Summary: The Ombudsmen will not investigate a complaint about the care and treatment the complainants’ son received in supported living, and the way a Trust handled an internal investigation. The complaints are late and there are insufficient grounds to accept them now

The complaint

1. Mr and Mrs X complain about the care and treatment their late son, Mr Y, received during a supported living placement at Barrantynes Supported Living Home (Barrantynes) between November 2010 and August 2012. Mr Y’s placement was funded by Oxfordshire County Council (the Council) and care was delivered by staff from the Ridgeway Partnership, which has since merged with Southern Health Foundation Trust (the Trust).
2. Mr Y passed away in August 2012 and Mr and Mrs X believe this could have been avoided had he received the correct care.
3. Mr and Mrs X say that the lack of compassion, candour or transparency from Southern Health NHS Foundation Trust following Mr Y’s death added to their great distress. They are unhappy that the Trust failed to involve them in an internal investigation.

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The Ombudsmens role and powers

4. 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,as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. The Ombudsmen cannot investigate late complaints unless they decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to the Ombudsmen 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).)

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How I considered this complaint

6. I considered the information Mr and Mrs X provided in support of their complaint and discussed the complaint with their advocate. I also reviewed Oxfordshire CCG’s independent investigation report.

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What I found

7. Mr Y was resident at Barrantynes supported living between November 2010 and August 2012, with care delivered by staff from the Ridgeway Partnership. He had athetoid cerebral and complex needs requiring support for the activities of daily living.
8. Mr Y was found unresponsive at 6am 22 September 2012 and sadly passed away shortly afterwards.
9. The Ridgeway Partnership decided to investigate Mr Y’s death, but the investigation did not progress because this organisation was waiting for the coroner’s inquest. In November 2012 the Ridgeway Partnership was acquired by Southern Health NHS Foundation Trust (the Trust). The Trust took over the responsibility for the internal investigation.
10. In December 2012, Mr and Mrs X complained to the Trust about staff conduct following Mr Y’s death. They also complained that they weren’t involved in the Trust’s internal investigation. The Trust responded to the complaint in February 2013 and apologised for not involving the family in its enquiries.
11. On 11 and 12 December 2014, the Coroner held an inquest into the death of Mr Y. The Coroner recorded that the immediate medical cause of death was aspiration of gastric contents leading to cardiac arrest. They were critical of aspects of Mr Y’s care and treatment, and found that agreed twenty minute checks has not been carried out on the morning that Mr Y passed away.
12. Following the inquest Mr and Mrs X pushed for an independent investigation into the care and treatment Mr Y received. In October 2015, Oxfordshire CCG commissioned an independent investigation to be carried out by the Health and Social Care Advisory Service (HASCAS). HASCAS published its report in May 2018, it stated that Mr Y’s conditions could have been managed better but did not conclude that this would have prevented his death. Mr and Mrs X’s advocate (the advocate) then complained to the Ombudsmen in September 2018.

My analysis

13. Mr and Mrs X complain about care and treatment Mr Y received between 2010 and 2012. The Trust acknowledged it had not involved them in its internal investigation in February 2013. These complaints are late and there are insufficient grounds for the Ombudsmen to accept them now. In making this decision I have considered:
• Mr and Mrs X say they were not able to raise a complaint earlier as they were waiting for the outcome of the inquest and the outcome of the independent investigation.
• That the family say the loss of their son, and the distress caused by the subsequent events prevented them from approaching us sooner.
• The advocate’s belief that had the family approached us at an earlier stage they would have been advised to wait until the other processes had ended as the Ombudsman is the final stage of the complaints process.
• The advocate’s comments about the seriousness of the complaint.
14. However:
• The family became unhappy with the care Mr Y received very shortly after he moved to Barrantynes in 2010, and these concerns persisted throughout his placement. Given these apparent serious and ongoing concerns, it is reasonable to expect the family to have pursued the NHS or Council complaints processes at the time. Had they done so and remained unhappy they could have complained to an Ombudsman at an earlier point.
• While it was reasonable for the family to wait until the inquest had concluded to raise a complaint, when the Coroner issued their verdict this provided another opportunity to approach an Ombudsman which they did not take.
• Mr and Mrs X complained to the Trust, and pursued an independent investigation following the inquest. As they were able to pursue these processes, my view is that there was not a significant barrier to them approaching an Ombudsman at an earlier point.
• It’s possible that if they approached us at an earlier point, we may have advised Mr and Mrs X to wait until the other processes had finished. We could then have taken this into account when deciding whether to investigate. However, because Mr and Mrs X first complained in 2018, this is not something I will consider now.
• While I recognise the seriousness of the issues complained about and their importance to the family, this is not in itself a reason to investigate this late complaint.
• In its report, the CCG was critical of the way the Trust dealt with the internal investigation and made recommendations for change. There is little more we could reasonably achieve by investigating this late complaint.

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Final decision

15. The Ombudsmen will not investigate the complaints about Mr Y’s care and treatment, and about the Trust’s internal investigation. These complaints are late and there are insufficient grounds to accept them now.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman