The Ombudsman's final decision
Summary: We will not investigate this complaint about Mrs Y’s death in a care home, which the family believe was due to choking on meat. We could not say that any fault had caused injustice to Mrs Y and her family, because a coroner found Mrs Y did not die from choking.
The complaint
Mrs X complained the Care Provider, commissioned by the Council, fed her mother (Mrs Y) meat when she should have had pureed food. She says Mrs Y choked on the meat and died. The family have experienced significant distress. Mrs X says the Care Provider did not properly investigate or provide information that she requested. She wants an acknowledgement of responsibility and service improvements.
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: any fault has not caused injustice to the person who complained, or there is another body better placed to consider the complaint.
(Local Government Act 1974, section 24A(6))
How I considered this complaint
I considered information provided by the complainant.
I considered the Ombudsman’s Assessment Code.
My assessment
Mrs Y lived in a care home, commissioned by the Council. A Speech and Language Therapist (SALT) assessed Mrs Y in early 2020 and found she did not need a modified diet as she could swallow normally. Mrs Y did not have further involvement from SALT.
Mrs Y passed away while eating a meal in mid-2021. Mrs X, her daughter, believes this was due to Mrs Y choking on meat. Mrs X says a person with late-stage dementia should not be given meat to eat.
It is not for the Ombudsman to determine cause of death. The paramedics who attended could not find anything lodged in Mrs Y’s throat. The coroner decided Mrs Y had not choked, and we could not overturn that decision. We could not therefore conclude that the care home was responsible for Mrs Y’s death and the distress this caused her family.
Mrs X’s complaint to us included that the care home did not provide her with information she requested. The Information Commissioner’s Office is the body responsible for considering complaints about organisations’ data practices.
Final decision
We will not investigate Mrs X’s complaint because we could not say that any fault caused injustice to Mrs Y and her family.
Investigator's decision on behalf of the Ombudsman