Essex County Council (23 017 341)
The Ombudsman's final decision:
Summary: We upheld a complaint from Mr D and Mr E that they did not receive enough support from the Council when they adopted a child from its area. In particular, when they needed support with the child’s challenging behaviours. We considered fault by the Council caused them unnecessary distress. The Council accepted these findings. At the end of this statement, we set out the action it has agreed to take to remedy their injustice and make service improvements.
The complaint
- Mr D complained on his own behalf and that of his husband, Mr E, that there were a series of failings by the Council when they adopted a child, F. In particular, he said the Council’s children in care team:
- communicated poorly, failing to let them know when F’s social worker was off work or could not attend meetings;
- showed poor professional practice, when its social worker spoke to him by telephone after he raised concerns with her manager and when they asked for a cuddle from F;
- did not liaise effectively around the transfer of F’s Disability Living Allowance (DLA) from F’s foster carers to Mr D and Mr E;
- did not liaise sufficiently with Mr D and Mr E’s local authority when F moved to a new school in their area;
- sent a life plan for F containing mistakes, which remained uncorrected. It delayed also in sending a life story book for F, which when received also contained mistakes and was not in a child-friendly format. It also sent a later life letter for F that contained errors and discrepancies;
- did not sufficiently forewarn them of F’s challenging behaviours, nor support them with these. It delayed in involving its post-adoption support service and refused transfer of those services to Mr D and Mr E’s local authority.
- Mr D said because of the above, the Council’s actions added distress to the adoption process and left he and Mr E feeling without support at a critical time. They also had unnecessary inconvenience and frustration in their communications with the Council.
The Ombudsman’s role and powers
- We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
- 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)
- 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)
- Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).
How I considered this complaint
- Before issuing this decision statement I considered:
- Mr D’s complaint to the Ombudsman and any supporting information he provided;
- correspondence exchanged between Mr D and the Council about the subject matter of the complaint, which pre-dated our investigation;
- information provided by the Council in reply to written enquiries;
- any relevant law, Government guidance or council policy referred to below;
- any relevant guidance published by the Ombudsman.
- I also gave Mr D and the Council an opportunity to comment on a draft version of this decision statement and provide any further information considered relevant to the investigation. I took account of their responses before finalising the decision statement.
What I found
Key facts
- F is a child of primary school age, known to the Council from birth. Because of concerns around parental neglect, they became subject to a child protection plan around their second birthday. They entered foster care before turning three. In April 2022 the Council recommended adoption for F. A child permanence report recorded F as the target of aggressive behaviour from an elder sibling with whom they initially shared foster care. This led the Council to separate the siblings. The report also mentioned F showing challenging behaviours.
- Later in 2022, the Family Court agreed F should be the subject of a placement order, meaning they could be placed for adoption. The Court received a report prepared by CAFCASS , which represents the interests of children in such proceedings. This too referred to F’s relations with their sibling and said there had been concerns they may “harm each other”.
- F has some special educational needs and in October 2022, received an Education, Health and Care (EHC) Plan. This described F settling in their current foster placement and becoming “less aggressive”. It said there needed to be a risk management assessment, because of F’s “general safety needs and their propensity to “run off”, hurt themselves and “hurt others”.
- By October 2022, Mr D and Mr E had come forward as prospective adopters for F. The Council considered them suitable and in February 2023 an adoption and permanence panel approved their application. The minute of the panel meeting refers to F showing challenging behaviours and asking Mr D and Mr E about how they would cope with these.
- Introductions began and the Council drew up a transition plan envisaging that F would move from foster care into Mr D and Mr E’s care in April 2023.
- Before F moved in with Mr D and Mr E, the Council says it sent them various documents, including the CAFCASS report and EHC Plan and a psychology report. I have not seen the psychology report but have seen it quoted, and that it refers to F having “aggressive behaviours”. F’s foster carers also completed a document about F, given to Mr D and Mr E. This described F having “challenging moments” when faced with disruption in routine or during personal hygiene routines.
- In March 2023, a looked after child review took place. It recorded that F had begun some self-harming behaviours. It noted F received DLA and recorded that their social worker would “inform payment to change”. It said the social worker would also complete a life story book for F.
- Contemporaneous to the meeting, Mr D and Mr E had begun researching schools for F. They needed a letter of support from F’s social worker for F’s prospective new school. The minutes of the looked after child review also recorded the social worker would send a letter ‘to education’. But this only followed at the end of the month, after Mr D sent two requests by email.
- In April 2023, F moved in with Mr D and Mr E. This was around a week earlier than anticipated, to limit the stress F experienced during the transitional arrangements. Mr D raised with me a concern the Council did not adequately prepare F for their move. He said it was only in March the Council began preparation work with F. The Council told me it considered this suitable at the time given its understanding of F’s needs. But with hindsight it considered it could have begun that work sooner.
- Shortly after F moved into the family home, their social worker was due to visit. However, the visit did not take place as the social worker was absent from work. Mr D only found out the day before. He complained the Council had not told them of the social worker’s absence sooner, as F needed some preparation for the visit given their needs.
- After the cancelled visit Mr D wrote an email to the social worker’s team leader, marked confidential, expressing dissatisfaction with the service provided from the children in care team. F’s social worker picked up this message and Mr D spoke to her the following week, describing a challenging telephone call.
- The social worker went on to visit F. Mr D said they arrived late and he felt it showed poor professional practice that she asked F for a cuddle before leaving.
- After F moved in with Mr D and Mr E, the Council produced a copy of F’s life plan. The Council describes this as setting out why a child needs to be in care and what will happen to them. It includes information such as where they will live and how they will receive support. The Council says the plan should be reviewed at looked after children review meetings.
- However, the Council did not produce a life plan for F until the day of their next looked after review meeting, in May 2023. Mr D said the first copy had errors around dates and names. When he tried to raise this issue at the meeting, F’s social worker was not present. The worker sent in her place, could not answer questions about this issue, being less familiar with F’s case.
- Mr D says at the same meeting he and Mr E discussed when they might apply to the Court for an Adoption Order for F. Mr D said the Council discouraged them from applying for such an order at an early stage, saying it was important they had enough support for F in place first. The minutes of the meeting say that after a “lengthy discussion” Mr D and Mr E agreed to postpone a decision about seeking an order until after the next review meeting.
- Also, in May 2023, Mr D enquired further about F’s DLA which had now stopped. He received a reply, around 10 days later, from the line manager of F’s social worker. They told Mr D he needed to apply to the Department of Work and Pensions (DWP) to arrange this.
- Next, Mr D set out his frustrations in an email to the service. This included raising concerns about the lack of visits, or preparation for visits, to F at their home; the delay in producing the life plan and the inaccuracies contained in it; and the failure to transfer F’s DLA as promised in March.
- Subsequently, the Council sent Mr D amended copies of the life plan (both later in May and July 2023). However, Mr D says the last copy circulated still contained errors. The Council recognises it produced the life plan late. In answering Mr D’s complaint, it promised it would “improve its practice” in this area. It told me that it considered it had made all changes needed to the plan. But among the documents it sent me was an email from Mr D in July 2023 asking for corrections to the document. I could not find an answer to that email.
- I saw a further exchange of emails between Mr D and F’s social worker in late May 2023 around F’s DLA. In which the social worker wrote “the change has been requested”, while suggesting Mr D speak directly to the DWP about the rate of payment F received. Later the social worker wrote to Mr D telling him he needed to complete a specific form to complete the transfer.
- At the start of June 2023 Mr D sent an email raising concerns about behaviours shown by F. Over the next month he had sporadic contact with F’s social worker who explained something of the difficulties F had living with their sibling in foster care. They also said they did not know why F’s EHC Plan referred to them “running away” or referred to aggressive behaviour.
- By the end of the month Mr D and Mr E arranged to meet with the Council’s mental health co-ordinator, a meeting attended also by F’s social worker. Mr D commented the co-ordinator did not have experience of such a meeting and seemed unsure of its purpose. The meeting discussed F’s behaviours but there was no agreed outcome. When I asked the Council about the meeting, it could find no record of it.
- In July 2023 the Council agreed to fund some equestrian therapy sessions. At a further looked after child review that month, Mr D and Mr E expressed the view that F needed more support with their emotional and behavioural development. The Council says that it had either agreed, or provided, some ‘theraplay’ at this point, but I found no clear record of this.
- In September 2023 Mr D sent an email raising further concerns about F’s behaviours. He said, “we need support and we need it now”. He asked, “where are we with the therapy referrals we asked for?”. Mr D and Mr E’s adoption social worker suggested meeting with the Council’s post-adoption support team to see what support it might offer.
- A meeting with the post-adoption team followed in early October 2023. But the service said it could not offer Mr D and Mr E support until they had an Adoption Order.
- Also, in October 2023 a meeting was held to review F’s personal education plan (a separate document to their EHC Plan). Mr D says F’s new school did not have access to their ‘virtual school’ record or their personal education plan. In response the Council has provided an email chain which shows that it confirmed with F’s school they could upload F’s PEP. The Council said that F’s social worker had set up the meeting, but that it was F’s school which was responsible for inviting any officers from the Council.
- Mr D and Mr E gained an Adoption Order for F later in October 2023.
- In December 2023 the Council’s Post Adoption Team undertook an assessment with Mr D, Mr E and F. The Council says it only undertook this assessment after discussion with Mr D and Mr E’s local authority. That agreed with the Council undertaking the assessment, rather than it doing so on the Council’s behalf.
- The Council described the assessment as an intensive piece of work, that took two to three days and it resulted in a long and detailed document. The assessment noted F did not have a life story book or a later life letter. During the assessment, Mr D and Mr E expressed concern they did not know enough about F’s early life story and how this might contribute to their behaviours. The assessment considered possible causes for F’s behaviours and noted Mr D and Mr E’s request for therapeutic support. As an outcome it recorded the Council would develop a support plan and discussed different types of therapeutic support. The Council also says that as part of the assessment its post-adoption social worker gave therapeutic support.
- At the end of January 2024 Mr D and Mr E wrote to the Council asking that it agree they could receive post-adoption support from their local authority. It asked the Council to commission this and pay for it, something allowed for by Regulation. They expressed dissatisfaction at the time taken by the Council to complete the post-adoption assessment and that they did not have enough support in place. They also said they still had no life story book or later life letter for F. They explained the continuing stress they experienced because of F’s behaviours.
- The Council says in immediate response to this letter it began providing more therapeutic support through its post-adoption social worker. It described this as an “interim measure”. The Council says that in March, Mr D and Mr E then began receiving more support via a local provider that it commissioned. Its plan was then for a third type of therapeutic support to follow in due course, which it would again commission from a specialist provider, local to Mr D and Mr E. The Council said that its post-adoption social worker remained in close contact with social workers supporting Mr D and Mr E from their local authority.
- In February 2024 the Council provided Mr D and Mr E with a ‘later life’ letter for F. This contained various errors and Mr D asked for various clarifications. The Council consequently sent an amended letter to them in March 2024.
- Also, in February 2024 the Council sent a draft life story book to Mr D and Mr E. It had difficulties sending this electronically because of its size and it did not have the preferred software. So, at first it only sent it as hard copy. By March 2024 the Council had sent an electronic version which Mr D and Mr E could edit. The life story book sent by the Council contained some factual errors and Mr D wanted to resize photos and amend captions and so on. Mr D told me he had spent around 10 hours working on it to make it more child-friendly and accessible for F.
My findings
- I considered each part of Mr D’s complaint in turn.
The complaint the Council did not tell Mr D when E’s social worker was off work or could not attend meetings
- I did not uphold this part of the complaint. I considered first the social worker’s cancellation of their visit to Mr D’s home in April 2023. I appreciate the social worker had been away from work for several days and so the Council could have given more notice of her absence. Mr D suggests it could have better checked her emails in her absence.
- But the absence was still unforeseen and the Council ensured Mr D had some notice of it, although at short notice. I can see it was not ideal for F, at what was a disruptive time in their life, to have arrangements changed given their additional needs. But I considered it unavoidable and so I could not say that any distress caused to F was an injustice arising from fault by the Council.
- I also noted the social worker’s absence from the May 2023 looked after child review. I accepted her absence may again have been unavoidable. So, I did not find fault with it. But her absence was unfortunate, because as I go on to discuss, Mr D and Mr E had legitimate questions about some outstanding matters concerning F’s care at that time. The social worker was not there to address those.
Complaints about the professionalism of F’s social worker
- I did not uphold this part of the complaint. I could not take a view on the social worker’s conduct during the telephone conversation they had with Mr D. In reply to Mr D’s complaint the Council did not agree his account of the call. We cannot come to a view when there are no agreed facts between both sides around the content of a call. This is because there is no evidence that would allow me to prefer one account of the call over the other.
- I noted Mr D’s more general concern the telephone call only arose following an email he sent to the social worker’s line manager, which he marked confidential. I considered the social worker would have to know of Mr D’s concerns, for it to respond to them. It was also inevitable there would be continuing contact between the social worker and Mr D because of the social worker’s role in F’s life. But I considered best practice would have been for the line manager to explain to Mr D the action they took with his email or to discuss it with him first. Not knowing this, put Mr D at a disadvantage before he spoke to the social worker and may have added some unnecessary tension to the call.
- I next considered the suggestion it was unprofessional for the social worker to ask F for a cuddle. Some authorities produce guidance for social workers and other officers on having touch with children (meaning to provide affection or reassurance). Here, the Council does not do so. I found it was not under any obligation to do so. In which case, having guidance would only be a matter of best practice.
- If the Council did have such guidance, it would not forbid touch in the way I describe it. But there would be an expectation officers weigh in advance factors such as the child’s life experience to see if touch may be traumatic or inappropriate. Also, that touch only take place where seen by other adults and only with the child’s consent.
- I have seen nothing in the records about F suggesting the social worker’s request was inappropriate. It took place in front of Mr D. And while I did not think it appropriate to consider consent in a child of F’s age, there was no suggestion the contact caused any distress to them.
- For these reasons, I did not consider we could fault the social worker for her action.
The complaint about delay in securing welfare benefits
- I took account here of Government statutory guidance on adoption. That says the Council should provide clear information to adoptive parents on accessing welfare benefits. I did not consider it did this and so I upheld this part of the complaint.
- The record of the looked after child meeting in March 2023 said F’s social worker would make the necessary enquiries to ensure DLA transferred to Mr D and Mr E. A further email exchange Mr D had with the social worker in May suggested this was still her intent. But it later transpired Mr D and Mr E had to contact the DWP to have the DLA paid to them.
- So, they received the wrong or incomplete advice and they had to wait several weeks to receive the correct advice. This was a fault.
- The fault caused Mr D and Mr E injustice. They experienced unnecessary distress and frustration in having to resolve an issue they thought was ‘under control’. This was in the context of what was a time of transition in their lives with F first joining their family that would bring with it some unavoidable stress.
The complaint about liaison with education services
- I partially upheld this part of the complaint. In March 2023, Mr D and Mr E were understandably keen to identify an education placement for F they could access once they moved into the family home. So, while the social worker did not delay excessively in sending a letter they needed in support of this, given the pressure of time it was unfortunate they had to chase this up. However, I am not persuaded the delay was significant enough we could say it was fault.
- Turning to later events, I noted that all looked after children should have a personal education plan (PEP). In addition, all councils must appoint a ‘virtual school head’ whose role is to promote the educational achievement and promotion of education of looked after children.
- F had a PEP. But that PEP did not follow F to their new local authority area as smoothly as it should have done. It was unclear to me the extent to which the Council’s virtual school head took an active interest in F’s case once they moved out of the Council’s area. The Council’s replies to my enquiries were contradictory. On the one hand it said its social worker set up meetings and sought to ensure F’s new school knew of their PEP. I saw emails that showed this. But it also said F’s new school had the responsibility for ensuring the Council received an invite to any meeting to discuss F’s PEP.
- I considered some confusion and uncertainty therefore surrounded the Council’s liaisons with the educational institutions around this issue and that was a fault. I found the injustice this caused Mr D and Mr E was some further avoidable distress in resolving that confusion and uncertainty.
The complaint about F’s life plan, life story book and later life letter
- I upheld this part of the complaint. The Council had already recognised fault in producing the life plan late. In considering the consequence of this, I noted the content would largely be familiar to all parties around the time of the looked after child meeting in May 2023. For example, in explaining why the Council had gained an adoption order for F. However, the life plan remained an important document drawing together different strands of information in a child friendly format. So, the Council should not have left its production until the last minute.
- The last-minute production contributed to the document containing errors. Individually I did not consider these were all significant. But cumulatively they combined to give an unprofessional impression. I also noted that as with the confusion around F’s DLA payments, the late production of the life plan came at a stressful time for Mr D and Mr E. They did not need the further avoidable stress of trying to obtain a corrected version.
- The Council said it made all necessary corrections to the document. However, the last message I saw exchanged on this subject in July 2023 suggested this was not the case and that it still contained some minor errors.
- Turning to F’s life story book and later life letter, I noted there was further delay with both. The former should be an account of a child's life in words, pictures and documents. It should provide for the child to explore and understand their early history and life before their adoption. The Council should have provided it, at the latest, around the time Mr D and Mr E obtained the Adoption Order.
- I understood Mr D’s concern at the quality of the book provided. While I could not say it was not fit for purpose, it contained some factual errors and its formatting was poor in places. Once edited, Mr D produced a life story book with greater personalisation and that appeared more child friendly. Although I considered what he produced went beyond what we might reasonably expect the Council to produce with the time and resources it has.
- That said, I thought the Council may want to take the opportunity presented by Mr D’s complaint to review how it produces such books. It has chosen not to do so. I am disappointed in that but cannot insist it do so, given my finding above stops short of saying it was at fault.
- The delay with the later life letter was less serious, given F will not see it for many years. However, it was still regrettable that Mr D and Mr E had to raise the matter several times before they received the letter. And that when they did receive it, that it raised so many queries and contained errors.
- I must therefore record further fault in the late production of both the life story book and the later life letter as well as in the quality of the latter. This will have further added something to Mr D and Mr E’s injustice in the form of more inconvenience.
The complaint about support
- Finally, I considered what I regarded as the most serious failings alleged by Mr D and Mr E, which concerned the support they received once F joined their family. I upheld this part of their complaint.
- From June 2023 onward Mr D and Mr E raised concerns about F’s behaviours and looked for support in how best to respond to these.
- I found several references in the papers given to Mr D and Mr E before F moved in with them, suggesting they had some challenging behaviours. The CAFCASS report, the EHC Plan, the psychologist report and the profile completed by the foster carers all referred to this. I found a lack of detail in explaining what F’s challenging behaviours were, although there was some suggestion of self-harming behaviour similar to what Mr D described to me.
- Before F moved in with Mr D and Mr E the transition period allowed them to meet and talk with the foster carers. They also had opportunity to talk to the social worker. On balance therefore, I could not say the Council under-prepared them for the challenging behaviour that F might present. I was also conscious that F’s behaviours with Mr D and Mr E may be much harder to manage than those described at an earlier stage of their life. Because F is now older and physically stronger.
- Instead, where I found the Council at fault, was for how it responded to Mr D and Mr E’s concerns. There was discussion in May 2023 at F’s looked after child review, around support Mr D and Mr E may need. This led them to postpone seeking an Adoption Order, understanding they would have support if needed. But after that, when Mr D asked for support, he waited around a month for a reply to his emails, distressing to him given the urgent context of his enquiry. Next there followed discussion around therapeutic support in June and July 2023. But no clear record of what the Council offered or agreed, including no record of the meeting with its Mental Health Co-Ordinator.
- In September 2023 Mr D sent an email that could not have been clearer in setting out how much he and Mr E wanted help. But the Council allowed weeks and then months to pass, with little in the way of practical support offered. I understood a barrier to Mr D and Mr E getting support was that an offer relied on them first gaining an Adoption Order. This was contrary to what they understood following the May 2023 meeting. It also suggested a systemic failing by the Council, because it could not offer the support it went on to provide in 2024 sooner. I feared in another case this could have resulted in an adoption breakdown.
- Even after Mr D and Mr E obtained the Adoption Order, it took more than three months for any regular therapeutic support to be in place. Fortunately, they were not without all support in this time. Mr D told me of his gratitude for that offered by their local authority and for the quality of support provided by the Council post-adoption social worker. But I had to regard the delay in providing therapeutic support as a fault.
- I understood therefore why Mr D and Mr E asked the Council to arrange for their local authority to provide post-adoption services, something the Regulations allow for. I found they did not receive a reply to their request. I recognised the Council had subsequently provided services, through its post-adoption social worker and providers local to Mr D and Mr E. It had therefore made up for some of its earlier unresponsiveness. But it was still right that Mr D and Mr E’s proposal receive proper consideration, which is something the Council has now agreed to do (see below).
- Finally, on this point I considered a concern raised by Mr D that the Council may have better prepared F for their adoption. The Council accepts ‘with hindsight’ that it may have begun preparation with F sooner. But it has explained why its thinking at the time was different. And that the preparation time each child has depends on a case-by-case judgment based on their individual needs. On balance, I accepted the Council had reflected on its preparation in this case and I did not think further investigation needed into this specific issue.
- The faults detailed above caused Mr D and Mr E further injustice. They added significant distress when their lives were already experiencing considerable change and faced challenges.
Agreed action
Personal remedy
- The Council accepts the findings set out above. To remedy the injustice caused to Mr D and Mr E by its faults, it has agreed that within 20 working days of this decision it will provide the following:
- an apology to Mr D and Mr E accepting the findings of this investigation. The apology should take account of guidance we publish at section 3.2 of our published guidance on remedies Guidance on remedies - Local Government and Social Care Ombudsman; and
- a symbolic payment of £1100 (see paragraph 78 for breakdown);
- to correct any remaining discrepancies or errors in F’s life plan (if Mr D still wants this). The Council will invite him to confirm these and on receipt the Council will commit to make any necessary corrections within 20 working days;
- to arrange a meeting with Mr D and Mr E to discuss their request to transfer post-adoption services to their local authority. Within 20 working days of that meeting it will set out in writing whether it agrees the request, providing reasons if it does not.
- The symbolic payment takes account of our guidance on remedies, as follows:
- for the avoidable distress caused by poor communications around the transfer of F’s DLA payments - £150.
- for the avoidable distress caused through poor communications around the meeting with F’s school in October 2023 - £100.
- for the avoidable distress caused by the delays and some errors in the life plan, life story and later life letter - £200.
- for the avoidable distress caused through not intervening sooner to support Mr D and Mr E with F’s behaviours before the Adoption Order - £400
- for the avoidable distress caused through not intervening sooner to support Mr D and Mr E with F’s behaviour after the Adoption Order - £250
Service improvement recommendations
- It is part of our role to consider how the Council may avoid any fault identified during an investigation from recurring. The Council has agreed that within three months of a final decision on this complaint it will make the following service improvements:
- social workers within its children in care service will receive a briefing or training session, clarifying the Council’s expectations when a child being adopted has disability or other welfare benefits payable to them which should transfer to the adopted parents. This is so they can offer the correct advice to the adoptive parents. Before delivering this briefing, the Council will review whatever written materials it provides to support those workers in this area to ensure those are up to date and reflect its policy in this area;
- social workers within its children in care team will also receive a briefing or training session, clarifying the Council’s expectations around education planning for children being adopted outside its area. This will cover such matters such as the transfer of any existing personal education plan and responsibility for arranging meetings to discuss provision once a child moves out of area. Before delivering this briefing, the Council will review whatever written materials it provides to support those workers in this area to ensure those are up to date and reflect its policy in this area;
- undertake a review of the support services it offers to adoptive parents in the time between a child moving in with them and the Adoption Order. It must have clear procedures showing who is responsible for considering any requests for services from the adoptive parents and details of what services are potentially available for support, including the role of its Mental Health Co-Ordinator. It will consider offering any further training or support as needed to social work staff who may face such requests. It will write to us to tell us the outcome of this work.
- The Council will provide us with evidence when it has complied with the actions set out in paragraphs 77 and 79.
Final decision
- For reasons set out above I upheld this complaint finding fault by the Council caused injustice to Mr D and Mr E. The Council accepted these findings, agreeing to take action that I considered would remedy that injustice. Consequently, I completed my investigation satisfied with its response.
Investigator’s decision on behalf of the Ombudsman
Investigator's decision on behalf of the Ombudsman