The Ombudsman's final decision
Summary: We will not investigate Mrs B’s complaint about care provided to her late mother Mrs C. This is because further investigation could not add to the Care Provider’s responses or make a finding of the kind Mrs B wants.
The complaint
Mrs B complains she has not received a full clear explanation into the circumstances surrounding late mother’s, Mrs C’s, fall in December 2020. Mrs B says Mrs C should have been provided with a fall alert mat at all times when she was in bed or in a chair because of her medical conditions as identified in her specialist care plan. Mrs B says the Care Provider should ensure it includes and follows conditions of specialist care plans and provide specialist training for specific conditions. In addition, Mrs C wants a full explanation why the fall alert mat was considered ineffective when the specialist care plan said it should be in place.
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.
I considered the Ombudsman’s Assessment Code.
My assessment
The Care Provider considered Mrs B’s complaint and responded to the points she raised. It explained Mrs C was a high risk of falls and her care plan was reviewed each time she fell. It said it was a clinical decision to remove the sensor mat, not as Mrs B alleged because of the regularity of the alarm going off. It explained a sensor mat does not guarantee the prevention of falls, and in Mrs C’s case, the outcome may not have been any different even if a sensor mat had been in place, given the nature and speed of the fall. The Care Provider acknowledged the reason for removing the mat was not documented and advised Mrs B recording has been addressed with staff as part of its lessons learned process.
Although Mrs B is concerned she has not had a full explanation about why Mrs C did not have a sensor mat in place, further investigation could not add to the Care Provider’s responses or make a different finding of the kind Mrs B wants. Sadly, Mrs C is deceased, so any injustice caused by fault which an investigation might uncover, cannot be remedied now.
Final decision
We will not investigate Mrs B’s complaint because further investigation could not add to the Care Provider’s responses.
Investigator's decision on behalf of the Ombudsman