The Ombudsman's final decision
Summary: We will not investigate this complaint about how the Care Home responded to an unwitnessed fall. That is because further investigation is unlikely to lead to a different outcome.
The complaint
Mrs X complained about the actions of a Care Home, after her mother, Mrs Y had an unwitnessed fall. She said the Care Home: Failed to fully explain the level of injury Mrs Y had sustained.
Did not have contingency plans in place to deal with the delay in the emergency services response.
Sent Mrs Y to hospital unaccompanied despite her having dementia.
Mrs X said the Care Home had failed to provide an adequate explanation for what had happened. She said she wanted to know what information the Care Home shared with the emergency services and whether Mrs Y was asleep or unconscious following the fall. She wants an independent investigation and for the Care Home to admit its failings.
The Ombudsman’s role and powers
The Ombudsman investigates 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 may decide not to continue with 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))
How I considered this complaint
I considered information provided by the complainant and the Council.
I considered the Ombudsman’s Assessment Code.
My assessment
In the Care Home’s response to Mrs X’s complaint, it explained that Mrs Y had an unwitnessed fall at around 11pm. The on-duty nurse assessed Mrs Y and decided to call the emergency services as she had sustained a head injury. The Care Home contacted Mrs X about the fall and told her it was waiting for an ambulance.
The Care Home apologised if Mrs X felt it had played down the extent of Mrs Y’s injury. It said that the care staff would not necessarily of seen any bruising to Mrs Y’s face at the time of the fall, as bruising tends to develop later. It recognised that Mrs X would have been distressed when she later saw Mrs Y in hospital with injuries.
The Care Home said nursing staff continued to check Mrs Y throughout the night whilst it waited for the ambulance. It said there was no immediate change to Mrs Y’s presentation. It said the nurse told the emergency services Mrs Y was sleeping and it advised the Care Home to continue with its observations.
The Care Home said it followed the correct procedure for alerting emergency services after Mrs Y’s fall. It said, it did not contact the out-of-hours GP, as it was most likely they would have directed them back to the emergency service. It said it would not use a taxi to transport a person with a head injury to hospital without the approval of a GP or paramedic. However, it accepted there were lessons to be learnt from the incident and it had made a self-referral to the Council under adult safeguarding because of the time it took for emergency services to attend.
It said that it sent Mrs X to hospital unaccompanied because of a COVID-19 outbreak at the Care Home. It said the ambulance staff did not request an escort and it sent information about Mrs Y to the hospital.
Although Mrs X is dissatisfied with the outcome of the Care Home’s investigation, we will not investigate this complaint further. There is nothing to suggest the Care Home’s investigation was flawed and it is unlikely that further investigation would add anything to the Care Homes findings. The Care Home has taken action where it identified lessons could be learnt from the incident, therefore further investigation is unlikely to lead to a different outcome.
Final decision
We will not investigate Mrs X’s complaint because we could not add to the previous investigation by the Care Home and further investigation is unlikely to lead to a different outcome.
Investigator's decision on behalf of the Ombudsman