Summary: there was delay and other faults in the way the Council carried out a safeguarding enquiry after Miss X reported concerns about the poor quality of care provided to her mother, Mrs Z, by a care agency. This fault caused avoidable distress and uncertainty. I also found fault in the way the Council handled Miss X’s complaint about this matter. The Council was not at fault for the time it took to find an alternative care agency to deliver Mrs Z’s care package.

The complaint

1. Miss X made this complaint on behalf of her mother, Mrs Z, and herself. Mrs Z has mental capacity to make decisions about her care and support needs and gave consent for Miss X to make this complaint.
2. Miss X complains there was significant delay, and other failings, in the way the Council carried out a safeguarding enquiry when she reported concerns in November 2021 that a care agency, Company A, was providing unsafe and poor quality care to Mrs Z. She says the Council’s poor communication with her about the progress and outcome of the safeguarding enquiry and care planning caused her distress and anxiety and had an adverse impact on her health and work.
3. Miss X also complains that the Council took more than twelve months to find a new care provider to meet Mrs Z’s care needs after Company A stopped providing the service in December 2021. This had a profound impact on Mr Z (Mrs Z’s husband) and Miss X, who both work full-time, and had to meet Mrs Z’s complex care needs while also meeting their work commitments.
4. Miss X wants the Council to improve the service and take safeguarding issues seriously. She wants it to adopt a more person-centred approach, liaise with family members and communicate with them better. She would like an apology for the stress and trauma she and her family experienced. She also wants a financial remedy to recognise the stress of looking after Mrs Z while she was working full-time without respite care.

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The Ombudsman’s role and powers

5. We investigate complaints about ‘maladministration’ and ‘service failure’. In this report, we have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. We refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
6. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

7. I spoke to Miss X about the complaint. I considered the Council’s response to my enquiries, safeguarding policies and operational guidance and relevant documents from the adult social care records.
8. I gave Miss X and the Council an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Safeguarding

9. If a council has reasonable cause to suspect abuse or neglect of an adult who needs care and support, it must make whatever enquiries it thinks necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42).
10. The enquiries a council makes under section 42 of the Care Act 2014 are known as safeguarding enquiries or a safeguarding investigation. The council is the lead agency for making enquiries, but it may require others to undertake them.
11. Under the Care Act 2014, and also as a matter of good administrative practice, the person who raised concerns should be asked for their comments in the investigation and receive feedback.
12. At the time of these events, the Council followed safeguarding guidance in the Pan Bedfordshire Multi Agency Adult Safeguarding Policy Practice and Procedure (2017). This was supplemented by its own operational policy and guidance which was updated in 2020.
13. The guidance says the Adult Safeguarding team should carry out an initial assessment of the level of risk to determine the most appropriate and proportionate level of response to a reported safeguarding concern. Informal enquiries are made to establish the impact, the risk to others and the views of the person concerned. This informs the safeguarding team’s decision on the appropriate course of action and should be completed by the end of the working day following the day on which the referral was received.
14. A Level 3 response (the highest level) is appropriate when a reported concern identifies risk or possible abuse, maltreatment or neglect.
15. When these initial enquiries establish the risk is high, or abuse maltreatment or neglect has already occurred, and it is proportionate to carry out a section 42 safeguarding investigation, the case is forwarded to the appropriate Adult Social Care team. The safeguarding advanced practitioner in each team is responsible for ensuring compliance with the safeguarding policies and procedures and the timely completion of safeguarding work.
16. The procedure says the safeguarding enquiry should be allocated to a named worker within 24 hours. The following timescales then apply:
• Initial safeguarding visit to carry out a risk assessment and draw up a protection plan – within 48 hours or sooner in urgent cases of receipt of the initial decision from the safeguarding team;
• Safeguarding planning meeting or discussion – within five working days of receipt of the decision from the safeguarding team;
• Risk assessment and enquiry – to be completed within four weeks of receipt of the decision from the safeguarding team;
• Safeguarding case conference – within four weeks of the assessment being completed – this is a multi-agency forum for further discussion, including lessons learned, risk assessment and protection planning when a section 42 enquiry has been substantiated or partly substantiated. It should include all relevant parties, including the person with care and support needs and their advocates, and it should record the outcome of the inquiry and ensure all parties are informed. Reports should be provided to the person affected and advocates in advance of the case conference.

