Summary: We will not investigate this complaint about an incident in a care home, which Mrs X believes caused her mother’s death. We could not add anything meaningful to the investigation that has already been carried out by the coroner, and we cannot achieve the outcome Mrs X seeks. We have no power to investigate the coroner’s actions as the coroner was not carrying out a function of the local authority.

The complaint

1. Mrs X complained about an incident in her mother’s care home, which she believed caused her mother’s (Ms Y’s) death. Ms Y suffered a broken sternum, subsequent lung collapse and pneumonia.
2. Mrs X said the family experienced significant distress, and said the Care Provider did not properly investigate the matter.
3. A coroner held an inquest. The coroner decided Ms Y died from natural causes, rather than because of any action of the Care Provider. Mrs X disputed the coroner’s findings.
4. Mrs X wanted answers to outstanding questions and a determination of who was responsible for her mother’s death. She wanted the responsible staff members to be dismissed.

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The Ombudsman’s role and powers

5. 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:

• we could not add to any previous investigation by the organisation, or
• further investigation would not lead to a different outcome, or
• we cannot achieve the outcome someone wants, or
• there is no worthwhile outcome achievable by our investigation.

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

6. We cannot investigate complaints about actions which are not the administrative function of a council. (Local Government Act 1974, section 26(1) as amended).

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How I considered this complaint

7. I considered information provided by the complainant.
8. I considered the Ombudsman’s Assessment Code.

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My assessment

9. Ms Y’s case was considered via a coroner’s inquest. This concluded she died from natural causes, contributed to by a fractured sternum. It found insufficient evidence to conclude Ms Y had fallen and could not determine the origin of the fracture.
10. Mrs X disputes the outcome of the coroner’s inquest. However, we could not add anything meaningful to the investigations that have already taken place, nor could we come to a different conclusion. We could not provide more answers or decide the Care Provider caused Ms Y’s death.
11. Our Guidance on Remedies explains we also have no power to ask organisations to discipline or dismiss staff members. We could not achieve the outcomes Mrs X seeks from complaining.
12. We have no power to investigate the coroner’s decision-making or overturn their findings. When undertaking tasks as part of the coroner’s statutory functions relating to coronial investigations, coroner’s officers are exercising the coroner’s functions, not those of the council. We cannot therefore consider complaints about those actions.
13. It is not a good use of public resources to investigate complaints about complaint procedures, if we are unable to deal with the substantive issue.

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Final decision

14. We will not investigate Mrs X’s complaint because we could not achieve a different or more meaningful outcome, and we cannot investigate the coroner’s actions.

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Investigator's decision on behalf of the Ombudsman