Summary: We will not investigate Ms X’s complaint about her late sister Ms Y’s stay in a care home commissioned by the Council. We do not investigate where we cannot remedy the core injustice caused to someone who has died. There is insufficient other injustice stemming from Ms Y’s provision to warrant us investigating. We cannot add to the investigation already done by the home, or reach a different outcome to that of the home and coroner.

The complaint

1. Ms Y was discharged from hospital to a care home placement commissioned by the Council for about a month before her death in 2022. She had health issues, including sleep apnoea and lymphoedema in her legs causing ulcers.
2. Ms X is Ms Y’s sister. She complains the Council gave Ms Y inadequate care at the home for her conditions. Ms X believes the lack of care contributed to Ms Y’s death. She wants the matter investigated.

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The Ombudsman’s role and powers

3. 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:

• any injustice we can remedy 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.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

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How I considered this complaint

4. I considered information from Ms X and the Ombudsman’s Assessment Code.

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My assessment

5. The core injustice from any fault in Ms Y’s care was to her as the person receiving the service. We cannot remedy that key injustice to Ms Y since her death, so we will not investigate. The circumstances around Ms Y’s provision at the care home would have caused upset to Ms X and the family. But this is not sufficient injustice to warrant us investigating.
6. The care home has investigated Ms X’s complaint and made findings about problems with some of the services provided to Ms Y. The home has stated it will be making changes to some processes in view of those findings to make similar issues less likely to reoccur. We recognise Ms X wants us to investigate matters further. But we could not add to this earlier investigation by the care home here. We also understand Ms X considers the service provided to Ms Y at the care home contributed to her death. But we cannot make such findings on what has caused or contributed to someone’s death. Those are matters for a coroner to determine, not the Ombudsman. The coroner has considered the information and issued their decision regarding Ms Y’s death. We cannot question or add to that formal decision by the coroner as an outcome to our complaint-handling process. Further investigation by us would not lead to a different outcome here than that already reached by the home and the coroner.
7. Ms X has reported the case to the Care Quality Commission (CQC) and received a reply. This is an action we would have taken had Ms X not already done so, under our information sharing arrangements. As the independent regulator of social care services, the CQC is the appropriate body to have received the information from Ms X’s complaint about the care home. It will be for the CQC to consider that information as it sees fit in future assessments of the home, applying the relevant standards and legislation.

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Final decision

8. We will not investigate Ms X’s complaint because:
• we cannot remedy any of the core injustice to the late Ms Y stemming from the care provision issues complained of, and there is insufficient other injustice to warrant investigation; and
• we could not add to the investigation by the care home; and
• investigation would not lead to a different outcome.

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Investigator's decision on behalf of the Ombudsman