Summary: We will not investigate Mrs X’s complaint about the Council failing to ensure improvements were made to care services provided to her late mother, Mrs Y. This is because it is unlikely we would find fault with the Council and Mrs X’s personal injustice is not significant enough to warrant an investigation.

The complaint

1. Mrs X complained the Council failed to ensure improvements were made to care services provided to her late mother, Mrs Y, following an independent investigation. She said the matter caused her uncertainty. She wants the Council to implement the service improvements.

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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
• any injustice is not significant enough to justify our involvement.

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

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How I considered this complaint

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

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My assessment

5. Mrs Y was receiving care from various healthcare organisations including a hospital and a domiciliary care provider. Mrs Y died and following her death, Mrs X raised concerns about the care her mother had received.
6. The Council’s Safeguarding Adults Board asked an independent person to investigate Mrs X’s concerns. The Independent Person produced a report which concluded there was some fault across the whole care Mrs Y had received. They made recommendations to the Council which included:
• the Council and the Integrated Care Board (ICB) to jointly review the domiciliary Care Provider and its recruitment, training, supervision and arrangements for end-of-life care; and
• the Council to lead discussions between various healthcare organisations to identify learning from communication, discharge planning and multi-agency working issues relating to Mrs Y’s care.
7. In response:
• the Council conducted reviews of the Care Provider. This resulted in a quality assurance report and a plan to improve its services. The Care Provider had completed the service improvements. Following this, the Council had no further concerns; and
• the ICB produced a report which concluded it had implemented all recommendations and improvements to the relevant services.
8. Mrs X does not consider the recommendations to be completed in line with the report from the Independent Person.
9. We will not investigate Mrs X’s complaint because it is unlikely we would find fault by the Council. It is not our role to determine precisely how the Council or the ICB should have implemented the recommendations. Rather, this is a matter for those organisations to determine. The evidence available shows the Council was satisfied that appropriate improvements and learning had been implemented across the relevant services following Mrs X’s concerns.
10. In any case, the personal injustice caused to Mrs X is not significant enough to warrant an investigation.

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Final decision

11. We will not investigate Mrs X’s complaint because it is unlikely we would find fault with the Council and Mrs X’s personal injustice is not significant enough to warrant an investigation.

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Investigator's decision on behalf of the Ombudsman