Summary: We found fault by a Trust with regards to how it handled concerns about Mrs P’s mental health. The Trust will apologise to Mrs P and take action to prevent similar problems occurring in future. We also found fault by the Council with regards to the record keeping of its Mental Health Duty Team. However, we found no fault with the care provided by that team or the Approved Mental Health Practitioner service.

The complaint

1. The complainant, who I will call Mrs P, is complaining about the care provided to her by Surrey County Council (the Council) and Surrey and Borders Partnership NHS Foundation Trust (the Trust).
2. Mrs P complains that the Council and Trust:

• failed to take appropriate action in July 2021 when they received police referrals suggesting she was at imminent risk of harm;
• failed to work together to assess her mental health and social care needs and did not take action to safeguard her;
• did not have proper regard for her human rights;
• ignored her wishes regarding her treatment; and
• failed to handle her complaint appropriately.

3. Mrs P says these events have caused her significant distress and that she has been left without confidence in the Council or Trust. As a result, she feels unable to engage with either organisation. Mrs P says this has had an impact on her ongoing care.

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The Ombudsmen’s role and powers

4. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1), as amended).
5. If it has, they may suggest a remedy. Our recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused.  We might also recommend the organisation takes action to stop the same mistakes happening again.
6. If the Ombudsmen are satisfied with the actions or proposed actions of the bodies that are the subject of the complaint, they can complete their investigation and issue a decision statement. (Health Service Commissioners Act 1993, section 18ZA and Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. In making my final decision, I considered information provided by Mrs P. I also considered records and documentation from the Council and Trust. The Trust deleted all care records related to Mrs P at her request. However, Mrs P retained some of this information and was able to provide me with copies of relevant entries. I also considered comments from all parties on my draft decision statement.

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What I found

Relevant guidance and legislation

Mental Health Act

8. The Mental Health Act 1983 allows for a person who has a mental disorder and is putting their safety or someone else’s at risk to be detained in hospital against their wishes. This is sometimes known as ‘being sectioned’.
9. Usually, three professionals need to agree that the person needs to be detained in hospital. These are either an Approved Mental Health Professional (AMHP) or the nearest relative, plus a doctor who has been specially approved in Mental Health Act detentions and another doctor.
10. The AMHP is responsible for deciding whether to go ahead with the application to detain the person and for telling the person and their nearest relative about this. Admission should be in the best interests of the person and they should not be detained if there is a less restrictive alternative.
11. The Mental Health Act Code of Practice sets out five overarching principles. These are:

• Least restrictive option and maximising independence
• Empowerment and involvement
• Respect and dignity
• Purpose and effectiveness
• Efficiency and equity

12. With regards to the least restrictive option, Section 1.2 of the Code of Practice says that “[w]here it is possible to treat a patient safely and lawfully without detaining them under the Act, the patient should not be detained.”

Care Act

13. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment of any adult who appears to need care and support. They must assess anyone, regardless of their finances or whether the council thinks they have eligible needs. The assessment must be of the adult’s needs and how they impact on their wellbeing and the outcomes they want to achieve. It must involve the individual and where appropriate their carer or any other person they might want to be involved.
14. An assessment should be carried out over an appropriate and reasonable timescale taking into account the urgency of needs and a consideration of any fluctuation in those needs. Councils should let the individual know of the proposed timescale for when their assessment will be conducted and keep the person informed throughout the assessment process.

Single Combined Assessment of Risk Form (SCARF)

15. Surrey Police triage all reports relating to children and adults who police officers consider may be vulnerable following a police call out.
16. The police triage process uses a four-level system:

• Level 1 – no action or sharing required
• Level 2/3 – shared with the Council’s Adult Social Care Information and Advice Service for information, signposting or consideration of a service
• Level 4 – shared with the local Multiagency Safeguarding Hub (MASH) as the police believe an adult may require a safeguarding response

17. The police complete a SCARF form and mark this with the appropriate triage level. This is then processed by the Adult Social Care Information and Advice Service to determine what, if any, further action is needed.

Human Rights Act 1998

18. The Human Rights Act 1998 sets out the fundamental rights and freedoms that everyone in the UK is entitled to. This includes the right to life, freedom from torture and inhuman or degrading treatment or punishment, liberty and security of person, a fair hearing, respect for private and family life, freedom of expression, freedom of religion, freedom from forced labour, and education. The Act requires all local authorities - and other bodies carrying out public functions - to respect and protect individuals’ rights.
19. Not all rights operate in the same way. Instead, they break down into three separate categories:

• Absolute rights: those which cannot be interfered with under any circumstances.
• Limited rights: those that can be interfered with in certain circumstances; and
• Qualified rights: those rights where interference may be justified in order to protect the rights of others or wider public interest. Any interference with a qualified right must be in accordance with the law; in pursuit of a legitimate aim; no more than necessary to achieve the intended objective; and must not be arbitrary or unfair.

20. The Ombudsman’s remit does not extend to making decisions on whether or not a body in jurisdiction has breached the Human Rights Act – this can only be done by the courts. But the Ombudsman can make decisions about whether or not a body in jurisdiction has had due regard to an individual’s human rights in their treatment of them, as part of our consideration of a complaint.
21. In practical terms, councils will often be able to show they are compliant with the Human Rights Act if they consider the impact their decisions will have on the individuals affected and that there is a process for decisions to be challenged by way of review or appeal.

Background

22. Mrs P is a woman with complex health needs, including diabetes. She lives at home with her husband and mother.
23. On 23 July 2021, the Council received a SCARF referral from the police. This noted that Mrs P had made comments about ending her life and planned to do so using an overdose of Insulin. However, the referral noted that “[t]his is not an immediate threat to harm herself, but a plan she has for the future.” The referral was marked as Level 2/3.
24. The police sent a further SCARF referral on 26 July. This reiterated concerns that Mrs P was planning to end her life. The referral recommended immediate intervention to ensure Mrs P received mental health care and support. However, it also noted that Mrs P “does not wish to approach any medical body for mental health assistance”. The referral was again marked Level 2/3.
25. On the same day, Mrs P sent her GP an advance decision document refusing mental health treatment. Mrs P says she subsequently spoke to a social worker to make her aware of her wishes. I found no evidence of this call in the Council’s records.
26. The second SCARF referral was passed to the Council’s Mental Health Duty Team on 27 July.
27. The police sent a third SCARF referral on the morning of 27 July. This explained that Mrs P retained plans to end her life and was refusing to engage with mental health services. The referral again recommended immediate intervention and suggested that, without this, Mrs P’s life would be in danger. The referral was this time marked as Level 4.
28. The Council says a senior social worker and the Mental Health Duty Team manager discussed the referral. The Council said they ruled out referral to the AMHP service as they concluded a less restrictive approach would be to make a referral to the Trust’s mental health services. This consideration was not documented in the Council’s records.
29. The Council’s Mental Health Duty Team referred the SCARF to the Trust’s Single Point of Access (SPA) later that day.
30. The police visited Mrs P at home on the afternoon of 27 July and submitted a fourth SCARF referral. This noted that Mrs P told officers she did not want to harm herself and had refused to seek mental health support. The referral noted that Mrs P “was left in a place of safety and is going to be monitored by her husband and mother”. The referral was marked as Level 2/3.
31. The SPA acknowledged the referral on 28 July. The clinical lead at the SPA queried whether there had been any discussion with AMHP service and whether the Council had Mrs P’s consent to make a referral.
32. The Mental Health Duty Team responded to say that Mrs P was not known to the Council and did not appear to have care and support needs. On that basis, it said the Trust’s mental health services would be better placed to consider her needs. The Mental Health Duty Team said data protection regulations allowed it to share information without consent where a person’s safety may be at risk.
33. The SPA called Mrs P’s home and spoke to her mother on 28 July. Mrs P’s mother reported that Mrs P did not want any intervention from mental health services and did not want the SPA to contact her GP. Nevertheless, the SPA subsequently wrote to Mrs P’s GP on 30 July.
34. Later that day, the Mental Health Duty Team wrote to Mrs P to explain that she could access mental health services via her GP if necessary. The letter also included details for local crisis services.
35. In her correspondence with the Ombudsmen, Mrs P provided a copy of an email she sent to the Council on 30 July. This was addressed to a social worker in the Mental Health Duty Team. This set out Mrs P’s wellness plan. The plan clarified that Mrs P did not want to receive any further contact from Council or Trust mental health services. Furthermore, Mrs P said she did not want services to contact her GP. I found no evidence of this email in the Council’s records. As a result, it is unclear whether the social worker saw it.
36. The SPA wrote to Mrs P’s GP that day. This letter explained that the SPA had attempted to contact Mrs P without success. The letter said an officer had spoken to Mrs P’s mother, who felt further contact from mental health services would cause the situation to deteriorate. The SPA noted that Mrs P was “well supported” by her husband and mother and recommended that the GP refer her to the local community integrated mental health service.
37. Mrs P subsequently contacted the Council to explain that she had not given consent for her data to be shared. She asked the Council to delete all records relating to her and said she did not wish to receive any further contact.
38. Mrs P contacted the SPA on 27 August to request that her information be deleted from the Trust’s records.
39. Mrs P attended a meeting with the Trust on 16 September to discuss her records. A Trust officer noted Mrs P became tearful and was trembling throughout. Mrs P said she would not engage with mental health services on any level. The Trust officer also noted that Mrs P had “decided that she will end her life.”
40. This led the SPA to refer Mrs P to the Mental Health Duty Team later that day to request a Mental Health Act Assessment.
41. An AMHP spoke to Mrs P on the telephone. Mrs P reiterated that she would not consider engaging with mental health services on any level. The AMHP noted "I have explained my role and about the duty of care we have as services to support her, this can be done voluntarily or compulsory [sic] if necessary.” The AMHP also spoke to Mrs P’s mother, who confirmed she was supporting her. The AMHP decided not to proceed with a Mental Health Act Assessment and referred the matter back to the SPA for further discussion.
42. A Trust clinician visited Mrs P at her home address on 17 September. She noted that Mrs P denied any suicidal ideation. The clinician concluded there were no risk factors and no evidence of a mental disorder. The clinician discharged Mrs P to the care of her GP.

Analysis and findings

SCARF referrals - July 2021

43. Mrs P complained that the Council failed to pass her case to the AMHP service, despite having information that showed she required immediate intervention to save her life.
44. Between 23 and 27 July, the police sent four SCARF referrals to the Council concerning Mrs P. These documented concerns about her mental health and recorded she was considering taking her own life.
45. SCARF referrals are a process by which the police can make the Council aware of people who may require additional support. It is for the Council to decide what, if any, further support would be appropriate.
46. Nevertheless, the SCARF referrals suggested Mrs P was at significant risk of harm. This placed a duty on the Council’s Mental Health Duty Team to consider the most appropriate way to support her.
47. Section 13(1) of the Mental Health Act says that “[i]f a local social services authority have reason to think that an application for admission to hospital or a guardianship application may need to be made in respect of a patient within their area, they shall make arrangements for an approved mental health professional to consider the patient’s case on their behalf.”
48. However, the Mental Health Act Code of Practice that accompanies the Mental Health Act makes clear that detention is a significant intervention in a person’s life. The Code emphasises the importance of following the least restrictive principle where possible. Section 1.2 of the Code says that “[w]here it is possible to treat a patient safely and lawfully without detaining them under the Act, the patient should not be detained.”
49. In the Council’s response to Mrs P’s complaint, it said a duty team officer discussed the case with the team manager on receipt of the SCARF referrals. They decided a more appropriate approach would be to refer Mrs P to the Trust’s SPA to consider whether she would benefit from mental health services.
50. In Mrs P’s case, Council officers were required to weigh the need to ensure she received the necessary care against the need to take the least restrictive approach. In my view, the decision to refer Mrs P to the Trust for a consideration of her mental health needs was proportionate and in keeping with the Mental Health Act Code of Practice. I find no fault by the Council in this regard.
51. The Social Care Institute for Excellence (SCIE) says that “[r]ecording is an integral and important part of social work and social care. It is not simply an administrative burden to go through as quickly as possible, but is central to good, person-centred support.”
52. However, I found no record in the Council’s case notes of the duty team officer’s discussion with her manager nor any explanation for the decision to refer Mrs P to the Trust. The failure of officers to keep a contemporaneous record of the decision-making process in this case represents fault by the Council.
53. This caused Mrs P avoidable confusion and uncertainty.

