Summary: Mrs X complained about various aspects of the way the Council considered a Safeguarding Adult Review. We found there was delay and fault in the process. We recommended a payment to Mrs X and Mr Y and various actions to review process and procedures.

The complaint

1. Mrs X complains there were failings in the way the Council investigated safeguarding concerns she raised in 2017 about a care home in which her mother was a resident. I refer to Mrs X’s mother as Mrs Z in this statement. She complains there was delay, correct procedures were not followed, information they presented was ignored and evidence was not properly considered. Two safeguarding enquiry reports were written about the matter. Both contained uncorroborated accusations about Mrs Z’s behaviour, and Mrs X complained the findings, as a whole were flawed. An independent investigation found various faults with the way the safeguarding reports had been investigated. It noted, amongst other issues, that the safeguarding reports did not accurately consider Mrs X’s concerns. It found, if they had been accurately described, the outcomes were likely to have been different. Mrs X complained that the action plan arising from the 2017 complaint investigation was inadequate.
2. Mrs X and her brother (referred to as Mr Y in this statement) complained that meetings about arranging a Safeguarding Adults Review (SAR) were not open and transparent and the process was delayed.
3. Mrs X states the Safeguarding Adults Board did not accept the Terms of Reference (ToR) written by the Investigator and family and there was significant delay agreeing the ToR for the SAR (between January 2019 and June 2019). A final copy of the ToR has not been provided to them, nor have the appendices from the SAR Report.
4. Mrs X also complains that the Council lost a folder of information for two months (Nov 2018 to Jan 2019).
5. Mrs X complains that the Safeguarding Adults Board failed to adhere to Sections 44 and 45 of the Care Act 2014, in that it only agreed to conduct a discretionary SAR and it did not use its statutory powers under Section 45 to obtain information from the nursing home.
6. Mrs X states the SAR report is inaccurate, flawed, omits crucial information and misrepresents the facts. She considers it is biased against the family. The report does not identify learning points from the parties involved in her mother’s care. This was acknowledged at a meeting in July 2021, but a promise to write and confirm the learning points was not kept. Rather, the Safeguarding Adults Board decided to include learning from the case in an annual report due to be published in September 2022 which meant further delay in resolving the matter and a lack of closure for the family.
7. Mrs X also complains that the SAR report discredits the family and portrays them as complainers as well as being potentially libellous in implying that Mrs X and her brother were coercive towards their mother. Mrs X complains that this was a malicious slur on herself and brother, designed to distract from the lack of care her mother received and shows a lack of empathy towards a bereaved family.
8. Mrs X complains that when the family responded to the draft SAR report nearly every point raised by them was deemed to be “invalid” by the Council. Mrs X also complains that the Council declined to compensate them for the impact that the lengthy and difficult SAR process had on the family.
9. Mrs X told us the Chair of the Safeguarding Adults Board stated medical advice had been sought to determine if the substantiated safeguarding issues contributed to her mother’s death. Mrs X established that no specific independent advice was sought, rather, the board had relied on information from the GP who treated her mother, which was not independent.
10. Mrs X complains that the Council bullied a witness and long-standing family friend who submitted to the Council a statement of support stating that she was shocked to hear Mrs X and her brother had been labelled as coercive. Mrs X told us her friend felt she had to withdraw her statement following pressure from the Council as she feared for her career.

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What I have investigated

11. I have investigated the events of the complaint from 2018. The reasons for this are set out in the last section of this statement.

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The Ombudsman’s role and powers

12. 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
13. 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

14. I spoke to Mrs X and considered the information she provided and the complaint she made. I asked the Council for information and I considered its response to the complaint.
15. Mrs X and the Council had an opportunity to comment on my draft decision. I considered the comments received before making a final decision.

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What I found

The Care Act 2014

16. Section 44 of the Care Act sets out when a SAB must arrange a SAR. One of the circumstances in which it must do so is where an adult has died and the SAB knows or suspects the person’s death resulted from abuse or neglect.
17. Section 44(4) also gives the SAB the discretion to conduct a SAR for any other adult in its area with care and support needs. There is no difference in the powers available to the SAB in conducting a ‘discretionary’ rather than a ‘mandatory’ SAR.
18. Section 44(5) says members of the SAB must co-operate and contribute to carrying out reviews.
19. Section 45 says broadly that if a SAB requests any person to supply information to enable or assist it to carry out its functions, the person who the request is made of must comply.

The SAR Process/Policy as at 2018

20. The policy sets out the purpose of a SAR. It says SARs are not enquiries into how an adult at risk died or who is to blame. They are not carried out to hold individuals or organisations to account. Their purpose is to determine what relevant agencies and individuals may have done differently, to identify learning and seek to avoid a repeat similar incident happening in future.
21. Sections 7 and 8 state, after receiving a request form, the SAB Manager will review the information, seek clarifications and will forward the request to the SAB Chair. Where the SAB Chair believes a SAR may be required, the Chair will write to all SAB partners requesting a brief chronology/initial report. This initial information gathering is considered by the Performance, Quality and Improving Practice Group of the SAB. This group make recommendations about the methodology, the Terms of Reference (ToR), whether an Independent Chair is required and what other agencies (in addition to statutory agencies) should be included in the review. Following this recommendation, the SAB will then make a formal decision as to whether a SAR will be undertaken and how this will be done.
22. Appendix 6 explains that when a SAR has been agreed, the initial information gathered will be used by the SAB Manager and Report Author to develop initial Terms of Reference (ToR). These will be agreed by the SAB and the Author/Independent Chair.
23. Section 10 notes that it may be useful to seek the involvement of some ‘non‑statutory’ organisations. The SAB panel or author may consider how best to gain the necessary information and learning. It notes that smaller organisations may lack capacity and experience and may need support.
24. Section 10.3 notes it is vitally important that the Persons or Organisations Alleged to have Caused Harm (POACH) are considered. It states each case should be considered on its merits to ensure a holistic view of the situation and maximum benefits from the SAR process. The SAB procedures do not anticipate that POACH would attend meetings of the SAB.
25. Section 11 covers the content of the SAR and the process for agreeing content. Section 11.6 states an executive summary will be written in addition to the full report. The summary will be available widely to the public and other agencies. It says that a decision will be made on a case by case basis about whether it is appropriate to publish the SAR report.
26. Section 12 states that a SAR goes before a SAR panel, and the SAB Board. Once the SAB has accepted the report and its recommendations Quality and Improving Practice Group will produce a multi-agency action plan and monitor the implementation of recommendations. Where a SAB decides not to implement an action, it must state the reason for this in the Annual Report.
27. Section 14 highlights that the real value of a SAR is that relevant professional lessons are learnt. Each agency will submit an action plan to the SAB and the SAB sub group will create a SMART action plan for the SAB to incorporate into its work.
28. The policy states the SAR should be carried out within six months of agreeing a SAR is required.

Background

29. Mrs Z became a self-funding resident at a Nursing Home in October 2015 following a period in hospital. She had a number of medical conditions and she required nursing care.
30. Mrs X raised numerous concerns about the care Mrs Z received with the Nursing Home and with CQC during the period she was a resident.
31. In January 2017 Mrs Z was admitted to hospital. A social worker who visited Mrs Z noted she was very unwell, she was unable to swallow properly and had declined a PEG feeding tube. It was noted Mrs Z had capacity to make this decision, her family were with her and they had met a Palliative Care Assessor. Mrs Y was transferred to a hospice, and sadly died the following day.

Safeguarding Reports & Investigation

32. On 4 January 2017 Mrs X raised concerns with the Council about the care Mrs Z had received at the nursing home. A social worker considered these concerns. Mrs X provided documents in support of the concerns she raised. The social worker had face to face meetings with staff at the nursing home, with Mrs X and spoke with Mrs Z’s GP. The Council produced a report in June 2017 about the issues Mrs X raised. It substantiated 13 reports, partially substantiated five and did not substantiate four. One finding was inconclusive.
33. Mrs X complained about the accuracy and completeness of the report. She stated that several concerns would have been upheld had all of the available evidence been considered. She also complained that the safeguarding report included accusations the nursing home made about Mrs Z’s behaviour and actions which were insulting. They were made without any evidence to support them. Mrs X told us the report was heavily biased in favour of the care home and the majority of their comments were ignored.
34. Mrs X noted that the nursing home was placed in special measures while her mother was resident there and a number of other families also raised concerns about the standard of care their relatives had received.
35. As a result of Mrs X and Mr Y’s comments about the safeguarding report, a fresh report was issued in September 2017. This report stated the safeguarding enquiry into Mrs Z’s care had been part of a larger, ‘whole-service’ safeguarding enquiry into the Nursing Home in which Mrs Y was a resident.
36. Mrs X told us the second report still did not adequately reflect the information they, as a family, had presented and important issues were ignored.
37. The Council arranged an independent investigation of the way Mrs X’s safeguarding reports had been handled. An Investigator was found in November 2017 and began the investigation. This was completed on 17 December 2017. The investigation focused on the process followed and the Council’s actions rather than re-investigating the concerns raised. Broadly, the report found:
• The reports were not heavily biased in favour of the care home and the family’s evidence was not completely ignored. However, there were shortcomings in both reports.
• The first report failed to reference Mrs X’s comments sufficiently, the author did not always make it clear if some uncorroborated comments in the report were opinions or feelings of staff at the home rather than actual evidence - particularly the accusations about Mrs Z’s behaviour (i.e. it was not clear if this was something they had witnessed or just their opinion). The author also accepted she should not have made a statement that Mrs X had not suffered medical neglect as she was not clinically qualified to do so.
• The second report also failed to adequately address comments made by Mrs X, some of the findings are questionable (the grounds for reaching only partly substantiated decisions rather than fully substantiated) and it too contained the uncorroborated reports.
• There was delay in investigating the safeguarding issues at various points, poor and protracted decision making and confusion over whether this would be a complaint or safeguarding matter at the outset. While there were issues, the investigation found no intent by the report author to exaggerate or alter points the family had made in order to discredit or minimise them.
• Overall, the investigation found that a proper enquiry plan was not prepared, other organisations could have been involved, the brief agreed between the Council and Mrs X was not followed and there was insufficient scrutiny and oversight of the author. Although considerable time was spent on the second report, it did not meet the principle of fairness. However, it was noted that there had been other reports about the care home and a number of agencies were working with the care home manager to improve practices. The information from the safeguarding reports was also used constructively in wider discussions about the issues at the home.
38. The investigation recommended, an apology, that consideration was given to Mrs X’s request for a 3rd safeguarding report which takes full account of the evidence they submitted. Alternatively, that the independent report’s findings were cross referenced to the safeguarding file to make the shortcomings of the safeguarding reports apparent. Also that the Council learned lessons. In particular if new multi-agency procedures provided guidance on safeguarding enquiries, that this guidance should be followed and training provided for staff.
39. On 3 July 2018 a senior council officer sent a written apology to Mrs X and Mr Y. It acknowledged the department had fallen short of the standards expected in dealing with their safeguarding alert and subsequent complaint. The Council agreed to take various actions. It stated it would:
• offer another independent review of the safeguarding reports.
• refer to see whether Mrs Z’s case met the criteria for an SAR.
• remove comments about Mrs Z from the safeguarding reports that were unsubstantiated.
• refund their travel costs.
• make a payment of £5000 in recognition of the additional distress caused by the shortcomings in safeguarding investigations at a time when the loss of Mrs Z was recent and painful.

The SAR Process and Timescales

40. Mrs X and her brother requested a SAR on 20 July 2018.
41. The Independent Chair of the SAB agreed to conduct a SAR at a meeting on 27 July 2018. The SAB decided that the circumstances did not meet the criteria for a mandatory SAR (set out in paragraph 16). However, a SAR would be carried out.
42. Mrs X and Mr Y raised a complaint about treatment provided by Mrs Z’s GP in addition to raising safeguarding concerns about Mrs Z’s nursing home. They were concerned that the SAB did not consider Mrs Z’s death resulted from abuse or neglect. We asked the SAB how it decided not to conduct a ‘mandatory’ SAR and the medical evidence it relied upon when reaching this view.
43. The SAB explained that its objective is to learn lessons about safeguarding practice and then disseminate the learning to the local care system to drive good practice. It was not its purpose to form judgements about professional competence in individual cases. Because the process is focussed on wider lessons it is not perceived as judgemental by those participating in it. The SAB explained this meant professionals generally participate openly. It noted the relevant statutory guidance considers it vital that individuals and the organisations they work for are not fearful of SABs to ensure their responses are not guarded or defensive. This ensures maximum learning is achieved.
44. The SAB explained that the medical opinion that it took account of when deciding the mandatory criteria was provided by Mrs Z’s GP. The SAB stated it’s practice was to consider the available evidence when reaching findings. It did not have the expertise or resources to obtain separate independent medical opinion.
45. In August 2018 Mrs X and Mr Y met two council officers. I refer to them as Officer A and Officer B in this statement. Officer B explained she had found an Author for the SAR report and hoped she would be able to start at the end of September 2018. Mrs X had previously expressed concern about a social worker authoring the SAR because the safeguarding enquiries and independent investigation had been conducted by social workers. Officer B stated they understood the Author had a different background.
46. At this meeting, Mrs X and Mr Y also explained they remained concerned that the earlier safeguarding reports were on record. They were uncomfortable that these had been relied upon when they were inaccurate. Officer A confirmed that hearsay remarks could be removed, and a document could be placed on file to be read in conjunction with these reports. This could set out the family’s concerns. But, it could not be changed. Officers A and B indicated that they could commission a further report into the safeguarding concerns.
47. Mr Y stated it was not just that they wanted the problems with the safeguarding process to be fixed, they wanted to know how and why they happened, why some of their words were changed and they wanted to know the SAR would look into the safeguarding process. Officers A and B indicated this could be considered as part of the SAR and included in the ToR. Officer A felt if they were to commission a further report it would be duplicating the SAR work.
48. At the meeting Officers A and B stated the SAB would have a panel meeting and talk about the ToR and after discussion, the ToR would be put back to the family. However, they stated there was flexibility about how a SAR was completed and the ToR could be personalised.
49. After the meeting the family established the proposed author was a qualified social worker and complained that Officers A and B had not been open with them about this. The Council agreed to find another author.
50. On 5 September 2018, the family told the Council they did not consider the SAR would be an appropriate way to deal with the inaccurate and inadequate safeguarding reports. They asked that, in parallel with the SAR process, the Council re-wrote them to reflect the evidence, their comments and to remove the hearsay remarks.
51. The SAB appointed an independent chair/author (referred to as the author in this statement) to carry out the SAR on 2 November 2018.
52. The family chased the Council for progress on re-writing the original safeguarding report on several occasions. In an update the Council stated it would make the changes agreed at their meeting. The Council sent a redacted version of the report on 4 December 2018. The family were not satisfied that the report had been amended sufficiently because it still made reference to Mrs Z self-harming.
53. I understand the author worked on a Terms of Reference (ToR) document with the family for the SAR. This was put to the SAB in January 2019. In January the SAB received scoping documents for Mrs Z’s SAR from the nursing home and various other organisations.
54. On 14 February 2019 the SAR author told Officer A that he considered involving the family and agreeing the ToR by the end of February was important. He felt it may be challenging but agreeing the ToR should be the focus. He also noted what had been discussed between the Council and the family in August 2018.
55. On 8 March 2019 Mrs X raised a complaint about the delay in agreeing the ToR, that a new sub-group was now in place and the ToR were being questioned. She said they had previously been advised there would be flexibility in the SAR approach. She also questioned why a meeting was being held about the ToR without involving them. Mrs X felt they were being ignored and there was a lack of communication about what was happening.
56. The sub-group of the SAB met on 13 March 2019. It had been the intention to discuss Mrs Z’s SAR at this meeting. However, the author was told the meeting was no longer to discuss the SAR, so he did not attend. Nor were the family invited. However, the nursing home was represented at this meeting, despite the home potentially constituting a POACH in this situation. The SAR was discussed. This is evident from the meeting minutes. The minutes record discussion about the process, how the author had begun working with the family and other issues. The way the meeting was conducted, without representation of the family led to a complaint from Mrs X and Mr Y that the approach being taken was secretive and not open and transparent.
57. In April 2019 the SAB responded to a complaint. They said the nursing home had been invited to the SAB meeting on 13 March to discuss the initial information they had provided to the SAB. The care provider was present while Mrs Z’s SAR was discussed. In terms of the decision that Mrs Z’s SAR should be a mandatory rather than discretionary SAR the response stated a medical opinion was sought to establish if the concerns raised had attributed to your mothers cause of death. The SAB stated there was no evidence to suggest any link between the safeguarding concerns raised and substantiated and Mrs Z’s death. There was no record of coroner’s involvement. Nevertheless, the decision was made that lessons could be learned from the case, so the discretionary criteria for a SAR was agreed.
58. At the end of July 2019 the SAB met with the report author and discussed progress and the family’s concerns. The minutes noted the family were concerned that the focus has drifted away from the safeguarding events. The SAB sub group recognised this but felt other platforms existed to deal with aspects of the SAR that were complaints. The sub-group agreed that partners of the SAB would answer a list of questions and the author would review the responses. The SAB anticipated this would take 10 weeks. The minutes noted that in future cases a ToR should be presented to the family to comment on, rather than the family drafting ToR for the SAB. It noted this was learning for future SARs.
59. On 14 August 2019 the care home told the Council they would not be part of the SAR process.
60. In October 2019 the author led a discussion about all of the evidence collected. The information and the discussion with other professionals enabled the author to draft the SAR.
61. In July 2020 Mrs X and Mr Y chased for progress and reiterated their misgivings with the process, communication and the time the SAR was taking.
62. The SAB provided Mrs X and Mr Y with a copy of the draft SAR report in October 2020.
63. A meeting was arranged in November 2020 to sign-off the SAR report. In November the SAB received correspondence from Mrs X’s MP. He set out concerns and asked the SAB to put a hold on the process until they were responded to. The SAB responded to the concerns raised and agreed to provide more time for the family to comment.
64. The SAB acknowledged receipt of detailed comments from Mrs X and Mr Y about the draft SAR in February 2021.
65. The SAR is lengthy and I cannot include the content in this statement. It is not for the Ombudsman to determine what the content or findings of a SAR should be. However, I comment below on the nature of the content Mrs X and Mr Y disagreed with and commented about.
66. Mrs X and Mr Y made a total of 163 concerns/objections to the draft SAR. These comments included points in the SAR that were not factually accurate (for example, a statement in a summary section that Mrs Z was admitted to a care home for her last years following a stroke. The family noted this had occurred some years earlier, and it was another condition that led to her re-admittance to a care home in her last years).
67. They also commented on paragraphs which were misleading. For example, a paragraph which did not properly distinguish between a care home Mrs Z resided at in 2012 and the care home that was the focus of Mrs X and Mr Y’s safeguarding complaints in 2015. In another example, the author had referenced the family having a different view of what treatment should be pursued for Mrs Z. The author referenced CCG and GP records about this. CCG records stated Mrs X was keen for Mrs Z to have more treatment and considered a Power of Attorney to ‘force’ investigations (which Mrs X believed were in Mrs Z’s best interests). GP records described an instance in which Mrs Z declined further tablets or scans, while Mrs X was present. Mrs X did not agree with her mother’s decision and wanted to see more investigations. In their comments, the family explained important context was missing from the description of these events. They explained they had not been told by professionals that Mrs Z had previously discussed and agreed a palliative care approach. They explained how their mother had always been keen to get their advice and they had helped her decide things, and of late she had been confused and disengaged, deferring to their judgement. They stated they would not ‘force’ her, rather they believed further investigation was in her best interests and they sought to reassure her that further scans need not be invasive. Issues around treatment and capacity of the elderly are obviously very sensitive and difficult topics for any family to navigate. The family objected to suggestions that they had attempted to ‘coerce’ Mrs Z, rather they sought the best care for her.
68. They also commented about numerous other references to them as a family and how they had been portrayed as difficult or challenging in a number of examples. They raised other comments about how the report was written, who the author was addressing and what some of his comments meant.
69. In March 2021 the SAB stated the discretionary basis of the SAR meant it was limited to reviewing the issues set out in the ToR and making recommendations to address shortcomings. It stated the SAB had discretion to extend the ToR if necessary. However, as an independent author, the SAB would generally only ask the author to amend content it considered to be outside the scope of the SAR, if he failed to consider relevant matters into account or his view on a matter was clearly perverse.
70. The SAB agreed 1) there were several ambiguous passages in the SAR which should be clarified, 2) the author should not have commented on the rationale for agreeing to a SAR, so this should be removed. 3) It also questioned why the NHS foundation involved had been anonymised. The SAB acknowledged that the circumstances described in a SAR were capable of being perceived in different ways by different people. It stated the SAB nor the family could dictate to the author how he should interpret the matters that had occurred. It had not found content was perverse, in a legal sense, and so it did not have grounds to seek the amendment of the report other than in the three ways it had set out.
71. A further draft SAR report was issued in April 2021. This removed the majority of the author’s judgement as to whether this should be a SAR (although it retained a suggestion that another approach may have been appropriate and still referred to it as a ‘misplaced notion’). Passages that the SAB considered ambiguous were amended or removed and the author added content about the anonymisation of the NHS partnership involved.
72. The majority of Mrs X and Mr Y’s comments were considered invalid. The SAB did not seek any change to the majority of the points that the family stated were factually incorrect or misleading/omitting important information.
73. There were 13 recommendations in the SAR. Three of these were about how the SAB conducted the SAR process. Three recommendations proposed improvements to communication and stated the outcome of ‘whole service reviews’ should be communicated to residents and families who have been involved.
74. Recommendation 5 proposed that the SAB considered how to include private companies in SARs positively in future.
75. Recommendation 6 recommended that the SAB reviewed promotion of safeguarding in care homes to make it clear to families how they could raise concerns.
76. Recommendation 8 proposed a review of how advance care planning was promoted and how this was shared with families. Recommendation 12 stated capacity should be carefully and clearly explained.
77. Recommendation 9 and 10 proposed changes to safeguarding. They stated staff doing safeguarding enquiries should be appropriately trained in making their enquiries and writing reports. They should also be appropriately supervised.
78. Recommendation 11 stated the SAB should consider producing practice guidance on identifying and dealing with “potential coercive behaviour over service users by families and others”.
79. The recommendations were for the SAB to consider where practice issues identified in this SAR could suggest wider learning and improvement. The SAR report did not set out specific learning for any of the agencies or organisations involved in caring for Mrs Z.
80. In May Mrs X’s MP questioned why content that the family stated was factually wrong was being published and why the family’s view on this had seemingly been ignored.
81. On 16 July 2021 Mrs X and Mr Y, their MP and a Councillor met with the CEO of the Council and the Chair of the SAB. At the meeting they discussed the issues that had occurred in dealing with Mrs Z’s SAR. Mrs X and Mr Y explained they had been misled about the scope of the SAR, they were unhappy at the time it had taken and the completed report contained inaccuracies and lacked learning points for the organisations involved. They also questioned why the nursing home were able to walk away from the process and questioned the basis on which the SAB decided this should not be a mandatory SAR. The family were unhappy that the majority of their comments about the SAR report had been regarded as ‘invalid’.
82. The Council’s CEO stated, if the family had been misled, an apology should be made. The Chair of the SAB explained that some of what the family wanted to be included was not in the gift of the SAB. However, she noted there had been a number of issues with the author and the SAB process which had changed part way through. A local councillor stated the report should include the voice of the family. However, the SAB Chair stated she had reviewed the family’s comments and taken legal advice. She stated the author had to have independence. After some further discussion, it was proposed not to publish the report due to the family’s concerns.
83. Actions from this meeting were 1) to gain agreement from SAB partners not to publish the SAR and to communicate this to Mrs X’s MP, 2) to request a learning plan from the nursing home, Mrs Z’s GP and the NHS hospital involved. Mrs X agreed to send the Council’s CEO a copy of their comments spreadsheet and the recording of the meeting from August 2018.
84. Rather than publish the SAR, the SAB told Mrs X and Mr Y the findings would be incorporated into their annual statement. This was due to be issued in September 2022.

Personal Statement

85. A close friend of Mrs X and Mr Y works for the NHS. In April 2021 she wrote a statement of support for the family after reading initial drafts of the SAR. She stated she first knew the family professionally when she was involved with Mrs Z’s care years previously. They became friends. She noted the comments about the family and she strongly disagreed with how the family were portrayed as challenging and always complaining. She stated the family just wanted answers and peace of mind that lessons had been learned. They only wanted the best for Mrs Z and it was shocking to suggest they were in some way coercive towards their mother. She stated the SAR report included inaccuracies, false allegations and needed a re-write.
86. A manager at the SAB wrote to Mrs X’s friend about her statement. He noted she had said the statement was sent from a personal perspective, but he asked what that meant. He asked if it was made as an NHS employee, a health professional who was involved in Mrs Z’s care or in a non-professional capacity as a family friend. He noted the statement was sent from an NHS email account and the SAB needed to ensure the reader was clear about the capacity in which the statement was made.
87. After taking some advice, Mrs X’s family friend withdrew the statement. She stated in doing so she had been concerned about the line of question by the SAB manager and no longer wanted the statement published.

Was there fault by the Council or SAB

Mrs X and her brother (referred to as Mr Y in this statement) complained that meetings about arranging a Safeguarding Adults Review (SAR) were not open and transparent and the process was delayed.

Mrs X states the Safeguarding Adults Board did not accept the Terms of Reference (ToR) written by the Investigator and family and there was significant delay agreeing the ToR for the SAR (between January 2019 and June 2019). A final copy of the ToR has not been provided to them, nor have the appendices from the SAR Report.

88. There was fault in the way that the SAR process was arranged.
89. At the August meeting with Officers A and B, Mrs X and Mr Y were given to believe that the SAR could encompass review of the safeguarding reports they remained dissatisfied with and that there was flexibility to do so. This did not prove to be the case. The SAR has a specific purpose to objectively determine what relevant agencies and individuals may have done differently, to identify learning and seek to avoid a repeat similar harm being caused in future. The SAB did not consider aspects of the ToR were appropriate. The discussion with Mrs X and Mr Y in August 2018 raised their expectations that a SAR could be an all‑encompassing review of everything that had happened.
90. Ultimately, the SAB sets the ToR for a SAR. Their processes show that they will take account of the family’s comments and wishes. However, the final ToR would be decided by the SAB. The Ombudsman cannot determine what the ToR for a SAR should contain. This is a judgement for the SAB in each individual case. However, I found there was a lack of clarity about the likely extent of the SAR’s ToR at the outset and this was fault.
91. There was also a lack of clarity about the original author the council proposed.
92. The early actions taken by the SAB were also outside of its processes. This exacerbated the ToR issue. The SAB procedures in place in 2018 show that when the SAB Chair believes a SAR may be required, they will write to all SAB partners requesting information, this initial information should be considered by a sub-group of the SAB - the Performance, Quality and Improving Practice Group. This group make recommendations about the methodology, the ToR, whether an Independent Chair is required and what other agencies (in addition to statutory agencies) should be included in the review. The SAB will then make a formal decision as to whether a SAR will be undertaken and how this will be done. In Mrs Z’s case, the SAB was agreed in July 2018, and an author was found before information had been received by any of the organisations involved. The author and family worked on ToR before the SAB sub-group became involved. So, while Mrs X and Mr Y had been told the SAB would need to agree the ToR, the approach taken and the initial mishandling of Mrs X and Mrs Y’s expectations led to conflict about the content of the ToR which may have been avoided.
93. These difficulties were worsened by fault in the way the SAB sub-group meeting was conducted in March 2019. The author was told the meeting would not be discussing Mrs Z’s SAR, so he did not attend. This proved to be wrong. Moreover, the SAB invited representatives of the nursing home to attend (a POACH). The nursing home’s input to the SAR was important, but it was inappropriate that they attended a SAB meeting about it, particularly as, at that point, ToR were being agreed. Their attendance was fault. The SAB told us the author is the link between the SAB and the family, but it seems clear the author was unclear at this stage what process was being followed. The fact that the nursing home attended a meeting to discuss Mrs Z’s SAR without the author of the report also resulted in a lack of balance and lack of transparency. This was fault too.
94. There was also significant delay in the process overall. This began at the outset where there were delays in agreeing the ToR with the author. The failure to complete the SAR within the expected timescale of 6 months was fault.
95. The delay, failure to follow the correct process and lack of transparency by the SAB at the outset caused distress to Mr X and Mr Y.

The Council lost a folder of information for two months

96. The chronology of events provided by the Council and correspondence with Mrs X shows that a folder of information she provided was lost between late 2019 and early 2020. This was fault. However, it is not clear, in itself, it added further to the time taken to deal with the SAR.

The SAB failed to adhere to Sections 44 and 45 of the Care Act 2014, in that it only agreed to conduct a discretionary SAR and it did not use its statutory powers under Section 45 to obtain information from the nursing home.

97. It is for the SAB not the Ombudsman to decide when the mandatory criteria for a SAR are met.
98. In August 2019, the care home told the SAB that it had decided to withdraw from the SAR. The SAB told us the home provided ‘a scoping document’ but did not attend meetings. As it was not a ‘partner’ of the SAB it could not be compelled to attend meetings. However, the SAB acknowledged that the Care Act provides the power to require any person to provide information to support a SAR. This could have been used to require the care home to provide information.
99. In the draft SAR, the Author stated “I can only refer to the evidence presented by the home while they took part in the SAR…” which he listed. He went on to say it was regrettable that the care home did not remain within the SAR process and provide specific information to specific questions. He stated he, and the ‘SAB manager’ tried but failed to persuade the home to re-engage. So, it seems evident that the SAR Author had specific questions for the care home, which went unanswered. The SAB was aware of this. It provided no reason why it did not use its powers to require the production of information from the care home. The failure to properly consider using its powers in this regard was fault.
100. I cannot determine if any additional recommendations would have followed, had the SAB used its powers to require the nursing home to continue to participate. However, this was a source of unnecessary distress for the family.

The SAR report is inaccurate, flawed, omits crucial information and misrepresents the facts. Mrs X considers it is biased against the family. The report does not identify learning points from the parties involved in her mother’s care and a promise to write and confirm the learning points was not kept. Rather, the Safeguarding Adults Board decided to include learning in an annual report in September 2022.

When the family responded to the draft SAR report nearly every point raised by them was deemed to be “invalid” by the Council. The Council declined to compensate them for the impact that the lengthy and difficult SAR process had on the family.

The SAR report discredits the family and portrays them as complainers as well as being potentially libellous in implying that Mrs X and her brother were coercive towards their mother.

101. I recognise that the SAB employs an independent author, and it acts to ensure the author’s findings are reached independently. However, I found that there was a failure to properly address the family’s comments about the draft SAR. While some of the family’s comments could be said to be them taking a different perspective to the author, others set out factual errors or areas in which they considered information was omitted and/or the text was misleading or lacking in proper context. I found the SAB failed to properly address their comments. I refer to a number of examples in paragraphs 66 and 67. The failure to properly address the family’s comments on the SAR was fault.
102. I cannot say that the overall outcome would necessarily have been different if the points raised by the family had been properly reviewed, and where necessary, corrected. However, it seems to me to be important to ensure that a Serious Adult Review is factual and not misleading if appropriate lessons are to be learned.
103. The SAB is entitled to reach a decision not to publish an individual SAR. However, I understand that there has been no communication to Mrs X and Mr Y about the learning points that various bodies have agreed to. I see no reason why the SAB has not obtained action plans from the relevant organisations and shared these with the family. This too was fault.
104. I also found that the SAB failed to properly consider the family’s concerns about the extent and nature of comments made about their behaviour. The need to show context is relevant here. A key example being that which I refer to in paragraph 67. The family provided us with a Council Assessment from 2015. This explored the extent to which Mrs Z needed an advocate and it explained Mrs X’s view that Mrs Z seemingly preferred to defer or delegate responsibility for decisions to her. The author was, of course, entitled to refer to CCG and GP records as he did, but the family’s comments to explain the context and why they advocated for Mrs Z are also relevant. I do not consider it was fair and balanced to dismiss them.
105. Again, I cannot say that the outcome would have been different had these comments been better reflected. Indeed, I note that the author makes recommendations about better explaining the complex area of capacity with relatives in general. However, it was understandably upsetting that the family’s comments were not presented alongside other evidence and that exacerbated a lack of trust in the impartiality of the SAR process.
106. Given the apparent lack of consideration given to the context in the report, I consider Recommendation 11, a reference to “potential coercive behaviour over service users by families and others” to be inappropriate. The SAB should have reviewed the validity of this recommendation.

The Chair of the Safeguarding Adults Board stated medical advice had been sought to determine if the substantiated safeguarding issues contributed to her mother’s death. Mrs X established that no specific independent advice was sought, rather, the board had relied on information from the GP who treated her mother, which was not independent.

107. I considered whether there was fault in the way the SAB decided that Mrs Z’s circumstances did not meet the mandatory criteria for a SAB. Specifically, I considered whether the SAB should have considered taking independent medical advice given Mrs X and Mr Y’s concerns about Mrs Z’s care included treatment by her GP.
108. I found there was no fault in the position the SAB took. Its practice and function is to consider the available information and to analyse this to determine what lessons can be learned and how this may affect future practice. Its role is not to make judgements about professional competence in individual cases. The SAB took its view based on the information from Mrs Z’s GP. It also noted a coroner was not involved. There is no requirement for a SAB to obtain independent medical evidence and I do not consider it was at fault for not doing so.

The Council bullied a witness and long-standing family friend who submitted a statement of support to the Council

109. The family friend worked as a health professional. I understand Mrs X’s family friend was concerned to be asked about whether their written comments in support of Mrs X and Mr Y were being made in a professional or personal capacity. I have read the email exchanges between the SAB and Mrs X’s family friend. However, I did not find that seeking to clarify this amounted to fault. I recognise the family friend was concerned about the nature of the questioning, but I do not consider the questions the SAB asked amounted to bullying or pressure to take a particular course of action.

Summary

110. There was injustice to Mrs X and Mr Y. The delay in the SAR process, and leading them believe that the SAR process would resolve previous concerns with the Safeguarding reports/the previous investigation caused distress. This was made worse when the SAR process was not followed properly and more so when the SAB inappropriately involved the nursing home, a potential POACH in a meeting to discuss Mrs Z’s SAR. The issues we identified with the way the family’s comments about the SAR were considered caused further distress.
111. I note that the SAB processes have changed since the events that are described above. This should ensure greater clarity in how SARs are agreed and how ToR are agreed with families. However, I have made recommendations. I have addressed my recommendations to the Council as it has overall responsibility for the SAB as part of its safeguarding functions.

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Recommended action

112. Within four weeks:
113. To recognise the distress caused by the issues summarised in paragraph 110, and the time and trouble Mrs X and Mr Y spent pursuing their complaint, I recommend that the Council sends a written apology to the family and pays them £1250.
114. The Council should review why the nursing home was not identified as a POACH and why it was considered appropriate to include staff from the nursing home in a meeting about Mrs Z’s SAR. It should ensure relevant guidance for officers is updated to prevent a recurrence of this.
115. The Council should review why the SAB did not consider using its powers under Section 45 of the Care Act 2014 to require the nursing home to provide information.
116. The Council should write to Mrs X and provide details of the learning points and actions taken as a result of the SAR process. It should also confirm it will feature in its annual report.
117. The Council should invite Mrs X and Mr Y to write a letter or statement (if they wish to) to be appended to the files on the SAR to set out their remaining concerns. A copy of our Final Decision and the family’s statement should be kept and read with the report to record the family’s view on the process and outcome. In order for the family to make comments, the SAB should provide the family with a copy of the final SAR report, including the final Terms of Reference that were agreed.

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Final decision

118. There was fault by the Council that warranted a remedy.

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Parts of the complaint that I did not investigate

119. We did not investigate the concerns Mrs X had about the handling of the safeguarding issues from 2017. This was because they occurred too long ago. We exercised discretion to consider the complaint about the SAR from 2018.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman