The Ombudsman's final decision
Summary: We will not investigate this complaint about adult social care. This is because it is a late complaint. But even if it were not, the Ombudsman would not add to actions already taken to recognise the impact on the family and to improve future service. The person using the service has died so we can provide no personal remedy.
The complaint
Mr B says his family member, Ms C, fell at the care home where she lived. Mr B says the Care Provider could have prevented the fall. Mr B and the family are distressed that Ms C was on the floor alone shouting for help.
The Ombudsman’s role and powers
We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by: their personal representative (if they have one), or someone we consider to be suitable.
(Local Government Act 1974, section 26A(2), as amended) 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/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended) We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended) We investigate 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 continue 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.
(Local Government Act 1974, section 24A(6), as amended, section 34(B)) If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)
How I considered this complaint
I considered information provided by the complainant.
I considered the Ombudsman’s Assessment Code.
My assessment
Ms C lived at Queens Court care home, run by Care UK Community Partnerships Ltd (the Care Provider). The Council arranged Ms C’s placement, and so remained responsible for meeting Ms C’s adult social care and support needs.
The complaint is about a fall Ms C had at the end of 2021, which Mr B knew about at that time. Mr B has not explained why he did not pursue a complaint sooner. This is a late complaint in accordance with paragraph three.
Even if we exercised discretion to investigate this complaint, I do not consider an Ombudsman investigation is justified. The coroner has completed an independent investigation and found fault with the actions of the Care Provider. The Care Provider only had a falls sensor mat on one side of Ms C’s bed. The coroner issued a ‘report to prevent deaths’ and the Care Provider has improved its service in response. The Council has also worked with the Care Provider to improve service. It is therefore unlikely an Ombudsman investigation would achieve anything further regarding service improvements in the wider public interest. We can provide no remedy to Ms C for her personal injustice because she has since died.
The Care Quality Commission (CQC) is the independent regulator of health and adult social care in England. The CQC sets fundamental standards below which care must never fall. The Care Provider’s failure to provide enough falls sensor mats for Ms C may breach the fundamental standard for person-centred care and for the provision of safe care. We will share this case with the CQC.
I recognise Mr B and the rest of Ms C’s family are distressed by what happened to her. The Care Provider has given the family a written apology and offered to meet them to apologise in person. I am satisfied this is appropriate action to acknowledge the distress, and an Ombudsman investigation would achieve nothing further.
Final decision
We will not investigate Mr B’s complaint because it is a late complaint. But even if it were not, the Ombudsman would not add to actions already taken to recognise the impact on the family and to improve future service.
Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
Investigator's decision on behalf of the Ombudsman