Summary: Mrs X complained the Council failed to put in place suitable alternative provision for her child, Z. Mrs X also complained the Council delayed completing an Education, Health and Care (EHC) needs assessment, delayed deciding whether to issue an EHC Plan, and handled her complaint poorly. We have found the Council at fault. We have made recommendations to address the injustice this caused.

The complaint

1. Mrs X complained the Council failed to put in place suitable alternative provision for her child from mid-2022. She also complained the Council delayed issuing a final EHC Plan, and about the Council’s complaint handling.
2. Mrs X said her child did not receive suitable education provision since mid-2022, affecting their educational attainment and wellbeing. Mrs X also said the Council’s actions caused avoidable frustration, uncertainty and distress.

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The Ombudsman’s role and powers

3. 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’. Service failure can happen when an organisation fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by an organisation to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
4. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. The law says we cannot normally investigate a complaint unless we are satisfied the organisation knows about the complaint and has had an opportunity to investigate and reply. However, we may decide to investigate if we consider it would be unreasonable to notify the organisation of the complaint and give it an opportunity to investigate and reply. (Local Government Act 1974, section 26(5), section 34(B)6)
6. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
7. 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

8. I considered information Mrs X provided and discussed the complaint with her.
9. I considered information the Council provided about the complaint.
10. Both Mrs X and the Council were able to comment on a draft version of this decision. I considered any comments I received before making a final decision.
11. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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Relevant legislation, guidance and policy

Alternative provision

12. Under section 19 of the Education Act 1996 councils have a duty to make arrangements for the provision of suitable education, at school or otherwise, for children who, because of illness or other reasons, may not receive suitable education unless such arrangements are made for them.
13. The statutory guidance says the duty to provide a suitable education applies “to all children of compulsory school age resident in the council area, whether or not they are on the roll of a school, and whatever type of school they attend”.
14. Suitable education means efficient education suitable to a child’s age, ability and aptitude and to any special educational needs he may have. (Education Act 1996, section 19(6))
15. The education provided by the council must be full-time unless the council determines that full-time education would not be in the child’s best interests for reasons of the child’s physical or mental health. (Education Act 1996, section 3A and 3AA)
16. The law does not define full-time education but children with health needs should have provision which is equivalent to the education they would receive in school. If they receive one-to-one tuition, for example, the hours of face-to-face provision could be fewer as the provision is more concentrated. (Statutory guidance, ‘Ensuring a good education for children who cannot attend school because of health needs’)
17. The statutory guidance also says that if specific medical evidence, such as that provided by a medical consultant, is not quickly available, councils should “consider liaising with other medical professionals, such as the child’s GP, and consider looking at other evidence to ensure minimal delay in arranging appropriate provision for the child”.
18. Where councils arrange for schools or other bodies to carry out their functions on their behalf, the council remains responsible. Therefore councils should retain oversight and control to ensure their duties are properly fulfilled.
19. We have issued guidance on how we expect councils to fulfil their responsibilities to provide education for children who, for whatever reason, do not attend school full-time. (Out of school, out of sight? published July 2022)
20. We made six recommendations. Councils should:
• consider the individual circumstances of each case and be aware that a council may need to act whatever the reason for absence (except for minor issues that schools deal with on a day-to-day basis) – even when a child is on a school roll;
• consult all the professionals involved in a child's education and welfare, taking account of the evidence when making decisions;
• choose (based on all the evidence) whether to require attendance at school or provide the child with suitable alternative provision:
• keep all cases of part-time education under review with a view to increasing it if a child’s capacity to learn increases:
• work with parents and schools to draw up plans to reintegrate children to mainstream education as soon as possible, reviewing and amending plans as necessary:
• put the chosen action into practice without delay to ensure the child is back in education as soon as possible;

Education, Health and Care Plans

21. A child or young person with special educational needs may have an Education, Health and Care (EHC) Plan. This document sets out the child’s needs and what arrangements should be made to meet them. The EHC Plan is set out in sections. We cannot direct changes to the sections about their needs, education, or the name of the educational placement. Only the tribunal or the council can do this. 
22. Statutory guidance ‘Special educational needs and disability code of practice: 0 to 25 years’ (‘the Code’) sets out the process for carrying out EHC assessments and producing EHC Plans. The guidance is based on the Children and Families Act 2014 and the SEN Regulations 2014. It says the following:
• Where the council receives a request for an EHC needs assessment it must decide whether to agree to the assessment and send its decision to the parent of the child or the young person within six weeks.
• If the council decides not to conduct an EHC needs assessment it must give the child’s parent or young person information about their right to appeal to the tribunal.
• The process of assessing needs and developing EHC Plans “must be carried out in a timely manner”. Steps must be completed as soon as practicable.
• If the council goes on to carry out an assessment, it must decide whether to issue an EHC Plan or refuse to issue a Plan within 16 weeks.
• If the council goes on to issue an EHC Plan, the whole process from the point when an assessment is requested until the final EHC Plan is issued must take no more than 20 weeks (unless certain specific circumstances apply);
• Councils must give the child’s parent or the young person 15 days to comment on a draft EHC Plan and express a preference for an educational placement.
• The council must consult with the parent or young person’s preferred educational placement who must respond within 15 calendar days.
23. As part of the assessment, councils must gather advice from relevant professionals (SEND Regulation 6(1)). This includes:
• the child’s educational placement;
• medical advice and information from health care professionals involved with the child;
• psychological advice and information from an Educational Psychologist (EP);
• social care advice and information;
• advice and information from any person requested by the parent or young person, where the council considers it reasonable; and
• any other advice and information the council considers appropriate for a satisfactory assessment.
24. The council must not seek further advice if it already has advice and “the person providing the advice, the local authority and the child’s parent or the young person are all satisfied that it is sufficient for the assessment process”. In making this decision the council and the person providing the advice should ensure the advice remains current.
25. Those consulted have a maximum of six weeks to provide the advice.
26. The council may decide to seek additional advice, for example from an Occupational Therapist (OT) or Speech and Language Therapist (SALT), or the child’s parent or young person may request this. The council should decide if this is necessary based on the individual circumstances of the case.
27. The SEN Regulations 2014 state where the SEND Tribunal decision requires the council to complete an assessment, the Council shall:
1. Within two weeks of the SEND Tribunal’s decision, confirm it will carry out assessment; and
2. As soon as practicable and within 10 weeks of the SEND Tribunal’s decision, confirm if it decides it is not necessary to issue an EHC Plan to the child or young person; or
3. As soon as practicable and within 14 weeks of the SEND Tribunal’s decision, issue the final EHC Plan to the child or young person. (SEND Regulation 44(2)(b)(i) and (ii))

Complaint procedure

28. The Council operates a two-stage complaints procedure:
• At stage one, the Council says it will normally respond to a complaint within 10 working days. If this is not possible, the Council will agree a new deadline.
• At stage two, the Council will review the complaint and consider any new or additional evidence. The Council says it will provide a response within 20 working days. If this is not possible, the Council will agree a new deadline with the complainant.

