Report Date


Case Against

A Care Home


Care Homes

Case Reference Number



Upheld in whole or in part

Mr X complained about aspects of care provided to his late father Mr Z, by the Care Home between April 2020 and May 2021.

The Ombudsman found that there was no failure to consider the interaction between trazadone (an antidepressant) and lamotrigine (epilepsy medication) and that it was, ultimately the role of the prescribing clinicians, as opposed to the Care Home staff, to consider and monitor these issues before prescribing. However, there was no written record to satisfy the Ombudsman that appropriate discussions were held with either Mr Z or the family surrounding the deterioration in his behaviour, how it might be managed or the potential impact of the medication. This was maladministration which left Mr X in some uncertainty about whether this might have been different had there been better communication from the Care Home. This was an injustice and this complaint was upheld to this extent.

The Ombudsman did not uphold a complaint about the decision to take Mr Z to hospital in April 2021 following a fall. She acknowledged the family’s concern about Mr Z being admitted but noted that the nature and circumstances of the fall were such that calling an ambulance was warranted, and following clinical assessment by paramedics, they (as opposed to Care Home staff) concluded that transfer to hospital for further investigations was necessary.

In relation to a complaint about the failure to identify that Mr Z was suffering from delirium in May 2021, the Ombudsman found that, whilst Care Home staff did not consider or record the possibility that delirium was the cause of the symptoms displayed, they took appropriate action to address Mr Z’s symptoms through investigations and referrals. On this basis, she found that a formal diagnosis of delirium would not have altered the care he received, which was appropriate. Whilst this complaint was not upheld, the Ombudsman invited the Care Home to familiarise itself with relevant guidance on recognising and preventing delirium and to consider providing training to staff on delirium.

The Care Home agreed to implement the Ombudsman’s recommendations to apologise to Mr X for the identified failings, to remind staff about the importance of discussing significant behavioural changes with family members and the importance of communication with residents and family members.