Consent to treatment (Council)

54. In her complaint to the Ombudsmen, Mrs P said Council officers ignored her advance decision and wellness plan in referring her to the Trust without her consent.
55. Mrs P sent a copy of her advance decision document to her GP on 26 July 2021. This made clear that she did not want to receive care from mental health services. However, this information was recorded on her GP’s system and so would not have been available to Council officers.
56. In her correspondence, Mrs P said she spoke to a social worker in the duty team on 26 July regarding her Advance Decision and wellness plan. This remains a point of dispute. I found no evidence of this call in the Council’s records and the social worker named by Mrs P denied having spoken to her. The case records suggest the duty team attempted to contact Mrs P on 26 July without success.
57. A subsequent case note (dated 2 November) refers to earlier correspondence between Mrs P and the social worker. However, the Council maintains that the social worker did not speak to Mrs P and that this case note refers instead to an email sent by the social worker to Mrs P on 28 July.
58. In the absence of any further contemporaneous evidence, I am unable to reach a view, even on balance of probabilities, on whether Mrs P spoke to a social worker on 26 July. This means there remains some uncertainty as to what extent Council officers were aware of Mrs P’s wishes regarding her care at that time.
59. On 30 July, Mrs P sent a copy of her wellness plan to the same social worker. Again, this said Mrs P did not want mental health input. The social worker could not recall having received this document and I found no evidence of it in the Council’s records. However, I note Mrs P asked the social worker not to retain the plan. It is possible, therefore, that the social worker deleted the email and attached plan in accordance with Mrs P’s wishes. I am unable to reach a meaningful conclusion on this point from the available evidence.
60. Irrespective of whether the social worker saw the email and attached wellness plan, the duty team had already made two referrals for Mrs P to the Trust by that point.
61. Taking everything into account, my view is that Council officers acted appropriately in sharing information about Mrs P with the Trust. I found no evidence to suggest Council officers deliberately ignored her wishes. Rather, they were trying to ensure she received appropriate care given the serious concerns raised in the SCARF referrals.

Social care needs (Council)

62. Mrs P complained that the Council failed to provide her with a social care assessment despite her vulnerability and its duty to promote her wellbeing.
63. The Care Act 2014 places a duty on local authorities to promote the wellbeing of people in their area. In addition, a local authority’s duties to assess a person’s social care needs are set out clearly in Section 9 of the Act. This section states that “[w]here it appears to a local authority that an adult may have needs for care and support” the local authority must carry out an assessment.
64. It is not in dispute that Mrs P has complex care needs. However, the SCARF referrals received by the Council refer exclusively to concerns about Mrs P’s mental health. There is no indication in these documents that Mrs P required, or was seeking, social care support.
65. Therefore, it was appropriate for the Council’s Mental Health Duty Team to focus on securing appropriate mental health care for Mrs P. It was open to Mrs P to request a social care assessment if she required additional support. I found no fault by the Council here.

Consent to treatment (Trust)

66. Mrs P said the Trust continued to share her personal information once it received a referral from the Council. This included sharing her information with her GP without her consent.
67. The Mental Health Duty Team made a first referral to the Trust’s SPA on 27 July. This led to an exchange of emails between the Mental Health Duty Team and the SPA as to whether Mrs P had consented to the referral. However, the Mental Health Duty Team concluded it could share information about her if her safety was at risk.
68. On 28 July, a nurse from the SPA contacted Mrs P’s mother. The nurse noted “Mother repeated that I was under no circumstance to tell the GP of the concerns, that [Mrs P] and the GP are on first name terms and to inform her GP would be devastating for [Mrs P], would alienate her from accessing both her GP and primary health services which she needs…Mother reported that [Mrs P] is not mentally unwell.”
69. Nevertheless, the nurse wrote to Mrs P’s GP on 30 July. The letter explained that the SPA had tried to speak to Mrs P without success. The letter noted that Mrs P was “currently well supported and in constant supervision with husband and mother”. The SPA also advised the GP to offer Mrs P a review and consider a referral to the local community integrated mental health service.
70. At this point, the case was closed by the Trust.
71. The available evidence shows that, by 28 July, the SPA was aware that Mrs P was being supported at home by her family. They were further aware of her wishes with regards to sharing information with her GP. Despite Mrs P’s wishes, the SPA contacted her GP. I could find no clear rationale for this decision nor any consideration of the potential risk to Mrs P arising from the decision. This was fault by the Trust. This caused Mrs P further distress.

Further intervention - September 2021

72. In late July and again in late August, Mrs P contacted the Trust to request that her personal data be deleted. This led the Trust to offer Mrs P a meeting with the records team and a nurse from the SPA to discuss her records. This was due to take place on 16 September.
73. On 13 September, the SPA nurse discussed Mrs P’s case with an officer from the Mental Health Duty Team. The duty team officer noted that “[a]t this stage, my view is that [a Mental Health Act Assessment] could be more harmful than helpful.”
74. On 14 September, Mrs P contacted the records team to request assurances that “my meeting…is simply to discuss data and not an attempt to undertake a mental health assessment”. She received a response from the records team to say that the nurse had agreed to meet with Mrs P “as a health care professional to discuss the contents of your records”.
75. The meeting proceeded as arranged on 16 September. I have not seen a contemporaneous note of that meeting.
76. That day, the SPA nurse referred Mrs P to the AMHP service for a Mental Health Act Assessment. The AMHP service contacted Mrs P that evening. I have commented on the AMHP’s actions below.
77. The SPA nurse subsequently sent an email to colleagues on 17 September (following the AMHP’s involvement). She noted that the meeting on 16 September “was face to face on the pretence to discuss her records. [Mrs P] appears acutely stressed and very tearful on every engagement”. She said “[Mrs P] has decided that she will end her life.” The nurse concluded that “this is a lady that is experiencing an acute mental illness with a considerable risk posed to herself”.
78. The Mental Capacity Act 2005 sets out the law for anyone working with adults who may lack capacity to make particular decisions. This is accompanied by the Mental Capacity Act Code of Practice. This sets out guidance for professionals on how to implement the Act.
79. Principle 1 of the Act says that “[a] person must be assumed to have capacity unless it is established that he lacks capacity.”
80. Principle 3 of the Act says that “[a] person is not to be treated as unable to make a decision merely because he makes an unwise decision.”
81. I have seen no evidence in the available records to suggest Mrs P lacked capacity to make decisions about her care. By 16 September, Mrs P’s wishes were clearly recorded regarding her care and treatment. She made clear to several professionals that she did not wish to receive any input from mental health services. Indeed, in the days leading up to the meeting, Mrs P sought specific assurances that this would not be treated as an assessment.
82. It is of significant concern, therefore, that the SPA nurse used the meeting as an opportunity to assess Mrs P without her knowledge or consent. The SPA nurse also appears to have disregarded other information that was available at that time. This included the fact that both Mrs P’s mother and an officer in the Mental Health Duty Team had advised that further mental health input would likely not be in her best interests. Furthermore, information gathered by the SPA in July showed Mrs P was supported at home and had access to care via her GP if necessary.
83. Mrs P says she did not, at any point during this meeting, inform the nurse that she was intending to take her own life. I consider it likely, on balance of probabilities, that Mrs P’s account is correct. This is because Mrs P also informed an AMHP that evening that she had no plans to end her life. Indeed, Mrs P was subsequently able to demonstrate that the initial police SCARF referrals were incorrect and that she had not made this threat at any point.
84. Taking everything into account, the decision to refer Mrs P to the AMHP service was disproportionate and was not taken in accordance with the Mental Capacity Act. The existing records suggest no new clinical evidence had become available that would explain this decision. In making this referral, the Trust did not have proper regard for Mrs P’s human rights. These included her rights to security and liberty (Article 5) and her right to respect for private and family life (Article 8). This was fault by the Trust.
85. I have commented specifically below on the subsequent contacts between Council and Trust officers and Mrs P. However, there is clear evidence to show that Mrs P was extremely distressed by the continued contact from mental health services.

