Summary: Miss X complained about the Council’s failure to act when she made several safeguarding complaints regarding the care her son received. We found the Council was at fault for not updating Miss X with its decision. This caused her significant distress. To address this injustice caused by fault, the Council has agreed to make several recommendations to address this injustice caused by fault.

The complaint

1. The complainant, Miss X, complains about the Council’s failure to act when she made several safeguarding complaints regarding the care her son received.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I 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. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. 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)

Back to top

What I have and have not investigated

4. I have investigated whether there was any fault by the Council when it considered the safeguarding investigation. I have not considered the actions of the care provider, GP or neurology department. This is because they are outside our jurisdiction.

Back to top

How I considered this complaint

5. I spoke with Miss X about her complaint. I considered all the information provided by Miss X and the Council.
6. Miss X and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

Back to top

What I found

Safeguarding

7. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

Summary of the key events

8. Miss X’s son, Mr Y, had significant learning disabilities and epilepsy. He lived fulltime at a care placement. Miss X reported safeguarding concerns to the Council on the 29 August 2022. She said:
• Mr Y was prescribed with 4mls of medication which had recently been reduced from 10mls;
• staff at the home had increased Mr Y’s medication to 10mls;
• she wanted this looking into as she said this could be contributing to an increase in seizures; and
• she would be raising these concerns at a planned review meeting that was due to take place the following day.
9. The Council’s safeguarding notes stated:
• a planned review took place. The care provider said when Mr Y moved into the home, it liaised with the GP to seek clarification around the dosage. The GP had confirmed the dosage to be 10mls;
• Miss X said the correct dosage was 4mls;
• the care provider spoke with the neurology department on the 30 August 2022 who confirmed the dosage of 10mls was correct. The neurology department said the last time it was recorded as being 4mls was in January 2022. But the records stated this was increased due to seizure activity;
• the neurology department later confirmed on the same day that Mr Y was on a gradual reduction from 10ml to 4ml from January 2022. But said this had not been actioned by the GP. It was noted they would not be able to reduce it down to 4ml straight away; and
• the care provider was not the source of the risk. It has been dispensing medication as prescribed which was currently 10mls. But further clarification was required to determine and clarify what changes had been made to the medication. It recommended enquiries be undertaken and that liaisons take place with Mr Y’s GP.
10. On the 2 September 2022, the care provider told the Council Mr Y had recently had a neurology appointment. It was noted the doctor would not be making any changes to his medication as it could have an adverse effect. It was noted the:
• doctor would arrange for a specialist nurse to contact staff to arrange specialised training. But it was noted this would only be used in the event of seizures lasting more than 10 minutes;
• the doctor said there was a slim chance of minimising Mr Y’s seizures using medication due his history; and
• the doctor would arrange a follow-up with a specialist nurse in three months to keep records up to date on recent seizures.
11. The care provider told the Council Miss X removed Mr Y from the care placement on the 23 September 2022. Mr Y went to live with Miss X as she had concerns about the care home.
12. Mr Y sadly died on the 19 November 2022 following him having several seizures.
13. Miss X complained to the Council in June 2023. She said:
• she had raised safeguarding concerns in August 2022;
• she removed her son from the care home in September 2022 due to safeguarding issues which she said were never addressed; and
• the care provider gave her son the wrong medication and she wants to know what investigations the Council had carried out since Mr Y’s death.
14. The Council wrote to Miss X the following month. It said it was unable to investigate as her concerns were being considered by the coroner’s office.
15. The Council responded to Miss X’s complaint in April 2024. It said:
• the coroner’s enquiry had now been concluded;
• it had established a medication error had taken place which was due to communication difficulties between the hospital and the GP; and
• the medication concerns had been reviewed as part of the coroner’s enquiry with requests being made from the coroner’s office for the release of the relevant clinical notes.

Analysis- was there fault by the Council causing injustice?

16. The Ombudsman’s role is to review councils’ adherence to procedure in making decisions. Where a council has followed the correct process, considered all relevant information, and given clear and cogent reasons for its decision, we generally cannot criticise it. I can only consider whether the Council investigated the safeguarding concerns. As stated in paragraph 4, I cannot consider the actions of the care provider, GP or neurology department.
17. Miss X told us between July 2022 and January 2022, it had taken 17 months to reduce Mr Y’s medication from 10ml to 4ml. She said it had not been recently reduced as suggested in the notes.
18. From the evidence seen, Miss X reported the safeguarding concern towards the end of August 2022. This is detailed in paragraph 8. The Council’s safeguarding notes state it had deemed that the care provider was not the source of the risk. This was because the medication dosage issues were due to communication issues between the neurology department and the GP. The care provider had provided medication in line with the prescription. The coroner’s inquest also found there to be miscommunication between the GP and the neurology department.
19. The safeguarding notes state further clarification was required to determine and clarify what changes had been made to the medication. On the 2 September 2022 the care provider confirmed the doctor would not be making any changes to the medication. They listed what action would be taken. This is detailed in paragraph 9.
20. Miss X said at a meeting in August 2022, she also raised safeguarding concerns about the care staff working with Mr Y. She said she questioned whether they were trained and whether they could meet Mr Y’s complex needs. I asked the Council to provide minutes of this meeting. It provided an email summary of the meeting which noted the Council would be sending a safeguarding referral to a different council area where Mr Y’s placement was.
21. The Council told us this action from the meeting was in relation to the safeguarding referral received from Miss X. But it said it was decided that as the referral was regarding medication and the issues involved Mr Y’s GP who was based in Stoke, the Council decided it would undertake the enquiry. This was a decision for the Council to make.
22. In my view, the Council has correctly investigated the safeguarding concerns detailed in paragraph 8. There is no fault in how this was carried out and I therefore cannot question the Council’s decision. There were no further investigations carried out after Mr Y died. As stated above the Council and coroner’s inquest found there to be miscommunication between the GP and the neurology department.
23. But as stated in paragraph 20 Miss X said she raised other safeguarding issues at a meeting in August 2022. She said this was in relation to staff conduct. There is no written evidence of these concerns being raised. When there is no available evidence, we have to consider whether we can make an on balance of probability decision. In this case, there is therefore not enough information for me to do so.
24. Whilst I have not found fault with the process followed by the Council, there is no evidence to suggest the Council updated Miss X with its investigation findings. This is fault. I cannot say that the outcome of the investigation would have been different if Miss X had been kept updated as the Council had determined that the care provider was not the source of the risk. But this did cause significant distress to Miss X.
25. Miss X initially made a complaint in June 2023. But the Council said it was unable to investigate as her concerns were being considered by the coroner’s office. We could not criticise this. It responded to her complaint once the coroner’s enquiry had concluded. Its response is detailed in paragraph 15. In my view, the Council’s response does not respond to all the point Miss X made. It did not clearly explain what safeguarding investigations had been carried out. This is fault. This caused further distress to Miss X.

Back to top

Agreed action

26. To address the injustice caused by fault, within one month of my final decision, the Council has agreed to:
• write to Miss X with an apology that takes account of our published guidance on remedies and accepts the findings of this investigation; and
• pay Miss X £250 in acknowledgement of the distress caused to her by the fault identified in this statement.
27. Within two months by training or other means remind staff of the importance of providing information about its safeguarding enquiry process and communicating outcomes to the service user and/or representatives in a timely manner.
28. The Council should provide us with evidence it has complied with the above actions.

Back to top

Final decision

29. There was fault by the Council. The actions the Council has agreed to remedy the injustice caused. I have completed my investigation.

Investigator’s final decision on behalf of the Ombudsman

Back to top

Investigator's decision on behalf of the Ombudsman