Summary: We will not investigate this complaint about the Care Provider’s actions when Mr Y fell in the care home. The Care Provider has agreed to take early action to remedy the remaining injustice we would likely find if we investigated the matter. It will pay Mrs X £500 to recognise the family’s distress and uncertainty, and it will issue a staff reminder about record-keeping. It is therefore not proportionate for us to investigate the matter further.

The complaint

1. Mrs X complained about the care her father (Mr Y) received in a care home. She said he did not receive adequate care, including in his last few days. She said her father, who was on blood thinners, had a significant number of falls and developed mixed dementia due to this. She said a member of staff failed to call for paramedics after Mr Y’s final fall, which had been from a hard chair while unsupervised. Mrs X said the Care Provider eventually sought medical assistance after 24 hours due to her emphasising how much pain her father was experiencing. She said the Care Provider did not keep contemporaneous records of this fall.
2. Mrs X said the matter caused significant distress for Mr Y’s family, they believed the fall could have contributed to Mr Y’s death. She wanted the Care Provider to pay the family a financial remedy and make service improvements.

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The Ombudsman’s role and powers

3. 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.

(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 provided by the complainant and the Care Provider.
5. I considered the Ombudsman’s Assessment Code.

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My assessment

6. If we investigated this complaint, it is likely we would find fault causing the complainant injustice. The Care Provider, and the local authority that investigated the matter, both indicated the Care Provider’s falls policy and procedure had not been followed on the occasion in question. The Care Provider also identified records had not been kept contemporaneously.
7. It is unlikely we could add to the investigations that have already taken place. We would be unlikely to gain any new information that has not already been gained via the Care Provider’s investigation, the local council’s safeguarding investigation, and an inquest that took place after Mr Y’s death. We could not say the fall caused Mr Y’s death. We could not make recommendations to remedy injustice to Mr Y, as he has died. We also could not make recommendations that relate to personnel matters, as requested by Mrs X during the Care Provider’s complaints process. The Care Provider has taken steps to learn from the experience and it has apologised for the circumstances surrounding Mr Y’s death.
8. However, if we investigated the matter, it is likely we would find outstanding injustice to the family that had not yet been remedied via the Care Provider’s complaints process. We would likely find that the family experienced distress and uncertainty over whether, had different actions been taken, the outcome for Mr Y may have been different. I asked the Care Provider therefore to consider making a symbolic payment of £500 to Mrs X, in line with our Guidance on Remedies, to recognise the family’s distress and uncertainty.
9. If we investigated, we would also likely find the Care Provider had not taken action to recognise the lack of contemporaneous records from the incident. I also asked it therefore to issue a staff reminder about the importance of keeping accurate and contemporaneous records.
10. The Care Provider agreed to take the above actions and remedy the injustice caused to the family at an early stage. It will take these actions within one month of my final decision. It would not be proportionate for us to investigate the matter further, as doing so would be unlikely to lead to a different outcome.

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Final decision

11. We will not investigate Mrs X’s complaint because the Care Provider has agreed to take action to remedy the outstanding injustice we would likely find if we investigated the complaint.

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Investigator's decision on behalf of the Ombudsman