Summary: We will not investigate Mrs X’s complaint about her mother’s care home and the way they handled her care before her death. This is because an investigation would not lead to any different findings or outcomes.

The complaint

• Mrs X complains about her mother’s care home and the way they handled her care before her death. She complains the care home:
• Delayed in telling the family that her mother’s condition had declined.
• Failed to tell the family they were administering end of life medication.
• Failed to explain what medication had been given and what effects to expect.

She also complains her mother’s driver that was administering the medication was leaking and that care home staff were not professional when around her mother’s bedside.

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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 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.

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

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How I considered this complaint

• I considered information provided by the complainant and the Council.
• I considered the Ombudsman’s Assessment Code.

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My assessment

2. Mrs X’s mother, Mrs Z received care and support in a care home. In March 2024, care home staff raised concerns about Mrs Z’s presentation as she appeared more confused than normal and was unsettled. A doctor visited and prescribed some medication.
3. The care home confirmed it had administered one of the prescribed medications to Mrs Z on 13 March due to her being agitated. The care home said this was in line with the doctor’s prescription.
4. On 14 March, records showed Mrs Z was again very agitated and that care staff had unsuccessfully attempted to contact the doctor. The care home made an urgent referral to the district nurse, who attended in the afternoon and administered medication to relieve Mrs Z’s distress and pain. The care home said the family were present at the time and that the district nurse was present to answer any questions from family.
5. In the evening, the district nurse attended and administered medication again to Mrs Z as she appeared to be restless and in pain. The care notes recorded the nurse had also prescribed a syringe driver to administer medication and that the nurse had a long conversation with Mrs Z’s family.
6. On 15 and 16 March, the care notes recorded that Mrs Z appeared much more settled since the driver was set up and that the district nursing team had visited to review her. The notes also detailed that Mrs Z’s family was present with her during this time.
7. In response to Mrs X’s complaint, the care provider acknowledged it had failed to tell the family that Mrs Z had deteriorated in the evening of 13 March. The care provider apologised for this. The provider also accepted that sensitive conversations had taken place outside of Mrs Z’s room and confirmed feedback would be provided to staff and the district nursing team. Regarding the syringe driver, the care provider explained the district nursing team did not tell them the driver had been leaking.
8. Most of Mrs X’s complaints relate to the medication that was administered to her mother, particularly regarding whether the medication was considered end of life medication. However, the evidence suggests it was the decision of the district nursing team to administer the medication that had been prescribed by the doctor.
9. Given the family were present when the nurse was visiting, on balance it is likely the care home considered the nurse would advise the family of what medication had been administered, why it had been administered, and what effects to expect. Therefore, an investigation is not justified as it would not lead to any further findings in relation to Mrs X’s questions around the medication that was administered.
10. Further, the care home cannot prescribe, or request medication be prescribed. The care home’s role is to administer medication in line with Mrs Z’s prescription. Again, given the evidence shows it was the district nurses who decided to administer the medication, Mrs X's concerns and questions would be best directed to the health service to address.
11. The care provider has acknowledged some fault for the delay in notifying Mrs X about her mother’s decline and for how some staff had discussed sensitive matters around Mrs Z. It has apologised for this.
12. I am satisfied an investigation would not lead to any further findings of fault or recommendations on these complaint points. Therefore, an investigation is not a proportionate use of our limited resources.

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Final decision

• We will not investigate Mrs X’s complaint because an investigation would not lead to any different findings or outcomes.

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Investigator's decision on behalf of the Ombudsman