AMHP contact - September 2021

86. On 16 September, the SPA nurse referred Mrs P to the AMHP service. An AMHP contacted Mrs P that evening to discuss her care. In her complaints correspondence, Mrs P made clear that she found this conversation distressing. She said the AMHP had threatened her and had behaved in an intimidating manner.
87. The AMHP’s case notes make clear that he decided to speak to Mrs P in the first instance. This was to help him decide whether a full Mental Health Act Assessment would be necessary. The AMHP noted that Mrs P denied having any plans to end her life. He also noted that Mrs P would not engage with mental health services but would seek treatment through her GP if necessary. The AMHP recorded that “I have explained my role and about the duty of care we have as services to support her, this can be done voluntarily or compulsory [sic] if necessary.”
88. Following this call, the AMHP discussed the case with a colleague. He decided not to proceed with a Mental Health Act Assessment as long as he could obtain assurances that Mrs P had support at home.
89. The AMHP subsequently spoke to Mrs P’s mother, who confirmed she was supporting her. As a result, the AMHP did not proceed with a full assessment and referred Mrs P back to the SPA.
90. As I have explained above, my view is that the decision to refer Mrs P to the AMHP service was disproportionate based on the evidence available at that time. However, I am satisfied that, once the referral had been made, the AMHP acted appropriately and in keeping with the ‘least restrictive’ principle set out in the Code of Practice.
91. I appreciate the call came as a shock to Mrs P and that she found this very distressing. Nevertheless, the AMHP was obligated to explain possible treatment options. This included compulsory treatment under the Mental Health Act. The Council acknowledged the call was distressing for Mrs P and passed the AMHP’s apology for this. In my view, this is a proportionate response to this issue. I found no fault by the Council in this regard.

Clinical input – September 2021

92. A clinician from the Trust’s community mental health team visited Mrs P at home on 17 September. She spoke to Mrs P for around half an hour. She concluded that Mrs P was not suffering from a mental disorder and did not require any further input from mental health services.
93. In her complaint to the Ombudsmen, Mrs P complained that the clinician had attended unannounced and without making an appointment. She said the clinician attended alone and that this was not in keeping with the requirements for an assessment.
94. The evidence I have seen suggests the clinician visited Mrs P to determine whether any further action was required by the Trust. This was not a formal Mental Health Act Assessment. There was no requirement for the clinician to be accompanied for the purposes of the assessment, therefore.
95. It is appropriate to recognise that the Trust was in a difficult position, having received a referral from the AMHP service. This required the clinical team to weigh Mrs P’s wishes against the serious concerns about her wellbeing set out in the SCARF referrals.
96. Nevertheless, the Trust should not have made an unannounced visit to Mrs P without exploring whether she would consent to an assessment. Again, this was against Mrs P’s wishes and represents fault by the Trust.
97. In my view, the injustice arising to Mrs P from this visit was mitigated to some extent by the conduct of the visiting clinician. Mrs P described the clinician as “professional, polite, empathetic and supportive.” Nevertheless, this further contact came as a shock to Mrs P and caused her additional distress.
98. I have considered whether it would be appropriate to recommend a financial remedy in recognition of the distress caused to Mrs P by the Trust’s actions in September 2021. However, I note the Trust has accepted some fault and has paid £2,000 towards Mrs P’s private counselling fees as part of its handling of her complaint. In my view, this represents a proportionate remedy. For this reason, my recommendations focus on action to prevent similar problems occurring in future.

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Agreed actions

Council

99. Within one month of my final decision statement, the Council will write to Mrs P to apologise for the distress and confusion caused to her by its failure to maintain accurate and complete records.
100. The Council told me it issued updated record-keeping guidance to all staff in May 2023. The Council will provide the Ombudsmen with a copy of the updated guidance and the accompanying email from the Caldicott Guardian.
101. The Council will also explain what action it will take to audit the standard of records on an ongoing basis.

Trust

102. Within one month of my final decision statement, the Trust will write to apologise to Mrs P for the distress caused to her by:

• Its decision to make a referral to her GP against her expressed wishes;
• its decision to undertake an assessment against her wishes and without her consent in September 2021;
• its decision to refer her to the AMHP service without good reason; and
• its decision to make an unannounced assessment visit to her home.

103. Within three months of my final decision statement, the Trust will explain what action it will take to:

• put clear guidance in place for Trust staff on the application of the Mental Capacity Act 2005. This should ensure that staff are aware of the importance of properly recording and respecting the wishes and decisions of a capacitated adult.

104. The Council and Trust will provide us with evidence they have complied with the above actions.

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Final decision

105. We found no fault by the Council in terms of the care it provided to Mrs P. However, we did find fault with the Council’s record-keeping.
106. We found fault by the Trust in terms of its continued contact with Mrs P in July and September 2021, which was against her expressed wishes.
107. I am satisfied the agreed actions set out above, along with the action already taken by the Trust, represent an appropriate and proportionate remedy for the injustice Mrs P suffered as a result of this fault.
108. I have now completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman