The Ombudsman's final decision
Summary: We will not investigate this complaint about the Care Provider failing to manage Mr Y’s pain properly at the end of his life. We could not add to the investigation that has already taken place, and we could not provide a meaningful outcome for Ms X.
The complaint
Ms X complained about her late father’s (Mr Y’s) care in a care home. The Care Provider failed to call the community nurses to give Mr Y medication which had been prescribed for the end of his life, therefore leaving him in pain while dying. Records for the last days of Mr Y’s life wrongly said he was settled and not in pain. Ms X experienced significant distress. Mr Y’s mobility aids were also wrongly removed from his room and a hearing aid broken.
The Ombudsman’s role and powers
The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide: we could not add to any previous investigation by the organisation, or further investigation would not lead to a different outcome, or we cannot achieve the outcome someone wants, or there is another body better placed to consider this complaint.
(Local Government Act 1974, section 24A(6)) We investigate complaints about councils and certain other bodies. We cannot investigate the actions of bodies such as the NHS. (Local Government Act 1974, sections 25 and 34A, as amended)
How I considered this complaint
I considered information provided by the complainant.
I considered the Ombudsman’s Assessment Code.
My assessment
Mr Y died in late 2021. Ms X says he had been calling out in distress in the days leading up to his death, and she was not aware at the time medication had been prescribed by his doctor to be used if needed. She believes the medication should have been administered and Mr Y died in pain.
The Care Provider contacted the community nursing team twice in the days leading up to Mr Y’s death. One of these occasions followed Ms X asking if Mr Y could have pain relief. The community nurses said there was no indication Mr Y was in pain and needed medication. The Care Provider recorded Mr Y as being settled and Ms X’s sister says he was not calling out at the time of his death.
We could not say now whether Mr Y was in pain at the end of his life. We also could not say that Mr Y required medication. It was the community nurses, rather than the Care Provider, who made decisions about whether to administer medication. When they visited Mr Y at the Care Provider’s request, their decision was Mr Y did not need medication. We could not add to the investigations that have taken place and we could not provide a meaningful outcome for Ms X.
Parts of Ms X’s complaint are about the decisions and actions of NHS staff, rather than the Care Provider. Should Ms X wish to escalate those complaints she should contact the Parliamentary and Health Services Ombudsman, as we cannot consider the actions of NHS staff.
We could not say now what happened to Mr Y’s mobility aids and how his hearing aid was damaged. The Care Provider has updated its processes to improve record-keeping in relation to residents’ personal items. We could not add anything of value if we investigated these parts of Ms X’s complaint.
Final decision
We will not investigate Ms X’s complaint because we could not add to the investigation that has already taken place, and we could not provide a meaningful outcome.
Investigator's decision on behalf of the Ombudsman