened to Mrs C to ensure it does not happen to other people.

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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 effect on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start an investigation if the tests set out in our Assessment Code are not met. (Local Government Act 1974, section 24A(6), as amended)

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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. The Council recently reviewed and acknowledged errors in previous safeguarding investigations into what happened when Mrs C did not receive her prescribed medication. It found inaccuracies with the information contained in previous reports regarding what medication Mrs C received on specific dates, dates she did not receive three of her medicines and what was said by the GP about the impact of Mrs C not having her prescribed medication over 13 days in 2019. The original report identified the risk for prescribed medications to be ‘mis-transcribed when handwritten on a DOMMAR chart by homecare staff’. The action it took following the outcome of the first investigation was recorded as ‘at the time of the incident [the Care Provider] confirmed that they implemented a new policy which included requesting prescription slips for the GP and waiting for printed DOMMAR charts to be provided by the pharmacy before commencing care provision’. The recent review of the safeguarding investigations said although ‘there had been identified errors in the enquiry report and first review, action had been taken at the time of the incident to reduce risk and ensure [Mrs C’s] medication needs were being met effectively going forward. As part of an interim protection plan, a robust safeguarding enquiry was completed, which included consultation with health and social care colleagues’.
6. The authorising Manager concluded the review had identified actions taken at the time of the incident to protect and reduce risk of further similar incidents not only to Mrs C but to other service users. It concluded no harm occurred to Mrs C as a direct result of the medication error and appropriate action was taken by health and social care professionals involved. While Mr B has not had answers to all his questions it is not our role to provide these. The review identified grammatical and factual errors. Further investigation by us could not make a different finding to that already given to Mr B as a result of the Council undertaking a review of the original safeguarding investigations.

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Final decision

7. We will not investigate Mr B’s complaint because further investigation by us could not make a different finding or provide Mr B with the answers he wants.

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Investigator's decision on behalf of the Ombudsman