The Ombudsman's final decision
Summary: We will not investigate this complaint about the outcome of safeguarding enquiries. Further investigation would not lead to a different outcome.
The complaint
Mrs X complained about the outcome of safeguarding enquiries into her late brother’s, Mr Y’s death. She believes the Care Agency who supported him should have contacted an ambulance sooner. She states there are still unanswered questions about Mr Y’s care. She wants an independent investigation into the Care Agency’s actions.
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 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 continue an investigation if we decide: we could not add to any previous investigation by the organization, or further investigation would not lead to a different outcome.
(Local Government Act 1974, section 24A(6), as amended, section 34(B))
How I considered this complaint
I considered information provided by the complainant and the Council.
I considered the Ombudsman’s Assessment Code.
My assessment
Following Mr Y’s death, Mrs X contacted the Council with safeguarding concerns about his care before he died. The Council completed safeguarding enquiries. It specifically considered Mrs X’s concerns about the Care Agency’s actions on the day he died, and if it should have called an ambulance sooner.
As part of its enquiries the Council reviewed Mr Y’s care records, sought additional information from care staff about Mr Y’s presentation during the day, contacted the ambulance service and Mr Y’s GP.
The Council was satisfied there was not enough evidence to suggest the Care Agency should have contacted an ambulance sooner. It found there was no evidence that Mr Y was struggling to breathe during the day. It found there were issues with the Care Home not ensuring Mr Y’s hoist was fully charged, which impacted on his transfer to the ambulance stretcher. It recommended additional training around this. However, feedback from the ambulance service was that did not delay Mr Y’s admission to hospital.
The Council considered other points raised by Mrs X suitability of the placement. It found Mr Y’s care had been reviewed by a multi-disciplinary team who felt the placement suitable for his needs. It noted he had received an increase in care hours, was receiving support from a speech and language therapist (SaLT) and that the GP had been involved. It found Care Staff were familiar with Mr Y’s needs and the Care agency had planned additional training.
Although Mrs X is unhappy with the outcome of the safeguarding enquiries, we will not investigate this complaint. The Council has already considered all available evidence, and set out why, on balance, it has not upheld the concerns expressed by Mrs X about the Care Agency’s actions. It has also set out why it was satisfied the placement was suitable for Mr Y’s needs. We could not add to the Council’s consideration of these matters. Where the Council found shortcomings in the Care Agency’s actions, it made recommendations for improvement. Further investigation by the Ombudsman would not lead to a different outcome.
Final decision
We will not investigate Mrs X’s complaint because we cannot add to the Council’s investigation.
Investigator's decision on behalf of the Ombudsman