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What I found

Summary of key events

29. Below is a summary of the key events leading to this investigation. It is not an exhaustive chronology of every exchange between parties. Where necessary, I have expanded on some of these events in the “analysis” section of this decision statement.
30. Mrs X said her child, Z, had not attended School P full time since June 2022, due to mental health conditions. She said Z had been unable to attend School P altogether since 12 October 2022.
31. Mrs X sought an EHC needs assessment for Z. Mrs X said the Council decided against assessing Z in September 2022. This decision came with a right of appeal to the SEND Tribunal. Mrs X appealed the Council’s decision. In February 2023, the SEND Tribunal directed the Council to assess Z’s EHC needs. The Council wrote to Mrs X in March 2023 to begin this process.
32. In April 2023, Mrs X complained to the Council:
1. Mrs X said the Council was assessing Z’s EHC needs, to ensure Z had the correct support. However, Mrs X said Z was a child in their second year of secondary education, who had not had any core subject teaching since October 2022. Mrs X said work sheets and online learning did not count as appropriate provision.
2. Mrs X cited statutory guidance confirming the Council should ensure suitable alternative provision was in place by the sixth day of absence, once the Council had known Z would be away from School P for more than 15 days.
33. The Council confirmed receipt of Mrs X’s complaint. It summarised the complaint as being about a delay in completing Z’s EHC needs assessment. Mrs X said this was incorrect, as the complaint was about the Council failing to provide alternative provision. The Council acknowledged its mistake.
34. The Council wrote to Mrs X:
1. The Council said School P remained responsible for providing a suitable education, in circumstances where a child could not attend due to illness or otherwise. It cited Section 100 of the Children and Families Act 2014, the SEN Code of Practice, and Section 7 of the Education Act 1996. The Council said where a young person had a diagnosed medical need, it discharged its Section 19 duty via its hospital education programme.
2. The Council asked if School P had referred Z to this programme. It said if not, School P had a duty to secure a suitable adapted education package for Z. The Council suggested Mrs X, School P and any other involved professionals work together to draw up an education support plan.
35. Mrs X replied to the Council, asking it to reconsider this decision. She again set out its duties under Section 19.
36. At the beginning of May 2023, the Council discussed the matter with Mrs X in a telephone conversation. Mrs X said the Council told her it would follow up with School P about referring Z to its hospital education programme. At the end of May 2023, Mrs X wrote to the Council:
1. Mrs X said School P said the Council had not been in contact.
2. Mrs X reiterated the Council’s Section 19 duties. She asked the Council to confirm what alternative provision arrangements the Council would make.
37. In May 2023, the Council commissioned an Occupational Therapy (OT) assessment as part of Z’s EHC needs assessment. The Council said a general lack of OT availability in its district delayed this assessment.
38. Mrs X said the Council agreed suitable alternative provision arrangements in July 2023. However, she said the Council then did not implement these arrangements as agreed.
39. In August 2023, Mrs X wrote to the Council to make a stage two complaint:
1. Mrs X said Z was still without full time education and had been since June 2022. Mrs X said School P told the Council this at the time. The Council also had notification through the EHC Plan process.
2. Mrs X said the EHC needs assessment was happening, but the Council had not secured any alternative provision in the meantime.
3. Mrs X set out the Council’s education duties under Section 19. Mrs X also set out the contact she had had with the Council about this matter over the previous five months. She said School P had also contacted the Council.
4. Mrs X set out why she believed the Council’s responses were inadequate. She also confirmed the outcomes she sought:
1. immediate alternative provision;
2. an apology;
3. a financial remedy in line with the Ombudsman’s guidance; and
4. a review of the Council’s policies to ensure others would not be in the same situation.
40. In August 2023, the Council wrote to Mrs X to confirm receipt of her complaint. The Council recorded this as a new stage one complaint. Mrs X responded, saying she had been clear this was a stage two complaint, as it followed the formal complaint she made in April 2023 and was about the same matters.
41. The Council responded to Mrs X:
1. The Council said it had emailed Mrs X in May 2023 to ask if she would be happy to speak to the service and resolve the matter informally. The Council said it did not receive a response and so proceeded informally.
2. The Council said it could consider the exchanges to date as being carried out under stage one of its complaints procedure. It said it could consider the recent correspondence as a stage two complaint.
42. Mrs X told the Council she did not receive its email from May 2023, but had now found it in her junk email folder. Mrs X said even so, nothing would have changed. She had still made a complaint in April and wanted to escalate this complaint to stage two. The Council confirmed receipt of Mrs X’s request.
43. The Council later said as the complaint related to its Section 19 duties and not SEN provision, it would treat the matter as a new stage one complaint. Mrs X again said the complaint was about the same set of issues, not new matters. She said it should therefore be a stage two complaint.
44. In September 2023, the Council responded to Mrs X’s complaint at stage one of its complaints procedure:
1. The Council summarised matters to date, the complaint, and the outcome Mrs X sought.
2. The Council upheld the complaint that Z had not received suitable education provision since June 2022. It noted some attempts made by School P to engage Z, but said there was evidence this provision did not meet Z’s needs. It also said the provision was not the equivalent of full-time education.
3. The Council said it had adhered to timescales relevant to the EHC needs assessment. It said a named officer would review Z’s provision once an EHC Plan was in place.
4. The Council upheld Mrs X’s complaint that it had not adhered to its Section 19 duty. It said this was because Z had not received appropriate full-time education since being unable to attend School P in October 2022.
5. The Council addressed the remedies Mrs X sought:
1. it said it had agreed and funded alterative provision for Z;
2. it apologised;
3. it said it would be in touch with Mrs X regarding compensation; and
4. it said it would review how it approached its Section 19 duties. It said it would make service improvements, such as introducing a new team of officers and an education resource panel.
45. In September 2023, the Council wrote to Mrs X. It said the OT advice it had sought was not yet available and would likely not be until Spring 2024. The Council said it would normally proceed to decision panel once it received the Educational Psychologist’s (EP) advice, which it had. It said the OT advice could be incorporated into the plan at the next review, if it was not yet ready for the decision panel.
46. Mrs X asked the Council to wait until it received the OT advice before taking Z’s EHC Plan to the decision panel. She said it would be better to identify all Z’s needs and make sure support was in place. She asked the Council to arrange suitable alternative provision until this could happen.
47. School P wrote to Mrs X. It said it had been in discussions with the Council. It mentioned an online learning package it believed would help Z transition back into an education setting. Mrs X told School P she did not think this provision would be suitable for Z. She said she had told the Council what type of provision she believe would meet Z’s needs.
48. Mrs X escalated her complaint further, while disputing how the Council had handled her complaint.
49. In November 2023, the Council responded to Mrs X’s escalated complaint:
1. The Council partially upheld Mrs X’s complaint concerning its failure to adhere to the EHC needs assessment timescales. The Council said Mrs X was responsible for some of this delay, as she had queried the EP’s report.
2. The Council accepted it had not yet awarded or discussed compensation with Mrs X. It apologised and said it would escalate this.
3. The Council said it believed it had offered an adequate apology.
4. The Council said it had agreed with Mrs X that Z would begin provision in November 2023. This would be one day per week, for six weeks. School P had also offered online home learning. The Council said it was also arranging further alternative provision to begin in January 2024, pending the provider’s availability.
5. The Council did not uphold the complaint about its complaints procedure. It accepted the April complaint was not managed in a manner consistent with its complaints procedure. Nonetheless, the Council believed it acted correctly by treating the April and August complaints separately, rather than as an escalation.
50. The Council later told the Ombudsman it still had not decided whether to issue an EHC Plan, due to delays with the OT assessment. The Council told the Ombudsman it funded alternative provision for Z until at least Easter 2024, as agreed with Mrs X in January 2024. The Council said when the OT finalised their report, it would share this with Mrs X and decide whether to issue an EHC Plan as soon as possible.

Analysis

Alternative provision

51. In its September 2023 complaint response, the Council accepted Z’s education provision had not been suitable since October 2022. It also accepted it had not adhered to its Section 19 duty during this period. I am satisfied the Council accepted it acted with fault and make the same finding.
52. The Council’s fault caused Z an injustice, in the form of missed educational provision. The Council’s admission recognises that Z did not receive a suitable education for nearly the entire academic year 2022/23, from October onwards. The loss of education for this length of time is a significant injustice to Z. I have recommended the Council act to address this.
53. For the 2023/24 academic year, correspondence I have seen shows School P wrote to Mrs X in September 2023, setting out details of an online learning package it could provide, aiming to reintegrate Z into a school setting. School P also mentioned the Council was exploring other provision. Mrs X responded to School P, thanking it for its efforts, but explaining the package proposed was not what she had agreed with the Council previously. The Council’s September 2023 complaint response suggests it accepted the provision in place up to that point remained unsuitable for Z.
54. Further correspondence I have seen shows the Council sought availability for another alternative provision provider in October 2023, but there was no capacity for Z. When the Council told Mrs X this, Mrs X confirmed her preferred alternative provision provider did have capacity, noting the Council had agreed in principle to this provider in July 2023. Mrs X asked why the Council still had not referred Z to this provision, given her clear preference, its agreement in principle, and the availability of spaces. Internal correspondence viewed shows the Council then sought to establish what it had agreed in July 2023, as it had no record of this.
55. The Council’s November 2023 complaint response states it arranged alternative provision for one day per week from November, with a view to arranging further provision after the Christmas break. In contrast to its previous response, the Council said it felt the online learning School P had offered was suitable provision, while noting Mrs X’s disagreement. I understand from Mrs X and the Council that the Council did secure alternative provision arrangements from January 2024, including at Mrs X’s preferred provider, funded until the May 2024 half-term.
56. I consider the evidence shows the Council failed to take a consistent or structured approach to securing alternative provision for Z for the first full term of the 2023/24 academic year. The Council also failed to clearly decide whether the provision in place constituted suitable provision until January 2024. The Council expressed contradicting views in its complaint responses, suggesting it had not properly decided whether the provision in place was suitable. The internal correspondence shows the Council being unaware of what it had previously agreed, causing further uncertainty. On a balance of probabilities, I believe the Council did agree Mrs X’s preferred provider would be suitable in July 2023, but did not put this in place. The provision in place for the first full term of the 2023/24 academic year was not suitable for Z’s needs, or was not all the provision Z could manage. I have found the Council at fault for this.
57. This fault caused Z an injustice in the form of missed education provision for the first full term of the 2023/24 academic year. I have recommended the Council address this injustice.
58. Mrs X provided additional evidence and information showing that while the alternative provision in place from January 2024 was satisfactory, Mrs X later developed concerns about whether it remained suitable. Mrs X also questioned the Council’s regard for medical evidence it received, and whether it had properly reflected the alternative provision provider’s views on Z’s engagement. Correspondence I have seen shows the Council deciding the provision was suitable, which Mrs X disagreed with.
59. I have not considered events from January 2024 onwards as part of this investigation. These are new events and concerns, which the Council has not considered as a formal complaint. The restriction set out in paragraph 5 therefore applies. It would be open to Mrs X to make a new complaint about these matters and approach the Ombudsman if she was dissatisfied with the outcome.

