The Ombudsman's final decision
Summary: We will not investigate this complaint about alleged neglect in a care home. The local Safeguarding Adults Board is completing a Safeguarding Adults Review into the care provider, it is unlikely an Ombudsman investigation would add anything further.
The complaint
Ms B says a care provider who was providing care to her mother (Ms C) on behalf of the Council, neglected Ms C. Ms B says Ms C’s suspicious death has not been properly investigated and she and the family are struggling to grieve.
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 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, or there is another body better placed to consider this complaint, or there is no worthwhile outcome achievable by our investigation.
(Local Government Act 1974, section 24A(6), as amended, section 34(B))
How I considered this complaint
I considered information provided by the complainant and the Council.
I considered the Ombudsman’s Assessment Code.
My assessment
The Council arranged to meet Ms C’s adult social care needs in a care home.
Ms B raises concerns of neglect of Ms C. Local authorities are responsible to safeguard adults in their area who have health and social care needs from abuse or neglect. The Council explains it did not carry out a safeguarding investigation into the concerns about Ms C’s care, because Ms C had died so no longer needed safeguarding from any neglect or abuse. However, the Council has referred the matter to the Safeguarding Adults Board who are going to complete a Safeguarding Adults Review of the care provider, including Ms C’s case. The purpose of a Safeguarding Adults Review is to promote effective learning and improvement action to prevent future deaths or serious harm occurring again.
The care provider has investigated Ms B’s concerns and accepted some failures in its service. The care provider apologised to Ms B for not telling her when Ms C became unwell and for dressing Ms C in warm clothes when she had a temperature. The care provider apologised that its records were not always complete. The care provider has advised on actions it will take to improve service, and the Council’s commissioning team is going to monitor this.
Ms B says the Care Quality Commission (who regulate care providers in England) and the Nursing and Midwifery Council (who regulate the nurses working in the care home) are both investigating Ms B’s concerns.
I do not consider an Ombudsman investigation could add to the investigations already undertaken or ongoing. Ms C has died so we can provide no personal remedy for any injustice to her caused by fault of the Council, or the care provider on its behalf. The care provider has apologised to Ms B, and it is unlikely we would achieve anything further to acknowledge the impact on her. The other bodies investigating will consider any service improvements to prevent future problems so there is no need for the Ombudsman to repeat that.
Ms B refers to Ms C’s death as suspicious. The coroner and/or police are the appropriate bodies to investigate suspicious deaths.
Final decision
We will not investigate Ms B’s complaint because it is unlikely we could add to investigations that have taken or are taking place.
Investigator's decision on behalf of the Ombudsman