Summary: Mrs A complains about the way the Care Home and GP Practice cared for her mother, Mrs B. We will not investigate this complaint because we are unlikely to achieve anything more. This is because the coroner has already looked at the issues, and there has already been an independent investigation.

The complaint

1. Mrs A complains about the care and treatment provided to her mother, Mrs B, at Spencer Grove Care Home (the Care Home), run by Milford Care Limited. She also complains her mother’s GP Practice, Whitemoor Medical Centre (the GP Practice), did not give her appropriate support while she was resident at the Care Home.
2. The events Mrs A complains about took place between March and August 2020. Mrs A complains about the lack of action taken by both organisations after Mrs B had a fall and a suspected fracture to her lower leg was treated at the Care Home. She also complains about the care she received when she reached the end of her life.
3. Mrs A explains prior to going into the Care Home, Mrs B was in good health. After moving to the Care Home, she lost weight rapidly and was at risk of malnutrition and falls. Mrs A has been left distressed by her mother’s suffering and feels that because of her age, she was not given proper care and feels guilty for not taking her out of the Care Home.
4. Mrs A wants an independent investigation into what happened and for both the GP Practice and the Care Home to admit it made mistakes. She wants an apology and the cost of the care her mother paid to the Care Home paying to her as compensation for the poor care her mother received.

Back to top

The Ombudsmen’s role and powers

5. We have the power to jointly consider complaints about health and social care. Since April 2015 a single team has considered these complaints acting for both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
6. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something an organisation has done. (Local Government Act 1974, sections 26B and 34D, as amended, and Health Service Commissioners Act 1993, section 9(4).)
7. The Ombudsmen provide a free service but must use public money carefully. They may decide not to start or continue with an investigation if they believe:
• it is unlikely they could add to any previous investigation by the bodies.

Back to top

How I considered this complaint

8. I considered all the information provided to us by Mrs A.
9. I considered the Ombudsman’s Assessment Code.
10. I have considered the actions taken previously in relation to the issues subject to this complaint, including the investigations by both organisations, the inquest and the independent investigation.

Back to top

What I found

11. The coroner opened an investigation in August 2020 and an inquest was scheduled for March 2021.
12. Milford Care, who run the Care Home, commissioned an independent investigation into the events which Mrs A complained about. This independent investigation was completed in October 2021. The investigation found Mrs B had been cared for well and she was “coming to the end of her natural life over these months, and there is nothing to indicate she was neglected.”
13. While Mrs A waited for the inquest, she made complaints to both organisations, and raised her concerns with the Care Quality Commission.
14. There were several delays with the coroner’s inquest and this did not take place until February 2023. The inquest found Mrs B died of natural causes and frailty due to her old age.
15. The events Mrs A complains about took place over four years ago. The complaint is late, but we acknowledge Mrs A has pursued the complaint throughout. She spoke to the PHSO on more than one occasion to ask for advice and the PHSO decided it was not ready for the Ombudsmen while the inquest was ongoing. Therefore, even though the complaint is late, we are satisfied she could not have brought the complaint to us sooner.
16. The events took place over four years ago. Due to this passage of time, recollections of staff could be unreliable and some of the staff involved no longer work for the Care Home. We would be able to consider the written records, but Mrs A has said several times she disagrees with these records and feels they are not a reliable account of what happened.
17. The issues Mrs A has complained have already been investigated by the organisations involved, as well as an independent investigation by a third party and a coroner’s investigation. When Mrs A went back to the organisations after the coroner’s outcome and they have refused to reply further because the issues have already been fully addressed by the coroner.
18. It is unlikely that further investigation would achieve anything more and we would not be able to achieve the outcome Mrs A seeks.

Back to top

Final decision

19. We will not investigate this complaint because it is unlikely we could achieve anything more.

Back to top

Investigator's decision on behalf of the Ombudsman