Date of decision: 28 May 2025
Summary
A complaint was made about a care home’s failure to notify a person’s family when a resident fell seriously ill and was hospitalised.
What happened
Mr Y required support with all daily activities and had resided in Bunkers Hill Care Home since April 2022. His family raised concerns about Mr Y’s health during a visit in August 2024. Staff assured them there was nothing wrong.
The following day, Mr Y became acutely unwell and was admitted to hospital by paramedics, but staff failed to inform Mr Y’s family. The hospital notified Mrs Y, Mr Y’s wife, the next day.
Mr Y’s condition worsened and he died four days later.
Mr X (Mr Y’s step-son) complained that Mr Y’s family’s concerns were not acted on the day before his hospital admission; staff failed to inform the family when Mr Y was admitted to hospital; staff failed to inform the family while he remained in hospital, and Mr Y’s family was not contacted after Mr Y had died.
The Care Provider responded to Mr X’s complaint and stated that their records showed that the staff did not express any concerns with Mr Y’s health prior to his hospital admission. They accepted the Nurse on Duty failed to inform Mr Y’s family of his hospital admission. This was due to the Nurse having to attend another urgent medical matter when the paramedics arrived. This error was addressed with the nurse and changes were implemented to prevent a recurrence of fault. Mr X received an apology and the care home wrote to Mrs Y to apologise about the lack of communication.
Mr X remained unhappy and complained to the Ombudsmen. In his complaint, it was stated that when Mr Y’s family visited the Care Home the day after his death, to collect Mr Y’s belongings, staff present were not aware, even then, that Mr Y had died.
What was found
The Ombudsman found the care home at fault for not informing the family promptly when the resident became unwell and was admitted to hospital, causing significant distress. This was a service failure impacting the family’s right to be notified and breaching good practice in care standards.
However, there was no fault found in response to concerns raised prior to admission, or in staffing levels.
The care home admitted the communication failure, apologised to the family, and immediately introduced new procedures to prevent a repeat. The Ombudsman decided these actions were appropriate and did not recommend financial compensation.
Points to note for councils, professionals, people using services and their carers, advocacy groups and members of the public
The investigation fairly looked at the evidence that the care home offered and was satisfied that in almost all respects, it was not at fault, and left it at that. For instance, it had liaised with the hospital and addressed the serious communication failure internally.
The expectation, merely in terms of good practice, would be that care homes always keep individuals and their representatives involved in decisions and events relating to their care.
Providers should ensure all family members and representatives are given clear information about how and when they will be contacted in emergency situations, and their rights if these duties are not met.
Please use the following link if you want to read the original Local Government and Social Care Ombudsman’s United Health Group Limited (24 009 910) report.
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