The guidance emphasises that the adult concerned, and their advocate, must always be invited to the case conference and the adult concerned must be asked if there is anyone else they would like to attend. They must also have had an opportunity to express their views and receive information on the enquiry outcome;

• Section 42 enquiry report – the lead officer should meet with the person affected to go through the enquiry report and findings and, with their consent, circulate a copy to all the parties involved.

The background

17. Miss X lives with her mother and father, who I shall refer to as Mr and Mrs Z. Miss X and Mr Z both work full-time.
18. Mrs Z has a progressive neurological condition and other medical conditions which affect her physical health. She cannot walk and she uses a wheelchair. There is a ceiling track hoist in her bedroom. Her ability to weight bear fluctuates and she uses specialist equipment to help her transfer from a sitting to standing position with assistance from others.
19. There is a wheelchair accessible lift in the house so Mrs Z can access the ground floor kitchen and living room.
20. The Council commissioned Company A to take over Mrs Z’s care package from another care agency from 17 November 2021.
21. At the relevant time, Mrs Z’s Care Plan provided four daily care calls by two care workers:
• 1 hour 15 minutes in the morning – to support her with having a shower, toileting, dressing and transferring to her wheelchair to use the lift to go to the ground floor. The care workers also gave her breakfast and administered her medication.
• 30 minutes at lunchtime – to take Mrs Z upstairs to use the toilet, transfer her into the wheelchair and go downstairs in the lift. They also ensured she had something to eat and drink and gave her medication;
• 30 minutes at teatime – the same tasks as the lunchtime call;
• 30 minutes in the late evening – to support Mrs Z with using the toilet, getting ready for bed, and taking medication.

