Summary: We will not investigate this complaint about the quality of Mr Y’s care in a care home and referrals to an NHS Trust’s falls team. This is because the coroner is still looking into related issues. Ms X can complain to us after the results of the coroner’s inquest are known.

The complaint

1. Ms X complains about the standard of her father’s (Mr Y’s) care at Lakeview Health Care (the home). She says his care plan did not contain correct information about his risk of falling and the Home did not give him support he needed to transfer. Ms X also complains the Home did not make appropriate referrals to the falls team and that the falls team did not respond appropriately when it received a referral. Ms X considers the failings led to Mr Y’s death following a fall in May 2022. She says the neglect and Mr Y’s death caused the family significant distress. She wants acceptance of fault and an apology.

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The Ombudsmen’s role and powers

2. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start an investigation if they believe it would be reasonable to wait for the outcome of investigations or reviews by other organisations before considering a complaint. (Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

3. I considered information from Ms X and the organisations complained about. I have also considered the Ombudsman’s assessment code.

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My assessment

4. Mr Y lived in a care home. Salford City Council (the Council) and the NHS jointly funded the placement. Ms X says Mr Y died after a fall in May 2022. She holds the Home responsible for this. Ms X also complains that the falls team at Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation Trust (the Trust) failed to respond to referrals from the Home or Mr Y’s GP.
5. Ms X previously complained to the Ombudsmen but we did not investigate. This was because an inquest into Mr Y’s death was due to take place in September 2022. Until this finished, we could not properly consider the circumstances and make sound decisions. We could not say what injustice any fault caused, and whether investigation by the Ombudsman could achieve anything more.
6. The coroner has delayed the inquest. Ms X brought her complaint back to the Ombudsmen to consider whether, because of the delays, we could now look at her complaints. The inquest is scheduled for September 2023.
7. The same rationale applies as with the previous complaint. Additionally:
• the organisations could unnecessarily duplicate work; and
• the outcome of the coroner’s investigation may provide Ms X with the outcomes she is seeking without the need for an investigation by the Ombudsmen.
8. We therefore should not investigate this complaint until the inquest has ended. Ms X can complain to us again if she has outstanding concerns once the coroner’s investigation ends. We will then reconsider whether we can and should investigate her complaint.

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Final decision

9. We will not investigate this complaint because it is reasonable to wait for the outcomes of the coroner’s investigation. Ms X can resubmit her complaint to the Ombudsmen if she has outstanding concerns after the conclusion of the coroner’s investigation.

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Investigator's decision on behalf of the Ombudsman