Summary: We will not investigate Ms M’s complaint about the actions of a health visitor, who was providing a service on behalf of the Council. An investigation by the Local Government and Social Care Ombudsman is unlikely to add to the outcomes of previous investigations by other organisations.

The complaint

1. The complainant, whom I shall call Ms M, complains about the actions of a health visitor who saw her baby, B, in the weeks before he died from a heart condition in 2018.
2. Ms M says the health visitor failed to act on her concerns that B sweated a lot but had cold hands and feet. Ms M considers these could have been symptoms of B’s heart condition and the health visitor should have referred him to a GP. Ms M also complains the health visitor failed to maintain accurate records in B’s personal child health record (“red book”). Ms M considers the health visitor’s actions were part of a set of medical failures that led to her son’s death.

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The Ombudsman’s role and powers

3. 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 a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
4. We investigate complaints about ‘maladministration’ and ‘service failure’ by councils and certain other bodies, which we call ‘fault’. We must also consider whether any fault has had an adverse effect on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start an investigation if the tests set out in our Assessment Code are not met. (Local Government Act 1974, sections 24A(6) and 25(7), as amended)
5. The duty to provide health visiting services lies with councils. This is why we are considering Ms M’s complaint about the health visitor’s actions. The Parliamentary and Health Service Ombudsman (PHSO) is considering Ms M’s other complaints about the actions of NHS health services.

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How I considered this complaint

6. I considered written information provided to us by PHSO with Ms M’s consent. This includes Ms M’s original complaint to PHSO and the health visitor’s electronic records of their contact with Ms M and B.
7. I considered the Ombudsman’s Assessment Code.
8. Ms M had an opportunity to comment on a draft version of this decision. I considered her comments before making a final decision.

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My assessment

9. Ms M complained about events that happened more than 12 months ago. However, I do not consider her complaint to us to be ‘late’. This is because there was a significant delay beyond Ms M’s control when she had to wait for the outcomes of:
• medical and legal investigations into B’s death;
• the local complaints process with the NHS; and
• PHSO’s initial consideration of her complaint.
10. Throughout this time, there is no indication Ms M was aware the Council rather than the NHS was responsible for the actions of the health visitor.
11. However, I consider there are other reasons why we should not investigate Ms M’s complaint about the health visitor. I will explain those below.
• The detailed electronic record of the health visitor’s appointments with B has no references to Ms M’s concerns about sweating and cold hands. I do not doubt Ms M’s strong view that such a conversation happened. However, with no additional evidence to corroborate her recollection, we cannot conclude Ms M’s evidence outweighs that of the electronic record.
• Ms M considers there were several factors leading to B’s illness not being identified earlier and contributing to his death, not just the actions of the health visitor. There were also several health professionals in addition to the health visitor who saw and examined B in the time leading up to his death, including a doctor.
• There have been several investigations, including by the NHS and police, into what happened. None of them have found a link between the actions of the health visitor and B’s death.
• An NHS investigation has already accepted that the health visitor did not record visits in B’s red book, apologised for this, and identified service improvements.
12. It is therefore very unlikely that an investigation by the Local Government and Social Care Ombudsman would be able to either:
• link the health visitor’s actions to B’s death;
• establish, even on balance of probability, that fault by the Council (responsible for the service provided by the health visitor) caused or contributed to B’s death; or
• add to the service improvements earlier investigations have already identified.

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Final decision

13. We have decided not to investigate Ms M’s complaint about a health visitor’s actions. This is because an investigation is unlikely to add to the outcomes of other investigations that have already happened.

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Investigator's decision on behalf of the Ombudsman