Safeguarding enquiry

22. Miss X had significant concerns about the quality of care provided to Mrs Z by Company A’s care workers. She says they:
• did not know how to use the specialist equipment for moving and handling Mrs Z which led to her having a fall and required emergency services to attend;
• left Mrs Z sitting in urine-soaked clothes;
• failed to administer Mrs Z’s medication on two specific dates;
• arrived late for care calls;
• did not give Mrs Z breakfast.
23. On 26 November 2021 Miss X contacted the Council to report that the care workers had refused to give Mrs Z her medication and breakfast that morning because they had run out of time. Miss X expressed concern about the impact on her mother if she had not been at home to meet her needs. This was treated as a reported safeguarding concern. The Council sent an email to Company A on the same day to remind them of their duty of care to administer medication.
24. A social worker in the safeguarding team screened the referral and made initial telephone enquiries on 30 November. She spoke to Miss X and the registered manager of Company A about the concerns. Miss X and the care agency manager gave conflicting accounts of what happened on 26 November. Miss X told the social worker about another incident on 21 November when she said the care workers did not give Mrs Z her morning medication. She also raised concerns that the care workers did not know how to safely use the equipment to move Mrs Z from a sitting to standing position.
25. The social worker also spoke to Mrs Z. She confirmed she would like these concerns to progress to a section 42 safeguarding enquiry. Miss X told the social worker she had requested a change of care agency. The social worker completed a risk assessment and categorised the overall level of risk to Mrs Z as “substantial”. She categorised the safeguarding concern as “neglect and acts of omission”. She decided it should proceed to a section 42 safeguarding enquiry and it required a Level 3 response. The risk assessment and initial assessment stage was completed by the end of the second working day after Miss X made the referral.
26. On the same day the social worker informed Miss X and Company A of the decision to conduct a section 42 safeguarding enquiry. She then referred the case to the Long Term Care team to conduct the safeguarding enquiry.
27. Mrs Z fell onto the bedroom floor on 3 December 2021 while the care workers were transferring her to her wheelchair on their morning call. They had been using the specialist equipment for standing to sitting transfers. According to the care agency’s incident report, Mrs Z told the care workers she felt unwell and weak and her legs gave way which caused her to slip out of the wheelchair on to the floor. The care workers called emergency services and informed Mr Z. Paramedics attended and examined Mrs Z. The incident report says they advised the care workers that Mrs Z’s blood sugar levels were low and she should eat breakfast. Mrs Z did not sustain any injuries and was not taken to hospital.
28. Miss X reported this incident to the Council’s Emergency Duty team on the same day. The case records say Miss X said the family would care for Mrs Z over the weekend due to concerns about her mother’s safety.
29. The Council’s case records show the safeguarding referral was not allocated to a named social worker in the Long Term Care team until 13 December 2021. This was almost two weeks after the referral had been forwarded by the Safeguarding team.
30. The social worker who was allocated the safeguarding enquiry then went on emergency leave in December. In his absence, an advanced practitioner in the Long Term Care team sent an email to the manager of Company A on 20 December to ask for her comments on the reported concerns and to request the relevant care records. She spoke to Miss X on 4 January and took over responsibility for the safeguarding enquiry two days later as the allocated social worker had not returned to work.
31. On 6 January the advanced practitioner sent Miss X an email to confirm she had taken over responsibility for the safeguarding enquiry. She arranged a telephone appointment to discuss the concerns with Miss X and Mrs Z on 11 January. She also agreed to Miss X’s request that Mr Z should take part. During the call, she obtained details of Mrs Z’s medication and Miss X’s account of what had happened on 21 and 26 November.
32. There is no record of any further communication with Miss X about the safeguarding enquiry until 7 March. The advanced practitioner sent her an email then and apologised for not contacting her sooner. She said she had been on sick leave. She said she had all the necessary information and would complete her report the following week. She said she would then contact Miss X and her family to discuss the findings.
33. The case records include a safeguarding adults closure report which states the advanced practitioner informed Mrs Z and Miss X of the outcome of the safeguarding enquiry on 29 March. However Miss X says she was not informed then. And the Council has not provided any records, such as an email or note of a telephone call, to confirm Miss X was contacted on this date.
34. The advanced practitioner received a detailed report from the registered manager of Company A in response to specific concerns Miss X raised in her complaint to them. Company A had also sent Miss X a copy of this report. Company A denied several allegations about the care workers’ conduct and poor quality and unsafe care. Company A did not uphold most of the complaints or found insufficient evidence to make a finding on some. Company A set out its proposals to address Miss X’s concerns and minimise future risks, including:
• Sending an independent consultant to meet Miss X, go through the tasks in the Care Plan and resolve issues within an agreed timeframe;
• Address issues around communication and treating service-users with dignity and respect in supervision meetings and training;
• Carry out spot checks on care workers for four weeks to assess their competency in moving and handling Mrs Z;
• Audit the medication administration records to ensure medications are given as prescribed.
35. The advanced practitioner considered the report from Company A and Miss X and her family’s evidence. She noted that most of the concerns Miss X had raised in her complaint to Company A were not upheld. But she decided, on the balance of probabilities, that the overall allegations of neglect and acts of omission had been partially substantiated.
36. The advanced practitioner completed a safeguarding closure report on 26 April 2022. It says the outcome of the safeguarding enquiry had been shared with Company A and Mrs Z and her family that day. It says the risk to Mrs Z had been removed.
37. The report says Mrs Z had commented she was pleased the safeguarding enquiry had been undertaken but wanted a new care agency to provide care for her. The form says no professionals meeting or case conference had taken place because they were not required.
38. Miss X says she was not informed that the safeguarding enquiry was closed on 26 April. She said she was only told in August 2022 when an officer met her during the subsequent complaint investigation. She says the officer simply told her the case had been closed and she was given no further details or information.
39. After Miss X made a complaint to the Council, the advanced practitioner sent her a copy of the safeguarding outcome on 19 November 2022.
40. Miss X says the recommended actions Company A proposed made no sense because it had stopped delivering the care package to Mrs Z months earlier.

