Summary: Ms X says her mother died in hospital because of poor care she received in a care home. There were admitted failings in the care Ms X’s mother received at the care home. But Ms X’s mother’s death cannot be attributed to poor care at the home through this investigation. Ms X or her mother did not suffer a degree of injustice in consequence of the identified failings that now warrants a remedy or further pursuit of this complaint by the Ombudsman.

The complaint

1. I refer to the complainant here as Ms X. Ms X says her mother contracted covid while in hospital and died there. But Ms X says her mother was admitted to hospital due to a fall from her bed and her mother only fell from bed because carers at the home removed bed drawers from her bed thereby making it unstable. Ms X says her mother was then exposed to a covid environment in hospital.
2. Ms X also complained to the Council about the following matters:
• A swab test was done on her mother without her permission.
• The care home did not tell her an alarm on her mother’s door was ringing without interruption for a whole day.
• The care home manager should not have sent an email to the social worker asking for a period of recuperation for her mother before she returned to the home from hospital. This was done without speaking to Ms X.
• A telephone call was not made to her by the care home manager despite a request made to the Council’s Locality Manager.
• An ambulance was called for her mother but she was not informed. Her mother had a pulsometer which she was not aware of.
• Her mother was not given her night-time medication on one occasion and she questions whether this happened on other occasions.
• The care home manager was rude to her.

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The Ombudsman’s role and powers

3. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
4. The law says we cannot normally investigate a complaint when someone could take the matter to court. However, we may decide to investigate if we consider it would be unreasonable to expect the person to go to court. (Local Government Act 1974, section 26(6)(c), as amended)
5. 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:

• there is not enough evidence of fault to justify investigating, or
• any fault has not caused injustice to the person who complained, or
• any injustice is not significant enough to justify our involvement, or
• 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,
• it would be reasonable for the person to ask for a council review or appeal.

(Local Government Act 1974, section 24A(6))

6. If we are satisfied with a council’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)

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How I considered this complaint

7. I examined background documents provided by Ms X and the Council. I discussed matters with Ms X by telephone. I sent a draft decision statement to Ms X and the Council and considered the comments of both parties on it.

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What I found

8. I will address the central element of Ms X’s complaint first. The Ombudsman cannot determine whether falls at the care home caused the death of Ms X’s mother. That is a matter for a coroner. The Ombudsman cannot consider complaints where the stated injustice involves personal injury and/or death.
9. If poor care at the home or removal of drawers under a divan bed led Ms X’s mother to fall and led to her death in hospital then Ms X can take legal action against the care home and/or the Council. Given Ms X’s mother’s medical condition I cannot now determine whether removal of the drawers or her medical condition led to the falls. I consider it reasonable to expect Ms X to take legal action because negligence is a legal matter that the courts are better placed to address than the Ombudsman.
10. I shall turn to the other aspects of Ms X’s complaint.

A swab test was done on her mother without Ms X’s permission

11. The care home says Ms X’s mother had capacity to decide on whether to take a swab test. Nonetheless, the Council stated Ms X had signed a form withholding permission for the swab test and so it should not have been completed. The Council apologised to Ms X.
12. I consider the apology was the appropriate remedy for the understandable frustration Ms X would have felt when she found out about the swab test. I do not consider there is an unremedied injustice that now requires further action by the Ombudsman on this point.

The care home did not tell Ms X an alarm on her mother’s door was ringing without interruption for a whole day

13. Ms X complains that when the alarm installed on her mother’s room door was faulty, staff or management at the care home did not quickly to inform her of the fault so she could take action. The Council accepted Ms X should have been informed of the fault sooner than she was told. It apologised again to Ms X.
14. I do not find this matter caused Ms X serious injustice that now warrants further pursuit of this matter by the Ombudsman.

The care home manager should not have sent an email to the social worker asking for a period of recuperation for her mother before she returned to the home from hospital. This was done without speaking to Ms X

15. Care homes, councils and hospitals all have input into the hospital discharge process. A hospital should discharge a patient when medical practitioners consider there is no clinical reason for the patient to remain in hospital. Care home managers, on the other hand, do not want patients to be discharged from hospital until the clinical issues that led to the patient’s admission are resolved.
16. It was not fault for the care home manager to write to the social worker to express concern that Ms X’s mother would not be safe at the home because of the number of falls she had. The manager asked the social worker for a period of recuperation or plan. That is not fault. I am not aware of any legal requirement or good practice guidance that stipulates the care home manager should have consulted with Ms X before contacting the social worker. So I cannot share Ms X’s view that the care home manager should have contacted her because Ms X has power of attorney for her mother.

A telephone call was not made to her by the care home manager despite a request made to the Council’s Locality Manager

17. Ms X says she asked the Locality Manager for a telephone call from the care home manager. The Locality Manager says she did not make a record of the request. She apologised to Ms X.
18. I do not find that Ms X suffered serious injustice because of this failing that now warrants further pursuit of this matter by the Ombudsman.

An ambulance was called for her mother but she was not informed. Her mother had a pulsometer which she was not aware of

19. The Council accepted that Ms X should have been informed when an ambulance was called to transfer her mother to hospital. The Council’s complaint response was silent on the subject of the pulsometer.
20. Ms X was not immediately informed when an ambulance was called for her mother but she was later informed when her mother was transferred to hospital. I do not find the time lag was significant or caused Ms X a serious injustice that now requires a remedy from the Ombudsman.
21. I do not find that Ms X suffered serious injustice because her mother had a pulsometer. It is a device to measure a heart rate. It is not inappropriate for the care home to seek to measure the heart rate of a person of Ms X’s mother’s age and with her medical condition.

Her mother was not given her night-time medication on one occasion and she questions whether this happened on other occasions

22. The care home explained that it used a lot of temporary staff during that period of the Covid pandemic. It said the carer would have given Ms X’s mother her medication but omitted to record it.
23. I acknowledge Ms X’s continuing concern about this matter. However, this investigation cannot now establish whether the carer administered the medication on that occasion as the care home says or whether the omission on the care records accurately shows the medication was not administered. There is no means of establishing the veracity of either claim.

The care home manager was rude to her

24. Ms X says the care home manager was rude to her when she raised the matter of the faulty door alarm. The care home did not consider the manager was rude to Ms X. Nonetheless, the Council apologised to Ms X for any distress she was caused.
25. Given the Council’s apology, I do not find this matter caused Ms X an injustice that now warrants further pursuit of this matter by the Ombudsman.

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Final decision

26. The Ombudsman cannot determine whether negligence by the care home led to the death of Ms X’s mother. However, there were identified failings in the care and service provided by the care home. The identified failings did not cause Ms X or her mother significant injustice that warrants a remedy or further pursuit of the complaint by the Ombudsman.

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Investigator's decision on behalf of the Ombudsman