Summary: The Ombudsman found failures on Mrs B and Ms C’s complaint against their late mother’s care provider which caused injustice. It failed to deal with their complaints according to its complaints procedure, failed to acknowledge and reply to correspondence, and failed to send copies of requested care records. The agreed action remedies the injustice caused.

The complaint

1. Mrs B and Ms C complain on behalf of their late mother and themselves that the care agency run by Innomarydom Limited, failed to:
1. ensure a carer carried out the first care visit of the day before 10am on the morning their mother died; and
2. respond promptly to the family’s formal complaint about its actions.
2. As a result, the family were caused distress due to Ms C discovering her mother’s death when entering her home and because of the care agency’s actions afterwards.

Back to top

The Ombudsman’s role and powers

3. We investigate complaints about adult social care providers and decide whether their actions have caused an injustice, or could have caused injustice, to the person making the complaint. I have used the term fault to describe such actions. (Local Government Act 1974, sections 34B and 34C)
4. If an adult social care provider’s actions have caused an injustice, we may suggest a remedy. (Local Government Act 1974, section 34H(4))

Back to top

How I considered this complaint

5. I considered all the information provided by Mrs B and Ms C, including the notes I made of the telephone conversations I had with them, the care provider’s response to my enquiries, a redacted copy of which I sent them, and an email from the neighbour who lived opposite Mrs D. I considered the responses from Mrs B, Ms C, and the care provider’s manager.

Back to top

What I found

6. Mrs D, 89 years old, lived alone in her bungalow and received care visits through the care provider. During the week, she would have a morning visit from a carer between 8.30-9.00am who would help her with breakfast and medication. Every Monday, at 9.55am, a community bus took her to a social club.
7. Mrs B says her mother had a friend who telephoned her every morning to check she was fine and spoke to her at about 8.30am on the day she died. Ms C told me he spoke to her at about 8.15am.
8. Mrs B was on holiday the day her mother died but, told me the bus driver arrived at the usual time, knocked on Mrs D’s door and receiving no answer, went across to a neighbour who alerted Ms C who lives nearby.
9. Ms C told me she arrived at her mother’s house, let herself in and found her mother laying on the floor dead near her bed. She called the GP who said she should call an ambulance.
10. When the ambulance arrived, they suggested she contact the police which she did. She says the care provider manager only arrived after the police. She also claims the manager did not reply when asked what happened to the carer visit. Ms C said it was clear no carer visit had taken place and she had not received a call telling her they were running late, as she had in the past. The manager did not stay long and took the care plans with her when she left.
11. The ambulance crew told Ms C the manager should not have removed the care plans.
12. The care provider claimed the carer due to visit that morning at 9am was held up with another visit. This meant the remaining visits on the carer’s list needed covering on short notice. As no other carer was free, the manager agreed to do the visit instead. The manager says she arrived at their mother’s house at 9.40am. Mrs B and Ms C disagree with the manager’s version of events. The care provider said the removal of the care plan followed company policy.
13. Mrs B and Ms C argue had the manager arrived at 9.40am, she would have found their mother. The care provider’s initial response to their complaint provided no details about what the manager did during this visit.
14. When Mrs B and Ms C complained further, the care provider said it would:

• review removing care folders with help from adult social care and the emergency services to ensure there was a clear protocol in place;
• Call the family member when a visit is disrupted due to unforeseen circumstances; and
• Introduce an electronic care management system that will automatically record the time of arrival and departure of the carer to ensure accurate record and time keeping.

15. The neighbour confirmed to me she checked her records which show she called Ms C at 10.02am. The neighbour was concerned the carer had not turned up because Mrs D was usually dressed, ready and waiting for the bus each Monday. She called Ms C because the curtains had not been pulled back. She says while speaking to Ms C, or shortly after, the community bus arrived. She told the driver she had called Ms C. After the driver knocked on Mrs D’s door with no response, she suggested he carry on with the rest of his pickups. Ms C then arrived. The neighbour added that because of the location of each of the houses, she cannot help but notice who visits Mrs D’s house.
16. The care provider sent a copy of the record made that day of the manager’s visit to Mrs D’s house. It states the manager was there from 9.40am to 10.10am. It records a neighbour telling her the curtains were still closed so she had called Ms C who had arrived to find Mrs D beside the bed. It recorded a conversation with Ms C about whether there was anything else she could do to help.
17. The account given by the manager through the care provider confirmed she arrived at 9.40am and there were no paramedics on site. It confirmed speaking to a neighbour, speaking to Ms C, and helping to find a funeral director’s telephone number. The care plan folder was removed as it was company policy and the manager noted she would not have access to the property once she left.
18. In response to my draft decision, the manger disputed the version of events given by Ms C and said she had no reason to fabricate the events of that morning. She says, for example, she arrived before the ambulance or police to find Ms C and a neighbour there. Ms C was on a call to the GP when she arrived. After finding a number for a local funeral director for Ms C, the manager left after 30 minutes just as the ambulance arrived.
19. The manager also said it is usual practice to alert a service user or their family of a late call due to unforeseen circumstances. It was not done on this occasion as she thought the call would be done before Mrs D left for the social club. She accepted it would have been better to make the call and still try to arrive on time.
20. The care provider’s policy states, ‘The file/folder and care plan will be removed/obtained from the premises and archived with all other correspondence’.

Analysis

21. I make the following findings on this complaint:
1. Through unexpected circumstances, the carer was unable to visit Mrs D the morning she died.
2. The care provider did not alert Ms C about the potential problem with finding cover on short notice to do the visit. While their expectations may have been raised by the carer calling Mrs B and Ms C in the past when running late, I am not satisfied this amounts to a failure in these circumstances. The care records I have seen do not provide a set time for the visit.
3. Mrs B and Ms C dispute the manager’s version of what happened that morning. The key discrepancy is the time of the manager’s arrival. The manager completed the form showing she arrived at 9.40am. While Mrs B and Ms C believe this was an attempt by the manager to make it look like the visit had been done before 10am, I am not persuaded this is true. I say this because the account given by the manager does not pretend she arrived there before Ms C, for example. What it does say is she was initially approached by the neighbour who explained her contact with Ms C. The account goes on to record a conversation the manager had with Ms C.
4. On balance, I consider the manager was also having a stressful morning that day and merely wrongly recorded her time of arrival. The manager had dashed over intending to visit before Mrs D left for the social club, only to find she had died. The manager’s account made no attempt at fabricating an earlier arrival on scene. The manager does not accept she recorded the time wrongly.
5. Mrs B was on holiday at the time so, I have given little weight to her evidence as she did not witness events first-hand.
6. I found there was no failure on the complaint about the manager removing the care records as this followed the care provider’s policy.
7. I also considered the way the care provider dealt with their complaint:

• Mrs B and Ms C wrote to the care provider on 14 September 2019. They wanted answers to understand what happened on the day of their mother’s death. They asked to see her care plans for the 4 days leading up to her death. They also asked 6 questions about events that day.
• Towards the end of October, they sent another letter to the care provider having had no response.
• On 11 November, they emailed the care provider again, referring to the many calls they had made asking for a call back and having no response. Six days later, the care provider sent its response, apologising for delay in dealing with their complaint.
• On 26 November, they wrote to the care provider again seeking clarification on its response. They again asked to see a copy of the care records. The care provider acknowledged this in early December saying it would send a response within the next few days.
• Towards the end of December, they again emailed the care provider, frustrated with its delays and failure to respond. The care provider emailed the following day responding to their request for clarification. Mrs B and Ms C replied, frustrated they had yet to receive copies of the care records they asked for.
• Hearing nothing further, they wrote to the care provider at the start of January 2020 saying they had contacted us and wished it to view their earlier correspondence as a formal complaint.
• In January, they sent a formal complaint. Hearing nothing further, they complained to us later that month.
8. The care provider’s complaints procedure states:
• Its aim is to properly and effectively implement it so service users feel confident their complaints and worries are listened to and acted upon promptly and fairly;
• Every written complaint is acknowledged within 5 working days and a leaflet is sent setting out the complaints procedure;
• All complaints are investigated within 14 days of receipt;
• All complaints are responded to in writing within 28 days of receipt but, if more time is needed, the complainant is told; and
• Complaints are dealt with promptly, fairly, and sensitively, with due regard to the upset and worry they can cause to service users and staff.
9. The care provider clearly dealt with their initial letter as a complaint as this is how it referred to it in its response. It failed to follow its own complaints procedure. It did not send an acknowledgement of their complaint within 5 working days. Nor did it send its response within 28 days of receiving it, which would have been 23 October. It sent its response 47 days after receiving it.
10. I received a copy of the undated investigation notes. This means I cannot say the care provider did the investigation within 14 days of receiving the complaint. This is a failing.
11. From the date they made the complaint to the care provider’s response, I saw no evidence of it acknowledging it or contacting them to explain what it was going to do with it. This is a failing.
12. The care provider also failed to send them a copy of the care records they asked for or, if this was not possible, explain to them why they could not have them. This is a failing.
13. In response to their request for clarification, they were told to expect a response, ‘in the next few days’. This did not happen. They had to chase the care provider just before Christmas to get a response. The requested copy care records were still not provided to them. These are further failings.
14. I am satisfied the failures with the complaints procedure and the delay sending them copies of the care records caused them injustice. The distress experienced included frustration, inconvenience, and suspicion about why it had not sent copy records. I also took account of the fact this avoidable distress took place at a time when Mrs B and Ms C were grieving for their mother and wanted to try and get some closure about what happened on the day she died. The failures gave the impression of no action being taken in response to their complaint and went against the complaints procedures aims of treating complainants sensitively, taking account of the upset that might be caused to both staff and Mrs B and Ms C.

Agreed action

22. I considered our guidance on remedies.
23. The care provider will, within 4 weeks of the final decision on this complaint, carry out the following action:
1. Send Mrs B and Ms C a written apology for failing to: respond promptly, or at all, to correspondence; keep to its complaints procedure deadlines; send them the case notes or explain why it could not do so;
2. Review its complaints handling to identify why these failures took place and act to ensure these are not repeated in the future;
3. Review why copies of the case records were not promptly sent to them when requested;
4. Provide evidence that it: carried out a review of its policy for the removal of care records from service user’s homes when they die; ensure carers call family members when a visit is disrupted due to unforeseen circumstances; introduced the time electronic management system; and
5. Pay Mrs B and Ms C £250 each for the distress the identified fault caused.

Back to top

Final decision

24. The Ombudsman found failings by the care provider on the complaint by Mrs B and Ms C. The agreed action remedies the injustice caused.

Back to top

Investigator's decision on behalf of the Ombudsman