Summary: We will not investigate this complaint about the Council’s response to a coroner’s prevention of future deaths report. Although the complainant disagrees with the Council’s response, there is no fault in process. It is for the coroner to decide if any further action is necessary following the Council’s response. There is no worthwhile outcome to achieve from an Ombudsman investigation.

The complaint

1. Ms B says the Council failed to respond effectively to the coroner’s prevention of future deaths report. Ms B worries the Council has not learned lessons and worries for public safety. Ms B says the Council has given her false information. Ms B feels exhausted and her mental and physical health have been impacted.

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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:

• there is not enough evidence of fault to justify investigating, or
• we could not add to any previous investigations, or
• further investigation would not lead to a different outcome, or
• there is another body better placed to consider this complaint, or
• there is no worthwhile outcome achievable by our investigation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

3. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)

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How I considered this complaint

5. I considered information provided by the complainant.
6. I considered the Ombudsman’s Assessment Code.

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My assessment

7. Ms B’s relative, Ms C, was receiving care at home arranged by the Council. Ms C died several years ago and there has been a coroner’s inquest into her death.
8. The coroner did not find the Council’s actions caused or contributed to Ms C’s death. But had concerns about the supervision and management of care workers, the care and support plan and whether all tasks were completed, and a failure to properly manage and check performance of the care agency. The coroner issued a prevention of future deaths report and asked the Council to consider the report and respond with the actions it proposes to take and a timetable for action or explain why no action is proposed.
9. The Council responded. It did not set out any proposed actions but explained the processes already in place to manage and check performance of care agencies working on its behalf to meet adult social care needs.
10. The Ombudsman would not now look at the care the Council provided to Ms C as this is a late complaint. It has also already been considered by adult safeguarding and the coroner.

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Final decision

11. We will not investigate Ms B’s complaint because there is not enough evidence of fault in the process to respond to the coroner’s report, or a worthwhile outcome we can achieve. Although Ms B disagrees with the Council’s response to the coroner, the Council met the requirement to respond. It is for the coroner to decide whether they wish to take any further action. It is unlikely the Ombudsman would add to investigations already undertaken or reach a different outcome. The Council has processes in place and there is no worthwhile outcome to achieve from an Ombudsman investigation.

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Investigator's decision on behalf of the Ombudsman