Summary: Mr X complains the Council did not properly gather and consider information during a safeguarding enquiry, and the Council concealed and obstructed his attempts to provide further evidence. The Ombudsman finds fault with the Council for how it managed communication with Mr X. However, the Council has already recognised and remedied this in its complaint response, and therefore no further remedy is warranted.

The complaint

1. Mr X complains the Council failed to seek enough information to fully inform its decision making as part of the safeguarding enquiry into the death of his mother.
2. Mr X says this meant the outcomes did not fully reflect the circumstances of the event and did not address the failings.
3. Mr X also complains that after the enquiry ended, he provided further evidence which would have changed the outcome of the enquiry. However, he says Council officers obstructed his letters, which meant the evidence was not considered.

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The Ombudsman’s role and powers

4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council/care provider has done. (Local Government Act 1974, sections 26B and 34D, as amended)
5. 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 future 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 considered Mr X’s complaint and information he provided. I also considered information provided by the Council.
8. I considered comments from Mr X and the Council on a draft of my decision.

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What I found

Legislation and guidance

Safeguarding

9. 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)

What happened

10. The following is a summary of what has happened between February 2020 and February 2023. It does not include all contacts between Mr X and the Council.
11. Mr X’s mother previously lived in her own home. Mrs X was admitted to hospital in February 2020, and discharged to a care home in March 2020.
12. After Mrs Y arrived at the care home, Mr X says staff told him she had arrived unwell. Mr X said the staff at the care home wanted Mrs Y to return to the hospital as she remained unwell, however she remained in the care home.
13. The Council told Mr X Mrs Y’s reablement package would begin on 8th April 2020, to support Mrs Y returning home.
14. Mrs Y was discharged from the care home to her own home on 8th April 2020. From this point she had a package of care to be delivered in her home by carers.
15. On 9th April 2020, Mrs Y’s carers called an ambulance due to concerns about Mrs Y’s health and wellbeing. Mrs Y was admitted back to hospital and died in hospital on 17th April 2020.
16. The Council opened a safeguarding enquiry into the care of Mrs Y and circumstances of her death and investigated the concerns raised about the care for Mrs Y. In the safeguarding report, the Council found the care home did not have satisfactory record keeping showing that it had provided suitable care to Mrs Y. The Council issued the final safeguarding report in October 2020 which said it would close the case.
17. Mr X was unhappy with the Councils findings in the report and sent letters in March 2021, April 2021 and May 2021 to say he was unhappy with the findings.
18. The Council wrote to Mr X in July 2021 confirming the outcomes of the investigation, and the report provided in October 2020 was the final position.
19. Mr X remained unhappy and so the Council invited Mr X to a meeting to discuss the findings and his concerns in October 2021, but he did not attend.
20. Mr X wrote to the Council and said that Mrs Y’s care notes had since been found, and that he would like the Council to reinvestigate the concerns about her care.
21. The Council added an addendum to Mrs Y’s safeguarding enquiry in 2022 to record that it was aware further notes had now been found. It said that it was satisfied the contents of the records found did not change its view and the outcomes of the enquiry and it would not reopen the investigation.
22. The Council confirmed the closure to the safeguarding enquiry on the system in March 2022, as it had been unable to meet with Mr X and its findings remained unchanged.
23. Mr X continued to write to the Council between May 2022 and February 2023 to express his dissatisfaction into how the Council conducted the safeguarding enquiry. Mr X complained to the Ombudsman in February 2023, but as the Council had not yet considered the issues as a formal complaint, the Ombudsman asked the Council to provide a complaint response.
24. The Council’s final complaint response said:

• It had received all the letters and concerns Mr X had been raising.
• It had already addressed most of the issues that Mr X had continually raised
• There had been a lot of correspondence from Mr X, and, it had not referenced all of his letters in its responses, but this did not mean the Council had hidden or obstructed them.
• The Council remained of the view it had considered the concerns raised and it was satisfied the review into the safeguarding concerns had drawn sound conclusions which had not changed.

25. Mr X remained unhappy and bought his complaint back to the Ombudsman.

Analysis

26. Mr X’s complaint to the Ombudsman was about hiding evidence and letters from Mr X to the Council. However, I have also considered the contents of the letters which were expressing concern about how the safeguarding investigation was conducted. It is therefore my view that Mr X’s complaint has multiple parts which need to be considered separately.

