Summary: We will not investigate Miss X’s complaint about her brother, Mr Y’s, care and treatment by Gloucestershire County Council, Gloucestershire Health and Care NHS Foundation Trust and Minchinhampton Surgery. A significant amount of time has passed since some of the events complained about occurred which impacts on our ability to consider them now. We are unlikely to find fault on some points. Finally, further investigation by the Ombudsmen is unlikely to achieve the changes to Mr Y’s care that Miss X is hoping for.

The complaint

1. Miss X complains on behalf of her brother, Mr Y, about the care provided by Stroud Court care home (the Care Home) on behalf of Gloucestershire County Council (the Council). Miss X also complains about her brother’s health care by Gloucestershire Health and Care NHS Foundation Trust (the Trust) and Minchinhampton Surgery (the Surgery).
2. Miss X complains about decisions surrounding her brother’s medication, diet and general care. Miss X would like a range of holistic measures to be implemented to support her brother, rather than psychiatric medication. Miss X feels she has not been adequately involved in these decisions, where she advocates on her brother’s behalf.
3. As a result, Miss X says her brother’s health has been negatively impacted. She has been caused a great deal of inconvenience and stress.
4. Miss X would like Mr Y’s care to be improved and for his food intolerances to be recognised. Ideally, Miss X would like the Surgery and the Care Home to allow Mr Y to take herbal supplements instead of psychiatric medication. Miss X would like their voices heard.

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The Ombudsmen’s role and powers

5. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, and Health Service Commissioners Act 1993, section 18ZA).
6. We will not generally investigate a complaint unless the matter has been bought to the relevant organisation’s attention and that organisation has had a reasonable opportunity to investigate and reply to the complaint. (Local Government Act 1974 section 26950, as amended and Health Service Commissioners Act 1993, section 9(5)). As such, this is not ready for us.
7. 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; or
• further 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

8. I have spoken with Miss X and considered the information she provided. I shared my draft decision with Miss X and carefully considered the comments I received.

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What I found

What happened

9. Mr Y is autistic and nonverbal. In April 2019, Mr Y moved from his previous care home to Stroud Court (the Care Home).
10. The Council funds Mr Y’s care. Since April 2023, the Trust’s Community Learning Disability Team has provided support for Mr Y’s health care, including psychiatric medication management. The Surgery is also involved with Mr Y’s medication and diet.
11. In December 2021, the Surgery prescribed Mr Y Olanzapine, an antipsychotic medication, to help reduce his anxiety. Mr Y continued to take Olanzapine until October 2023.
12. In 2021, Mr Y had an NHS blood test for coeliac disease. The result was negative. The test was repeated again in 2023 and was also negative. In June 2023, Miss X arranged a private blood test for Mr Y, which showed gluten and dairy intolerance.
13. In August 2024, Mr Y was prescribed Diazepam for four weeks to help reduce his anxiety. In late 2024, Mr Y was prescribed Aripiprazole for his anxiety.
14. Miss X has ongoing concerns about Mr Y’s medication, diet and care. Despite raising several complaints, this matter remains unresolved.

Analysis

Pre-2024 complaints

15. Some of Miss X’s complaints relate to events happening between 2019 and 2021. While Mr Y did not have the mental capacity at the time to raise concerns himself, Miss X was aware of some of the matters complained about during that period.
16. When a lengthy period has passed, it can directly affect any attempts to gather information at a much later stage. For example, people’s memories and recollections fade and it can be much harder to obtain accurate accounts of an incident which occurred years before. This could impact on the Ombudsmen’s ability to consider this complaint fairly and robustly now.
17. As such, we will not consider complaints about specific incidents which occurred prior to 2024.

Mr Y’s diet

18. Miss X complains that the GP and the Care Home are not properly managing Mr Y’s diet. This includes failure to recognise his gluten intolerance and poor management of his blood sugars.
19. Miss X is unhappy that the Surgery will not accept the private blood test results as evidence of Mr Y’s gluten intolerance and therefore his diet has not been modified. Miss X says the NHS test is inappropriate as it only tests for allergies, not intolerance.
20. The Surgery explained to Miss X that Mr Y had two negative NHS blood tests and the private test would not be accepted by the NHS as evidence of a gluten intolerance. The Surgery also discussed Mr Y with an NHS gastroenterologist with an interest in coeliac disease. No further investigations were required.
21. Our role is not to ask whether an organisation could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how it made its decisions. If we find there was no fault in how it did so, we cannot ask whether it should have made a particular decision or say it should have reached a different outcome.
22. As a result of Miss X’s concerns, Mr Y the Trust conducted two blood tests and a gastroenterologist has considered him. Following this, the Surgery decided that Mr Y did not require a gluten free diet. The private blood test is not accepted by the NHS and therefore the decision was made based on the accepted evidence. We are unlikely to find fault in how the decision was made. Even if we did find fault, we could not influence whether Mr Y has a gluten free diet.
23. Miss X also complains about the way Mr Y’s diet is managed to reduce the risk of developing Type 2 diabetes. In 2021, a blood test showed Mr Y was borderline diabetic. Following this, his diet was modified and his blood sugars returned to the normal range. Mr Y’s blood sugars are also monitored yearly as part of his annual health review. We are unlikely to find fault with the way this has been managed.
24. Recently, Mr Y’s blood sugars have increased again. Miss X is unhappy that the Care Home has not made dietary adjustments to address this. This is a new matter which has not yet had a formal complaint response. As such, this is not ready for us. Miss X intends to submit formal complaints on these matters.
25. Miss X complains that Mr Y has not been allowed food supplements or herbal preparations. Historically Mr Y was taking some food supplements however this was discontinued in 2023 due to concerns over elevated vitamin D levels. We are unlikely to find fault with this decision.
26. I acknowledge Miss X’s strength of feeling on these points and that she would like to see changes to Mr Y’s diet. This is not something an investigation could achieve. We cannot decide what level of care is appropriate and adequate for any individual. This is a matter of professional judgement and a decision that the relevant responsible organisation has to make.

Medication

27. Miss X is unhappy that Mr Y has been prescribed medication for his anxiety and is concerned about side effects.
28. Mr Y has not taken Olanzapine for over eighteen months. He was weaned off it slowly, which it intended to reduce withdrawal issues. While Miss X says Mr Y is still experiencing side effects, we are unlikely to be able to say that any symptoms he is experiencing now are as a direct result of a medication he took so long ago.
29. In August 2024, Mr Y was prescribed Diazepam for four weeks. Mr Y has recently been prescribed Aripiprazole for his anxiety.
30. I acknowledge Miss X’s strength of feeling around Mr Y’s medication. However, as explained above, an investigation is unlikely to resolve this issue. We cannot direct that Mr Y should not be prescribed a certain medication. Nor can we recommend that the Care Home should give him herbal supplements as an alternative.

Consultation with Miss X

31. Miss X says she is not being properly involved in decisions about her brother’s care and their voices are not being heard. Miss X says she knows her brother best and can offer insight into his needs that no one else can.
32. As result of Miss X’s concerns, there have been several changes to Mr Y’s care. This includes historic diet changes due to his blood sugar levels, discontinuing Olanzapine, a period of food supplements and dietary intolerance investigation.
33. Multiple best interests meetings have taken place about Mr Y’s care, which have included Miss X. In December 2021, there was one occasion when she was unable to attend an urgent psychiatric review which was arranged at short notice. However, Miss X’ concerns about psychiatric medication were presented on her behalf and considered at the meeting.
34. From what I have seen, it seems the Care Home, the Surgery and the Trust have considered Miss X’s concerns and this has led to some direct changes in Mr Y’s care. There are also times where professionals have not made the changes sought by Miss X, as it was not deemed necessary or appropriate. Making decisions in a person’s best interests is a finely balanced process involving weighing up all the relevant information. This includes Miss X’s personal knowledge of her brother and specialist knowledge from professionals. Not agreeing with Miss X does not necessarily mean her views are not being heard. We are unlikely to find fault on this point.

Person centred care

35. Miss X says the Care Home does not do enough to explore other ways to calm Mr Y, instead of medication. Miss X gave examples of things Mr Y enjoys including a foot spa, music and aromatherapy.
36. The Care Home are providing Mr Y access to a foot spa each week and has confirmed that he has had aromatherapy sessions since 2023. I acknowledge these are not provided with the frequency or way Miss X wishes, however we would be unlikely to find fault on this point.
37. In October 2024, the Care Quality Commission (the CQC) responded to Miss X’s concerns. Following its enquiries, the CQC was assured Mr Y’s needs were being met.

Refused visit

38. Miss X complains about an incident in October 2024 where she visited the Care Home as she was concerned about Mr Y. Miss X says she was made to wait outside until later and then Mr Y wasn’t asked properly whether he wanted to see her. Miss X says a manager was rude and unprofessional to her. I acknowledge this was frustrating to Miss X. However, Miss X did get to visit Mr Y. There is insufficient injustice on this point to warrant an investigation. Further, given that much of this was a verbal exchange, this is unlikely any investigation by us could resolve this matter.

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Decision

39. There is no basis for the Ombudsmen to investigate the complaint. Some parts of the complaint occurred a long time ago and it would be difficult to carry out a fair and robust investigation now. There is insufficient evidence of fault in relation other parts of the complaint. Further investigation by the Ombudsmen is unlikely to achieve the changes to Mr Y’s care that Miss X is ultimately seeking.

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Investigator's decision on behalf of the Ombudsman