The Ombudsman's final decision
Summary: We will not investigate this complaint about care provided to the late Mr B. This is because we could not add to the Care Provider’s response or make a different finding of the kind Mrs C wants. We could not now provide a remedy for any injustice caused by fault which might be uncovered during an investigation as sadly Mr B has passed away.
The complaint
Mrs C complained about the care and support her late brother, Mr B received from his care provider acting on behalf of the Council. Mrs C says Mr B’s call bell was left unanswered and his care provider failed to adjust his oxygen properly when he requested the levels to be adjusted. Mrs C says this resulted in his life being endangered. Mrs C wants the Care Provider to amend their procedures to include prioritising residents at high risk. Mrs C wants a personal apology from senior management and an acknowledgement the Care Provider’s report contains contradictions and untruths.
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 do not start an investigation if we decide 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.
I considered the Ombudsman’s Assessment Code.
My assessment
The Care Provider explained the call bell system is recorded and most of Mr B’s calls were answered within an acceptable response time with the exception of one call which recorded a waiting time of 15 minutes. The Care Provider acknowledged this was unacceptable. It explained call bell times have been discussed with staff who have been reminded to ensure delays are communicated to residents. The Care Provider says it found no evidence of a call bell not being responded to. We could not add to this or make a different finding even if we investigated.
The Care Provider explained what happened when a carer switched off Mr B’s oxygen. Mr B became anxious and panicked when his oxygen levels fell and used his call bell for assistance. The machine was turned back on, and his oxygen levels increased. The Care Provider apologised to Mrs C for this incident and advised of the action it has taken to ensure this does not happen again. The Care Provider implemented group supervision with all carers to ensure staff are aware only registered nurses and senior carers can deal with oxygen and reiterated all care and support provided is to be documented in the daily notes. We could not add to this or make a different finding even if we investigated.
Sadly, Mr B is now deceased so we could not provide a remedy for any injustice caused to him by the action of his care provider even if we investigated and found evidence of fault. The Care Provider has apologised to Mrs C and advised of the actions it has taken to minimise the risk of a similar occurrence. We could achieve no more than this.
Final decision
We will not investigate Mrs C’s complaint because further investigation could not provide a different outcome to that she has already received. We could not provide Mr B with a remedy for any injustice caused by fault even if we found evidence of fault because he has passed away.
Investigator's decision on behalf of the Ombudsman