Analysis

Safeguarding

41. The Council has robust multi-agency policies and procedures in place which provide a sound framework and timescales for section 42 safeguarding enquiries. However, in this case, officers failed to follow the guidance and did not complete all the required actions within the specified timescales. That was fault.
42. The initial screening and assessment of the safeguarding concern was done reasonably promptly within two working days of receiving Miss X’s referral in late November 2021. But there was then a delay in allocating the case to a named social worker once it was passed on to the Long Term Care team. The safeguarding procedure says the referral should be allocated to a named worker within 24 hours but it took almost two weeks. This delay was fault.
43. The safeguarding enquiry did not get properly underway until early January 2022 because the case had to be reallocated. This means the initial safeguarding visit (in this case done by telephone due to the COVID-19 pandemic) did not happen within the specified 48 hour period.
44. Following the telephone contact with Miss X and Mrs Z on 11 January, there was then no further contact with Miss X until early March 2022. The failure to communicate with Miss X and update her on the progress of the safeguarding enquiry was fault. She did not know what was happening and felt the serious concerns she had raised about Mrs Z’s care were not being investigated with appropriate urgency.
45. There were further significant faults, some of which the Council acknowledged during its investigation of Miss X’s complaint:
• There is no evidence in the records that a safeguarding planning meeting was held;
• The safeguarding enquiry report did not make findings on each of the specific concerns Miss X reported to the Council. Instead it incorporated Company A’s findings on Miss X’s complaint to them and only gave a very general analysis;
• Despite the entries in the case records, there is no evidence to show the outcome of the safeguarding enquiry was shared with Miss X in March or April 2022. There is no record of any email or telephone contact with her in those months and she was not informed when the safeguarding enquiry was closed.
• There was no safeguarding case conference to discuss the outcomes and findings and to which Miss X should have been invited. This should have taken place because the enquiry found the concerns were partially substantiated. As a result, Miss X was denied the opportunity to express her views on the findings before the enquiry was closed.
• The actions in the protection plan appear to have been based on an incorrect assumption that Company A would continue to deliver the care package to Mrs Z. It failed to address the need for an alternative care provider or the option of Direct Payments to enable the family to employ personal assistants.
46. The Council’s handling of the safeguarding enquiry caused Miss X avoidable distress, uncertainty and frustration.

Mrs Z’s care package

47. Miss X had COVID-19 in December 2021 so she had to self-isolate at home. She informed Company A on 14 December 2021 that she needed to suspend Mrs Z’s care package for this reason. Mr Z stayed at home to care for Mrs Z.
48. On 23 December Miss X contacted Company A to arrange for the care package to restart. But Company A told her it had no staff available.
49. On 4 January Miss X informed the Adult Social Care duty team that she had to return to work on 5 January but Company A could not restart the care package. The brokerage service sent a request to care providers on its portal on the same day to try to find a new agency to take over Mrs Z’s care package.
50. The Council sent us a detailed chronology outlining the steps officers in the Long Term planning team and the Care Placement team took between January 2022 and March 2023 to try to find a new care agency to take over the care package. I have summarised the key actions below:

January 2022: eight care agencies responded to the brokerage service to say they could not take on Mrs Z’s care package. Some did not have capacity and others gave different reasons. Mrs Z’s social worker contacted the family to discuss the alternative option of Direct Payments but they did not wish to consider this.

February 2022: a care agency which did not have a contract with the Council offered to take on the care package but the care workers’ hourly rate exceeded the Council’s agreed rates. Mrs Z’s family did not wish to pay the top-up fee.

April 2022: a referral was made to the Occupational Therapy service to assess whether Mrs Z still required double-handed care calls. Mrs Z’s social worker also gave the family a list of local care agencies in case they wished to make a private care arrangement because Mrs Z self-funded her care.

May 2022: the Council agreed funding for a Direct Payment and the social worker sent the relevant Direct Payment agreement forms to Mrs Z’s family to sign.

June 2022: a care agency offered to take on the care package for Mrs Z subject to finalisation of the Direct Payment arrangement. Miss X said she needed more time to review the documents before she signed them. The care agency subsequently withdrew its offer.

July 2022: Mrs Z’s social worker suggested a face to face meeting at Mrs Z’s home to explore the best way to meet Mrs Z’s care needs and their concerns about the Direct Payment arrangement.

August 2022: the family confirmed they did not wish to proceed with a Direct Payment in a meeting with the social worker and wanted the Council to commission the care. A new request was made to the Care Placement team to find a suitable care provider. A care agency came forward and visited Mrs Z on 17 August to carry out an assessment. It said it could start to provide care for Mrs Z from 22 August. It subsequently withdrew its offer because it said Mrs Z’s family did not respond to their messages.

September 2022: another care agency offered to take on the care package. It visited Mrs Z and her family in October 2022 to carry out the assessment and subsequently decided it could not support her.

October 2022: the care package was put on the brokerage service portal again – two care agencies responded to say they could not provide support. The Care Placement team asked the social worker to reconsider the option of a Direct Payment.

November 2022: two other care agencies said they did not have capacity to take on Mrs Z’s care package. The social worker took the case to the Complex Case Panel. The Panel advised the social worker to write to the family about the option of a Direct Payment to employ a personal assistant to provide Mrs Z’s care. It said the Care Placement team should continue searching for care providers. Miss X requested a new assessment of Mrs Z’s needs and a change of social worker.

December 2022: the new social worker visited Mrs Z to complete the reassessment of her care needs.

January 2023: an amended Support Plan, showing Mrs Z’s increased care and support needs, was sent to the Care Placement team.

February 2023: a care agency was found which started to provide care for Mrs Z from 7 February.

March 2023: a different care agency took over the care package from 15 March.

51. In response to my enquiries, a senior manager said several complex factors in this case meant it took longer to find an alternative care provider for Mrs Z. Some care agencies had no capacity and others decided not to work with the family. The Council has since introduced a new “Unmet need/ Unable to place” process so cases are escalated sooner when it is proving difficult to find appropriate care and support.

The impact on Mrs Z and her family

52. Miss X said she and Mr Z had to share responsibility for meeting Mrs Z’s care needs until the new care agency started in early February 2023. Fortunately her employer agreed to flexible working which allowed her to work from home most of the time. Her father got home from work in the late afternoon and took over from Miss X who then caught up with her work in the evenings.
53. Miss X said the lack of professional care also had an impact on Mrs Z. She needed double-handed care calls four times a day to meet her needs. Miss X struggled to manage her mother’s needs single-handedly. So Mrs Z spent more time in bed because Miss X was worried about the risk of injuring her mother and herself if she tried to transfer her with the hoist on her own.
54. Miss X told me her father gave up work in the summer of 2022 to look after Mrs Z. He started looking for a new job after the new care agency started in February 2023.

Analysis: Care package

55. Miss X and Mr Z had to meet Mrs Z’s complex care needs without support from a care agency between mid-December 2021 and February 2023. I recognise this was very challenging for them.
56. During this time, the Council’s records show officers were taking steps to try to find an alternative care provider. The brokerage service put details of Mrs Z’s care package on the portal twice in this period. Many care agencies said they did not have the capacity to take on Mrs Z’s care package. Some agencies had worked with the family before and did not wish to take on the care package again.
57. Officers also discussed the option of Direct Payments with Miss X and her family on two occasions but they chose not to pursue this. It also offered to arrange Carer’s Assessments but Miss X did not take up this offer.
58. Some care agencies initially expressed interest in providing the support but did not proceed, for various reasons, after they visited Mrs Z at home to complete their assessment.
59. Much of this was outside the Council’s control: it could not compel a care agency to take on Mrs Z’s care package if it did not have capacity to do so. The difficulty in finding a care provider did not result from fault by the Council.
60. However there was one fault. The case should have been escalated to senior management sooner because it was already clear by early 2022 that the Care Placement team was struggling to find an alternative care provider. It was fault not to have had special arrangements in place to consider these complex cases. However, even if these arrangements had existed at the time, I cannot say that would necessarily have resulted in a better outcome for Mrs Z. It may not have led to earlier identification of a suitable care agency. But escalation of the case is likely to have led to greater management oversight and monitoring.
61. The time taken to find a new care provider took a considerable toll on Miss X and Mr & Mrs Z. Miss X and Mr Z had to fit their full-time jobs around meeting Mrs Z’s care needs. This was extremely challenging and exhausting for them. Mr Z gave up work to care full-time for Mrs Z. Miss X told me Mrs Z could not be transferred out of bed so regularly while she was being cared for single-handedly by her or Mr Z. This had a significant impact on her wellbeing and upset her daily routines. I recognise this had a serious impact on Miss X and Mr & Mrs Z. But, on the evidence I have seen so far, I am not likely to find the delay in finding an alternative care provider was due to fault by the Council.
62. The Council has apologised to Miss X and introduced a new process for handling these complex cases.

The Council’s handling of Miss X’s complaint

63. Miss X complained to the Council on 13 June 2022 about its delay in carrying out the safeguarding enquiry and its failure to find an alternative care agency to meet Mrs Z’s care needs. She also raised concerns about the quality of care provided by Company A.
64. A manager in the Long Term Care team investigated Miss X’s complaint. She met Miss X with Mrs Z’s social worker on 3 August and replied to the complaint on 23 August. She fully upheld Miss X’s complaint about the conduct of the safeguarding enquiry. Specifically she found the outcome of the safeguarding enquiry was not fully shared with Miss X and there was no safeguarding case conference.
65. Miss X asked for her complaint to be investigated at the second stage of the complaints procedure in September 2022. She was not satisfied because Mrs Z still had no support from a care agency and Miss X had not received a copy of the safeguarding enquiry report.
66. A senior manager from a different Adult Social care team handled the Stage Two investigation. He sent his response on 22 February 2023. He upheld Miss X’s complaints. He apologised for the delay in providing an alternative care provider for Mrs Z. He acknowledged the outcome of the safeguarding enquiry had not been shared in a timely way with Miss X and she did not see the report until November 2022. He also said the Safeguarding team had reviewed the way the safeguarding enquiry was carried out. It found the enquiry had not addressed Miss X’s specific concerns about the care provided by Company A and had dealt with these in a general way. It should also have specified in the protection plan that Mrs Z should be offered a Direct Payment or the Council should source an alternative care provider as Company A was no longer delivering the care package.
67. The Stage Two response apologised for the delay in providing an alternative care provider for Mrs Z. It said the Council had learned lessons from her experience and had introduced a new process for handling cases where it was difficult to find care providers to deliver a care package.
68. In response to my enquiries, the Council said it had taken longer than usual to complete the Stage Two investigation because the manager was working with the team to try to resolve the outstanding issue of finding a new care provider to deliver Mrs Z’s care. It accepts there should have been better communication with Miss X to explain this was delaying the response and it should have sent her a holding letter. The senior leadership team has taken this on board to improve complaint-handling.
69. The Council also accepts it overlooked and failed to respond to one point in Miss X’s Stage One complaint. She referred to an outstanding request for Mrs Z to have support to access the community to reduce her social isolation. The Council accepts it missed an opportunity to address this in the complaint investigation. It says Mrs Z does not wish go back to a day centre. But the Long Term Planning team has been asked to follow this up to help find other community activities she may be interested in.

Analysis: Complaint-handling

70. There were significant delays at both stages of the complaints procedure. I accept the senior manager responsible for the Stage Two investigation was trying to resolve the outstanding issue of finding an alternative care provider before he sent his Stage Two response. But this was not communicated to Miss X at the time so it appeared to her that the investigation had stalled.
71. The complaint responses also failed to address Miss X’s concern about the need to provide Mrs Z with support to access the community.
72. The delay increased Miss X’s frustration and distress and reinforced her view that the Council was not giving her concerns the serious and timely attention they deserved.

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Agreed action

73. Within one month of my final decision, the Council will:
• Arrange for a senior manager to send a further written apology to Miss X which acknowledges the impact of all the faults identified in our investigation;
• Arrange for a senior manager to write to Miss X to explain, in plain English, what practical steps the Council has taken to improve safeguarding processes in response to the lessons learned from her complaint. In its reply to my enquiries, the Acting Head of Service offered to arrange a face to face meeting with Miss X and her family. It should include that offer in this letter.
• Pay Miss X a symbolic payment of £350 to recognise the distress caused by its poor handling of the safeguarding enquiry, its poor communication with her and its failure to involve her at key stages in the process;
• Pay Miss X £200 for her time and trouble in pursuing the complaint and the significant delays and fault in the way it handled the complaint;
• Review the need for refresher training for staff responsible for safeguarding enquiries in the ASC teams to ensure they are familiar with, and follow, all the required stages in the safeguarding procedures and work within the specified timescales. Staff should be reminded of the need to communicate with the person who made the referral and ensure they are invited to case conferences and given the opportunity to discuss the outcome of the enquiry.
74. The Council should provide us with evidence it has complied with the above actions.

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Final decision

75. I have completed the investigation and found the Council was at fault and this caused injustice to Miss X and her family.

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Investigator's decision on behalf of the Ombudsman