Safeguarding enquiry

27. The contents of the letters and concerns Mr X sent to the Council was about the care Mrs Y received in the care home and on discharge. Mr X was raising concerns that he felt the safeguarding enquiry had not adequately addressed or investigated these issues.
28. The Council finished the safeguarding report in October 2020 and issued it to Mr X. Mr X wrote to the Council in March 2021, April 2021 and May 2021 to say he was unhappy with how the Council had investigated and the information it had got during the investigation. The Council wrote to Mr X in July 2021 to confirm the report sent to him was the final version and responded to other concerns about how it had collected the information in the report. It also invited him to a meeting in October 2021 to discuss his concerns but he did not attend.
29. The Council has confirmed that no major changes were made to the findings or records after October 2020, and that it confirmed this to Mr X in July 2021. Some formatting changes were made after this and the Council added a note to the file to recognise Mr X’s views and the care home notes had since been found. However, it remained of the view the outcomes should not change.
30. Mr X contact the Council several times in 2021 to express his dissatisfaction with the report and its findings, with the Council responding to these concerns in July 2021. Therefore, from this point Mr X knew the outcome of the report and the Council’s view on his concerns. Mr X had 12 months from this point to bring the matter to the Ombudsman’s attention if he remained unhappy.
31. Mr X did not complain to the Ombudsman until February 2023. If Mr X wanted the Ombudsman to consider how the Council carried out the safeguarding investigation, he should have complained within 12 months of becoming aware of the issues. This would have been when he received the report and the Council’s response in July 2021. As Mr X did not do this, I am not exercising discretion to consider this element of the complaint.
32. Mr X has said the Council closed the safeguarding enquiry in March 2022 and therefore he came to the Ombudsman within 12 months. The Council finished investigating the safeguarding concerns in October 2020, and told Mr X this. Mr X wrote various letters of concerns in 2021 expressing that he was unhappy. The Council confirmed its position in July 2021 but invited Mr X to a meeting. It held the case open on the system to meet with Mr X, but for all intents and purposes, Mr X was aware of the Council’s final position from July 2021, and his continuing letters of concern in 2021 and 2022 reflect that he knew this. I remain of the view that Mr X’s complaint is late.
33. Mr X has said he did not come to us sooner as he was dealing with Mrs Y’s estate, and he had another complaint with us at the time which needed his attention. Mr X also says that he was hoping involving his MP would resolve the issues. This reasoning does not convince me that Mr X could not bring his complaint to us sooner and shows that he was aware of the Ombudsman’s service.
34. Concealment of evidence and letters
35. Part of Mr X’s complaint is the Council hid evidence and letters about his concerns for Mrs Y’s care. This meant his previous concerns and complaints were not fully considered or responded to, and it meant the Council did not reopen the safeguarding investigation.
36. The Council’s complaint responses to Mr X upholds that it could have considered some of the correspondence has a complaint sooner. It also recognised that due to the large volume of correspondence, not all letters were referenced to in responses sent to Mr X. The Council confirmed each letter was received and have since been considered and responded to. The Council further evidenced this in the addendums added to the safeguarding investigation in 2022. The addendum recognised the Mr Y concerns and the care records being located, but the contents of the notes and letters did not change the findings or the outcomes.
37. The Council has accepted there were ways that communication could have been handled better. However, I cannot see this has caused Mr X injustice, as considering and responding to the letters did not result in any new findings or changes for the outcome of the safeguarding inquiry. The Council has already apologised to Mr X for its management of communication, and this is the most suitable remedy for the fault identified.
38. The Ombudsman is not an appeal body. This means we do not take a second look at a decision to decide if it was wrong. Instead, we look at the processes an organisation followed to make its decision. If we consider it followed those processes correctly, we cannot question whether the decision was right or wrong, regardless of whether you disagree with the decision the organisation made.
39. In making its decision not to reopen the safeguarding investigation, the organisation took account of the letters from Mr X and that Mrs Y’s care notes had been found. The Council considered whether the information meant it should reopen the enquiry and decided it did not. This was a decision the Council was entitled to make and I cannot therefore criticise it.

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Final decision

40. I have completed my investigation. I find fault with the Council for how it managed communication with Mr X. However, the Council has already provided a suitable remedy for this.

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman