The Ombudsman's final decision
Summary: We will not investigate this complaint about care provided to the late Mr B. This is because further investigation could not add to the Council’s response.
The complaint
Mrs C complains about care provided to her late father, Mr B. Mrs C says Mr B was neglected by his Care Provider. Mrs C says communication with the Care Provider was poor and she was not told of the numerous unwitnessed falls Mr B sustained. In addition, Mrs C is concerned the falls were not properly recorded. Mrs C is unhappy with the outcome of the safeguarding investigation into the falls and says information contained in the report is contradictory to that received from the Care Provider. Mrs C says Mr B had six unwitnessed falls in the eight months he lived in the home and died within eight weeks of returning home.
The Ombudsman’s role and powers
We investigate complaints about ‘maladministration’ and ‘service failure’, 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, section 24A(6), as amended)
How I considered this complaint
I considered information provided by the complainant and the Council.
I considered the Ombudsman’s Assessment Code.
My assessment
The Council investigated the falls Mr B sustained through its responsibility for Safeguarding Vulnerable Adults and responded to Mrs C’s complaint. It said Mr B sustained five unwitnessed falls between November 2020 and August 2021. It explained the outcome of the investigation confirmed there were no witnesses to any of the falls, and although there was a sensor mat in situ, Mr B who had capacity, appeared to have moved the mat which prevented carers being alerted to him falling. Mr B advised the investigating officer how he had fallen and sustained the injuries to his ear and confirmed no one was present with him at the time. The Council confirmed it received copies of the incident forms from the Care Provider and falls were recorded in line with policy and procedure. It said following its investigation it will ensure regular communication between the Social Worker, family members and the Care Provider happens both verbally and in person. It says all safeguarding incidents will be fully investigated in line with its policy and procedure and assistive technology will be used and reviewed regularly.
Although Mrs C remains unhappy with the Council’s actions, further investigation could not achieve any more than this. Sadly Mr B is now deceased so we could not provide him with a remedy for any fault which might be uncovered in an investigation.
Final decision
We will not investigate Mrs C’s complaint because we could not achieve a different outcome even if we investigated.
Investigator's decision on behalf of the Ombudsman