Summary: Dr Y complained the Council failed to provide services to her father in the weeks before he died. She says the lack of support from the Council caused him to suffer unnecessarily. Dr Y also complained about the communication the Council maintained with her family after her father’s death, and its record keeping. We found fault with some actions of the Council. The Council apologised for this fault. This was an appropriate remedy for the injustice caused.

The complaint

1. Dr Y complained about the lack of social care support for her father, Dr Z, in the lead up to his death (January – February 2024). She said she asked the Council to carry out an NHS continuing healthcare assessment and a Care Act 2014 (care and support) assessment, neither of which it did.
2. Dr Y complained about the Council’s insensitive actions following her father’s death, and the Council’s poor complaint handling. She complained about the Council being unable to locate her father’s care records, when she contacted it.
3. Dr Y said her father lived through poor health with no support at home because of failings by the Council. Dr Y said her father died in hospital, against his wishes, and support at home could have prevented this.

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The Ombudsman’s role and powers

4. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these.
5. If we are satisfied with an organisation’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

6. I considered evidence provided by Dr Y and the Council.
7. I made written inquiries of the Council and considered its response along with relevant law and guidance.
8. Dr Y and the Council had the opportunity to comment on the draft decision. I considered any comments before making a final decision.

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What I found

Law and guidance

9. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
10. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve. It must also involve the individual and where suitable their carer or any other person they might want involved.
11. Councils must carry out assessments over a suitable and reasonable timescale considering the urgency of needs and any variation in those needs. Councils should tell people when their assessment will take place and keep them informed throughout the assessment.
12. Where it appears a person may be eligible for NHS Continuing Healthcare (NHS CHC), councils must notify the relevant integrated care system (ICS). NHS CHC is a package of ongoing care arranged and funded solely by the NHS where the individual has been found to have a ‘primary health need’ as set out in the National Framework for NHS Continuing Healthcare and NHS-Funded Nursing Care. Such care is provided to people aged 18 years or over, to meet needs arising from disability, accident or illness.
13. Complaints about NHS CHC are dealt with by the Parliamentary and Health Service Ombudsman.

What happened

14. Dr Z was known to the Council in 2023. Adult social care provided equipment to Dr Z to support his physical health needs. It used a specialist contractor (company B). Dr Z had support in place from different medical practitioners.
15. At the start of 2024 Dr Z’s health deteriorated. Dr Y, Dr Z’s daughter, complained to the local NHS Trust about the care her father was receiving.
16. In February 2024 an ambulance was called to the home, to attend to Dr Z.
17. A few days later the ambulance crew made a safeguarding referral to adult social care at the Council. This was because Dr Z had deteriorated, and concerns about how the family were coping.
18. On the same day, Dr Z was admitted to hospital. The Council records show it made a telephone call to Dr Z’s son. This was in response to the safeguarding referral made by the ambulance crew. Dr Y strongly disputes this call took place.
19. Council records show Dr Z’s son explained Dr Z was receiving ‘end of life’ care. It said it offered advice about a local charity that might be useful.
20. On the same day, while in hospital, Dr Z died.
21. About a week later the equipment used to help Dr Z with his physical health needs was collected from the home.
22. In April the Council received a notification that Dr Z had died.
23. The Council called Dr Y and asked for its equipment back.
24. Dr Y complained to the Council a few days later. She complained about the communication from the Council, the lack of case records about her father’s care, and the lack of support from the Council in 2024.
25. About one month later the Council made its stage one complaint response to Dr Z. In summary, the Council upheld Dr Z’s first point about the unnecessary contact with her about the equipment. It apologised. It explained company B’s system was not up to date. It said it had been in contact with company B about the incident.
26. The remainder complaint points were not upheld. The Council said its staff had to ask questions to verify Dr Z’s identity, as when Dr Y made the initial complaint, some of Dr Z’s information was missing. It also explained the process it followed to locate service user records. From Council records there was only one telephone call made in April 2024 to Dr Y. The Council had no record of any other calls. The Council told Dr Y what it had done in response to her complaint, and how it would update process and deliver training to staff.
27. Dr Y was unhappy with the stage one complaint response and escalated her complaint to stage two.
28. A few weeks later the Council made its stage two, and final, response to Dr Y.
29. The Council said it did not deliver care to Dr Z, in the year leading up to his death. The Council reiterated some of the response it made at stage one. It signposted Dr Y to the Ombudsman.

My findings

30. The Council completed a care and support needs assessment in March 2023 and no eligible needs were identified. The Council had no reason to complete another care and support assessment, or NHS continuing care assessment. This is because Council records show it had no contact from Dr Z or Dr Z’s family to ask for another assessment.
31. Dr Y was in contact with several NHS teams delivering care to Dr Z. A review of Dr Z’s needs may have been discussed with clinicians involved in Dr Z’s medical treatment. These are separate matters and have not been investigated.
32. I do not find fault with how the Council delivered care to Dr Z. The Council records show it had no reason to believe Dr Z required more support than he was receiving. While Dr Y strongly disputes this, I have no evidence to corroborate any fault in the actions of the Council.
33. When the Council was notified of concerns, by the ambulance crew that attended the home, its records show it called Dr Z’s son the same day. There was no delay in attempting to make enquiries about Dr Z and his family.
34. The Council responded thoroughly to Dr Y’s complaint. The Council explained why it asked several times to clarify Dr Z’s identity. It also explained why this may have taken longer than usual.
35. The Council upheld the complaint point about the unnecessary phone call made about the equipment collection. Council management have discussed the incident with company B’s management. The Council understands why the error occurred and is working with company B to try to ensure it does not happen again.
36. The Council told us company B is working with commissioners to implement a new data system this year. Staff have been trained. There is now a new process in place to check unclear information, prior to contacting families. This should alleviate the concern about this happening again, prior to the new system being installed.
37. The Councils response to the complaint, and the upheld point, is thorough, and adequate. There is nothing further I can add to its investigation The apology it gave is an appropriate remedy for the injustice caused.

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Decision

I find no fault in how the Council delivered care to Dr Z. The Council admitted fault in its handling of the equipment collection. The Council has already taken action to remedy the injustice caused.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman