The Ombudsman's final decision
Summary: We will not investigate this complaint about adult social care at the end of life. The Care Provider failed to treat its resident with dignity and respect following death. The Care Provider has taken action to improve service and apologised to the family for their distress pursuing a complaint. It is unlikely an Ombudsman investigation would lead to a different outcome.
The complaint
Ms E says the Care Provider failed to treat her relative, Ms F, with dignity and respect at the end of her life, as it sent Ms F to the funeral home without underwear. Ms E also says the Care Provider was not empathetic with Ms F’s daughter, Ms G, when Ms F died. This has caused distress to Ms E and Ms G.
The Ombudsman’s role and powers
We investigate complaints about adult social care providers. We provide a free service but must use public money carefully. We may decide not to start or continue with an investigation if we believe: the action has not caused significant enough injustice to the person who complained to justify our involvement, or it is unlikely further investigation will lead to a different outcome.
(Local Government Act 1974, sections 34B(8) and (9)) When considering complaints, we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
How I considered this complaint
I considered information provided by the complainant.
I considered the Ombudsman’s Assessment Code.
My assessment
Ms F lived at Southampton Manor Care Home run by Willow Tower Opco 1 Limited (the Care Provider).
Ms G was present at the care home when Ms F died. Ms G felt the staff gave her no time to process her mother’s death and Ms G did not feel treated with empathy.
Ms G says she was asked to pick out a dress for Ms F to wear to the funeral home. Ms G later found out the Care Provider had failed to put underwear on Ms F, or a petticoat which Ms F always wore and was part of her care plan.
The Care Provider says it dressed Ms F as Ms G requested; its care records do not detail what it had dressed Ms F in. Ms E has a statement from the funeral directors confirming what Ms F was dressed in, and it does not include a petticoat or underwear.
It is more likely than not the Care Provider failed to appropriately dress Ms F, as it failed to include underwear, or the petticoat Ms F always wore and was detailed in her care plan. This is based on the information provided by Ms G and the funeral directors, and the Care Provider has no record to confirm what it dressed Ms F in at the end of her life.
If the Care Provider was unsure because Ms G had not specifically picked out the petticoat or underwear, it could have checked with the family before sending Ms F to the funeral directors. It would be common sense to ensure Ms F’s dignity to dress her in underwear even if the family had not specifically picked those out.
The Care Quality Commission (CQC) is the independent regulator of health and social care in England. The CQC has fundamental standards below which a person’s care should never fall. The Care Provider should have provided Ms F with person-centred care meeting the needs and preferences detailed in her care plan and should provide care with dignity and respect. The Care Provider should also keep full and accurate records of the care it has provided. Its failures in these areas may be breaches of the fundamental standards.
I understand these matters have been distressing to Ms E and Ms G, but this would not justify an Ombudsman investigation. The Care Provider has accepted fault in several areas and has provided a list of improvements it will make to its service, including: ensuring end of life wishes are noted in residents’ care plans and are always followed and recorded, Any communications about end of life wishes and details of after death care to always be in writing and recorded in care records, Further staff training in supporting relatives who’s loved on is receiving end of life care.
Although the Care Provider has not given Ms E and Ms G a specific apology for the faults the Ombudsman has identified, it has apologised for the distress caused by raising their concerns. I do not consider it likely an Ombudsman investigation would lead to a significantly different outcome.
Final decision
We will not investigate Ms E’s complaint because it is unlikely further investigation would lead to a different outcome. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).
Investigator's decision on behalf of the Ombudsman