The Ombudsman's final decision
Summary: We will not investigate this complaint about care provided to Mr C shortly before he died. This is because further investigation by the Ombudsman could not add to the Council’s response.
The complaint
Mrs B complained about the care provided to her late father, Mr C, shortly before he died. Mrs B says carers should have realised he had an infection when he refused care and called her. Mrs B says if she had of been contacted, her father may not have died alone three hours later. Mrs B says staff need more training and they should ensure family are contacted.
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 effect on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We may decide not to start an investigation if the tests set out in our Assessment Code are not met. (Local Government Act 1974, section 24A(6), as amended)
How I considered this complaint
I considered information provided by the complainant and the Council.
I considered the Ombudsman’s Assessment Code.
My assessment
The Council says Mr C was assessed as needing a discharge to assess (D2A) placement when he was ready to leave hospital, but he decided he wanted to return home with a package of care. Once home Mr C refused some aspects of care. The Council acknowledged, because of his presenting behaviours, the Care Provider should have contacted Mrs B even though Mr C had capacity to make decisions for himself. The Council confirmed, as the commissioning authority, it has raised this issue with the provider and reminded it of the importance of following procedures around what to do if they are not familiar with a person’s behaviours, and the presenting behaviours raise concern.
It is understandable that Mrs B feels upset that Mr C died alone and would have endeavoured to be with him if she was aware of the situation. However, Mr C had capacity and decided he did not want the care he initially agreed to having on discharge from hospital. The Council has acknowledged Mrs B should have been contacted and has explained what it has done to minimise the risk of a similar occurrence. We could achieve no more even if we investigated.
Final decision
We will not investigate Mrs B’s complaint because further investigation could not add to the Council’s response.
Investigator's decision on behalf of the Ombudsman