Summary: We will not investigate Ms X’s complaint about Hartcliffe Nursing Home’s actions before and after Mr Y’s admission to hospital. We are unlikely to achieve a different outcome for her.

The complaint

1. Ms X complains that Hartcliffe Nursing Home (the Home) did not close another resident’s door when her relative, Mr Y, significantly deteriorated one evening. The other resident was able to watch events unfold. Ms X also says the Home did not secure his room after he moved to hospital. That same resident entered Mr Y’s room and took his personal belongings, including his phone. That resident then called Mr Y’s family while the hospital was providing end of life care to him. Ms X says the events caused significant distress to the family, and they are not able to grieve Mr Y’s death. Ms X would like the Nursing Home to put service improvements into place.

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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 an investigation if we decide:
• we could not add to any previous investigation by the organisation, or
• investigation would not lead to a different outcome.

(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 the complainant and the Nursing Home.
4. I considered the Ombudsman’s Assessment Code.
5. Ms X had an opportunity to comment on my draft decision. I have considered her comments before making a final decision.

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My assessment

6. The Home confirmed Bristol City Council partly funded Mr Y’s residential care. Therefore, as commissioner of Mr Y’s social care, it is ultimately responsible for the actions of the Home.
7. In February 2023, Mr Y’s physical health worsened at the Home. A nurse called for an ambulance and paramedics decided to admit him to hospital. Following end of life care at hospital, Mr Y died a few days later.
8. The same month, Ms X complained to the Home. She said before Mr Y moved to hospital; it allowed another resident to watch Mr Y deteriorate by not closing his door. Also, during Mr Y’s stay in hospital the same resident entered Mr Y’s room and took his belongings, including his phone. That resident then called Mr Y’s daughter (not Ms X) while she was in hospital with him.
9. In response to Ms X’s complaint, the Home said it was sorry the distress caused to Ms X. Staff should have closed the other resident’s door during Mr Y’s emergency, to preserve his dignity. It agreed to remind relevant staff of this in team meetings. Also, when rooms are temporarily empty, it will place a sensor mat down so staff would know if another resident enters the empty room. It said those improvements should avoid similar fault happening again.
10. The Home has provided evidence to me it has carried out those improvements above. But instead of using a sensor mat, it agreed to install “hook and eye” locks on doors when rooms are vacant.
11. I am not persuaded an investigation by the Ombudsman could anything more for Ms X. I agree the Home acted with fault by not preserving Mr Y’s dignity, and not securing his room. That would have caused Ms X distress. The Home has apologised, learned from its fault and put important service improvements in place. I consider the Home’s actions appropriately remedy the distress she and the family suffered.

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Final decision

12. We will not investigate Ms X’s complaint about the Nursing Home. An investigation would not lead to any different findings our outcomes.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman