Summary: Mrs X complained West Sussex County Council failed to provide her late husband, Mr X, with alternative domiciliary care after a care agency ended its contract. She said this meant he had to go into residential care in one of Saffronland Homes’ nursing homes. Mrs X says he received poor care there from both the nursing home and Maywood Health Centre. Mrs X says Mr X was unhappy in the care home and considers he would still be alive, had he received better care. We will not investigate this complaint. Parts of the complaint are late. For other parts, it would have been reasonable for Mrs X to seek a legal remedy in the courts. We are unlikely to achieve the outcome Mrs X seeks by investigating the rest of her complaint.

The complaint

1. Mrs X complained about West Sussex County Council (the Council), Saffronland Homes and Maywood Healthcare Centre (the GP Practice). She complained that:
1. the Council failed to arrange alternative domiciliary care for her late husband, Mr X, after his previous care agency ended its contract in May 2022. Mrs X says this forced Mr X into residential care;
2. one of Saffronland Homes’ nursing homes (the Home) provided Mr X with poor care. This included poor social and nursing care; and
3. the GP Practice failed to ensure a GP examined Mr X when he was unwell, and sent a paramedic or nurse to see him instead.
2. Mrs X said the Council’s failure to provide domiciliary care meant Mr X had to go into the Home, which neither she nor Mr X wanted for him. She said Mr X was unhappy in the Home and the poor care he received there from the Home and the GP Practice led to his avoidable death. She said this caused her significant distress.
3. Mrs X seeks:
• compensation for the distress she suffered as a result of witnessing the poor care and what she considers the premature loss of her husband;
• an investigation which results in action against the three organisations; and
• for the organisations to improve their practice to avoid similar problems happening to others.

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The Ombudsmen’s role and powers

4. The Local Government and Social Care Ombudsman (LGSCO) and Parliamentary and Health Service Ombudsman (PHSO) have the power to jointly consider complaints about health and social care. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA).
5. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
6. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended and Health Service Commissioners Act 1993, section 4(1b))
7. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe we cannot achieve the outcome someone wants. (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

8. I considered evidence provided by Mrs X, the Council, the GP Practice and Saffronland Homes.
9. Mrs X had an opportunity to comment a draft version of this decision. I considered any comments before making a final decision.

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What I found

10. The complaint about Saffronland Homes includes elements of social care the Council was responsible for as commissioner. It also includes elements of NHS Funded Nursing Care, which fall under PHSO’s remit. Following PHSO’s approach, we consider Saffronland Homes to be the responsible organisation for the nursing elements of Mr X’s care.
11. We have therefore considered this complaint as against the Council as commissioner of Mr X’s care by Saffronland Homes, Saffronland Homes as the provider of Mr X’s NHS-funded nursing care and the GP Practice as the provider of Mr X’s GP care.

A – Failure to arrange replacement domiciliary care

12. Mrs X was aware of this since June 2022, when Mr X went into residential care because no domiciliary care was available to him. This is more than 12 months before Mrs X first complained to us in February 2024. This part of the complaint is therefore late. There are no good reasons for us to investigate it now. In reaching this view, I have taken the following into account.
• Mrs X told us she spent a long time chasing the organisations for responses to her complaints and for relevant information. However, there is a significant gap between June 2022, when Mrs X first became aware of the lack of domiciliary care, and her first complaint to the Council in October 2023. Mrs X has not provided a good reason why she could not have started the Council’s local complaints process sooner.
• More than three years have now passed since the matter started. While documentary records should be available, people’s recollections of what happened will be less reliable because of the passage of time. The availability and nature of domiciliary care in the area is also likely to have changed over the past three years. As Mr X has died, we cannot seek his views on what happened. This means it is less likely an investigation could reach a fair and meaningful decision.

B – Social care by the Home, commissioned by the Council

13. Mrs X complains of lack of support with eating, not providing an appropriate diet, incorrect positioning, and lack of social stimulation. She says these made Mr X unhappy and contributed to his worsening health.
14. Mrs X’s complaint about poor social care that happened before February 2023 is late, because she was aware of the problems at the time and more than 12 months before complaining to us. For the reasons in paragraph 12, there are no good reasons to investigate them now.
15. Mrs X only became aware of other instances of what she considers poor social care as they happened from February 2023 onwards, less than 12 months before complaining to us. This means there is no time bar to us investigating those later issues. However, my view is that the Ombudsmen should not investigate this part of the complaint, for the following reasons:
• the Care Quality Commission (CQC), the social care regulator, has inspected the Home relatively recently. This means that CQC has much more recent information about any problems that could affect current residents. An investigation by us into what happened in early 2023 is unlikely to recommend any service improvements that are relevant to current residents of the Home; and
• this is a small part of the whole complaint. Even if we investigated and upheld it, we would be unlikely to recommend the financial remedy Mrs X seeks.

C – Nursing care provided by Saffronland Homes and medical care by the GP Practice

16. Mrs X complains about the Home’s nursing staff administering unnecessary constipation treatment and failing to refer Mr X to the ambulance service or a hospital when his health worsened significantly. She complains the GP Practice sent nurses and a paramedic to see Mr X when he should have been seen by a doctor.
17. Mrs X’s complaint about flawed medical care that happened before February 2023 is late, because she was aware of the events as they happened and more than 12 months before complaining to the Ombudsmen. For the reasons in paragraph 12, there are no good reasons to investigate them now. Mrs X only became aware of other instances of what she considers poor medical care as they happened from February 2023, less than 12 months before complaining to us. This means there is no time bar to us investigating the GP Practice’s and Saffronland Homes’ actions in relation to Mr X’s medical care from February 2023.
18. However, Mrs X considers Mr X’s medical care by the GP Practice and Saffronland Homes was so poor that it amounted to negligence, harmed him and contributed to his death. She is seeking financial compensation for the impact on her of Mr X’s death. The Ombudsmen cannot decide whether an organisation has been negligent; this is a matter for the courts. Our investigations also do not award compensation in the same way as the courts. It would have been reasonable for Mrs X to pursue this part of her complaint in court if she wanted a finding of negligence and an award of compensation. This means we cannot investigate complaint C.

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Decision

19. We cannot investigate significant parts of Mrs X’s complaint because they are late, or because it would have been reasonable for her to seek a legal remedy in the courts. We will not investigate the rest of her complaint because we are unlikely to achieve the remedy Mrs X seeks.

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Investigator's decision on behalf of the Ombudsman