The Ombudsman's final decision
Summary: We will not investigate Mrs D’s complaint about care and medication given to her late father, Mr E, shortly before he died. This is because further investigation could not provide Mrs D with a different outcome to that she has already received or make a finding of the kind she wants.
The complaint
Mrs D complained about the care her late father, Mr E received from his Care Provider and the way it treated her. Mrs D says the Care Provider: failed to provide Mr E with adequate end of life care, failed to properly assess him and did not give him his prescribed medication; failed to keep her informed about Mr E’s care and medication; failed to keep Mr E clean and left him with long nails and hair; lied about Mrs D’s character and made false allegations about her commitment to Mr E.
left a bucket of faeces in his room.
Mrs D says Mr E’s Care Provider is lying about her character and wants a full investigation and compensation.
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))
How I considered this complaint
I considered information provided by the complainant.
I considered the Ombudsman’s Assessment Code.
My assessment
The Care Provider said Mr E would often refuse to have his hair and nails cut even though they tried to encourage him and explained they cannot make someone do anything against their will. It said they do as much as possible to ensure residents are clean, smart and well-presented and Mr E took pride in his appearance. It says his last haircut was on 8 December a few weeks before he passed away. We could not add to this point even if we investigated.
The Care Provider said it believed the stopping of Mr E’s medication had been communicated to her by the health professional who stopped the medication. It said it has now made changes to its processes regarding documenting visits from professionals to ensure families are informed of changes to medication and care. We could not add to this point even if we investigated.
The Care Provider apologised that night staff had not checked Mr E’s Medication Advice Record (MAR) sheets and had overlooked that Mr E was to be given Oramorph to keep him pain free and comfortable at the end of his life. Night staff maintain they wanted Mr E to be seen by a GP who attended and prescribed Morphine and Midazolam. The Care Provider acknowledged staff did not read the electronic notes or written handover sheet advising Mr E was to be given Oramorph PRN, i.e. when circumstances arise. It explained it could not give Mr E constant Oramorph as Mrs D wanted. The Care Provider says all staff have been spoken to about listening, checking and double-checking records/MAR sheets/written sheets and calling senior staff for advice if they are unsure of anything. We could not add to this even if we investigated.
The Care Provider apologised that Mr E’s bin had dried faeces in it. It said there was no excuse for this, and it should have been picked up and cleared. It apologised this situation happened. We could not add to this point even if we investigated.
Mrs D remains unhappy with the Care Provider’s responses and wants the Ombudsman to consider them further. The Care Provider has apologised for its failings and advised what it has done to minimise the risk of similar occurrences. Further investigation could not provide a different answer or achieve any more than the service improvements already identified by the Care Provider. We could not provide Mr E with a remedy for any injustice caused by the failings as he is now deceased.
Mrs D is unhappy and feels insulted by the allegations made about her in the Care Provider’s response to her complaint. We could not make a finding on this point. We cannot say what occurred when we were not there, and it is one person’s word against another. Defamation claims are properly for the courts to determine.
Final decision
We will not investigate Mrs D’s complaint because further investigation by the Ombudsman could not make a different finding.
Investigator's decision on behalf of the Ombudsman