Summary: Representatives for the late Mrs X complained that she did not receive the care and support she should have in a short-term residential care unit operated by Kent County Council and Kent Community Health NHS Foundation Trust. We decided not to investigate the complaint. Mrs X has died, so an investigation would not achieve a remedy for her.

The complaint

1. Mrs X’s representatives complained that she did not get the care and support she should have when living at the short-term residential care unit in the last few months of her life between 2024 and 2025. They say this meant she had an undignified last year, and particularly last week, of life. Mrs X’s representatives would like a refund of care fees to go to her estate. They would also like the Council to consider refunding some of her rental costs to the estate.

Back to top

The Ombudsmen’s role and powers

2. The Local Government and Social Care Ombudsman and Health Service Ombudsman 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).
3. 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:

• an investigation would not achieve a remedy for the person affected by the complaint, or
• 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)

Back to top

How I considered this complaint

4. Mrs X spent around nine months between 2024 and 2025 in what was meant to be a short-term residential care placement. For the first few weeks of her stay, and for the last week of her life, Mrs X was in the nursing part of the unit, which is part of the Trust. In the months between, Mrs X was in the social care part of the unit, which is the responsibility of the Council. This is why the Ombudsmen have considered this complaint jointly.
5. I considered evidence provided by Mrs X’s representatives and the Council, as well as relevant law, policy and guidance.
6. Mrs X’s representatives had an opportunity to comment on a draft version of this decision.

Back to top

What I found

Key background

7. Mrs X’s representatives said that:
• she should only have been at the unit for a few weeks, while her long-term care needs were assessed;
• the placement did not meet Mrs X’s long-term care needs, including her need to be with her husband who was in a different residential care home; and
• as a result, Mrs X did not get the care and support she should have in the last year of her life. She also missed out on an opportunity to spend the last months of her husband's life with him because they were in different care homes until he died in late 2024.
8. Mrs X’s representatives said that in the last week of her life, Mrs X experienced particularly bad care and loss of dignity for the following reasons:
• at the start of that week, Mrs X was living in the social care unit of the care home and became seriously ill;
• paramedics concluded Mrs X was in the last days of her life and provided the care home with special medication to keep her comfortable;
• the staff on the social care unit could not administer the medication and the nursing unit was unable to admit Mrs X that evening;
• nursing staff from the nursing unit agreed to come to the social care unit periodically to check on Mrs X and administer end of life medication if she needed it; and
• Mrs X moved to the nursing unit the following day, but the previous day was not a calm and dignified one for her. The experience was unacceptable, especially as Mrs X was in the last days of her life.

My assessment

9. Mrs X’s representatives raised concerns about significant injustice to Mrs X in the form of poor care which may have caused her significant distress. The concerns are particularly serious as Mrs X was vulnerable throughout the period, but especially so in the last days of her life.
10. Even if we were to investigate and uphold this complaint, we could not achieve a remedy for Mrs X’s distress as she has died. In line with our guidance on remedies, we would not usually recommend remedies for distress to deceased people’s estates. Mrs X had no close surviving relatives when these events happened, so there is nobody else who can reasonably claim to have been caused significant distress by witnessing the distress of a close family member.
11. Having considered our Assessment Code together with the information provided by Mrs X’s representatives and the Council, I consider there are no other good reasons for us to investigate the complaint. An investigation is unlikely to find evidence of systemic problems affecting many others or achieve significant service improvements that prevent future injustice to others.
12. Therefore, we will not investigate this complaint.

Back to top

Decision

13. We will not investigate this complaint because an investigation is unlikely to achieve the complainants’ desired outcomes.

Back to top

Investigator's decision on behalf of the Ombudsman