Summary: We will not investigate Mrs B’s complaint about care provided to her late mother, Mrs C. This is because further investigation by the Ombudsman could not add to the Care Provider’s response or make a different finding of the kind Mrs B wants.

The complaint

1. Mrs B complained about care provided to her late mother, Mrs C. Mrs B says Mrs C was left in a hot room with no cooling aids for days, did not act on concerns she raised about her mother’s breathing. Mrs C died of pneumonia a few weeks later. Mrs B says Mrs C was not seen by her GP for 12 months when she lived in the home.

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The Ombudsman’s role and powers

2. 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)

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How I considered this complaint

3. I considered information provided by the complainant and the Care Provider.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Mr and Mrs C lived in the same care home from August 2020. Mrs C passed away on 10 August 2021. The Care Provider responded to Mrs B’s complaints. It says:

Mrs [C] was present in the meeting that took place on the 10 August 2021 about Mr [C]. It was clear that she was not physically comfortable and when she needed the toilet she withdrew before the meeting was concluded. On that same day she passed away. Mrs [C] was living with hypertension, ischaemic heart disease, aortic stenosis, depression and anxiety. No indications of pneumonia were observed in the days before her passing. No signs were observed during the meeting and no one present commented on that possibility.

6. We could not add to this or make a different finding even if we investigated.
7. The Care Provider explained between 2 September 2020 and 6 August 2021 it had contact with clinical specialists on 19 occasions six of which were with Mrs C’s GP. Mrs C’s GP prescribed appropriate medication for her. It would be for Mrs C’s GP to decide whether a home visit would have been necessary. We cannot comment on decisions taken by health care professionals because they are not within our jurisdiction.
8. Mrs B complained about the heat in Mrs C’s room and said she had found her curtains left open. The Care Provider explained it was usual practice to close the curtains in the afternoon to avoid direct sunlight and said it was regrettable on this occasion it had not done so. It explained although the recommended minimum temperature is 21 degrees, on nine days throughout July the temperature had exceeded this. The Care Provider says windows are open with a 150mm gap to allow air to circulate. The Care Provider says it has reflected how to best meet hot episodes in future given they are likely to become more extreme and frequent. We could achieve no more even if we investigated.
9. The Care Provider says it does not have a record of Mrs B’s concerns about Mrs C’s breathing and no staff members recall this. We could not make a finding on this point.

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Final decision

10. We will not investigate Mrs B’s complaint because further investigation by the Ombudsman could not add to the Care Provider’s response or make a different finding of the kind Mrs B wants.

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Investigator's decision on behalf of the Ombudsman