Timescales for assessment and issuing EHC Plans

60. The SEND Tribunal instructed the Council to carry out an EHC needs assessment for Z. When a SEND Tribunal decision requires the Council to do so, specific timescales apply. Paragraph 27 sets these out. If the Council was not going to issue an EHC Plan, it should have decided this within 10 weeks of the SEND Tribunal’s decision, on or around 6 June 2023. If the Council was to decide to issue an EHC Plan, it should have issued this plan on or around 4 July 2023. The Council confirmed it had not issued an EHC Plan as of May 2024.
61. Part of this delay relates to Mrs X’s wish to ensure the OT assessment is finalised and accounted for in any decisions about the EHC Plan. The professional advice the Council is required to obtain is set out in paragraph 23. OT advice is not a necessity; however, the Council must obtain any other professional advice it feels is necessary. The fact the Council commissioned an OT assessment and agreed to wait for the outcome suggests the Council believes this advice is necessary. I note the Council had been prepared to proceed without waiting for the OT advice, to expedite matters, but Mrs X wished to wait.
62. The Council confirmed delays in obtaining OT advice was a problem generally, not just in Mrs X’s case. It attributed this problem to high demand for assessments and a lack of available referrals. The Council said it had sourced further private OTs to allow it to undertake further assessments.
63. While a contributing factor, I do not consider Mrs X’s wish to wait can be used as justification for such a significant delay. The time required to obtain advice is allowed for in the regulations. The Council instructed the OT in May 2023 and should receive advice it seeks within six weeks. I note the Council’s explanation that this is due to factors beyond its control, such as the low availability of OT capacity in its district. While this may be a factor, the Council remains responsible for the overall administration of the assessment process. I have found the Council at fault for not adhering to the timescales set out in the regulations.
64. This fault caused Mrs X an injustice. The time taken to decide whether to issue an EHC Plan has exceeded statutory timescales. This delay increases uncertainty about whether specialist provision should be in place for Z. It also defers Mrs X’s right to appeal possible adverse decisions to the SEND Tribunal. This causes avoidable frustration, uncertainty and distress.
65. I note the Council’s explanation of its actions to address this issue. I have addressed this further in my recommendations.

Complaint handling

66. Paragraph 28 sets out the timescales and stages for the Council’s complaints procedure.
67. Mrs X complained to the Council on 13 April 2023. The Council responded to Mrs X’s complaint in April 2023, setting out its understanding of its duties. It suggested School P was responsible for Z’s ongoing educational arrangements. It cited different legislation in its response, including Section 100 of the Children and Families Act 2014.
68. Section 100 of the Children and Families Act 2014 concerns adapting education provision within a school setting to accommodate existing medical conditions. This may include information captured in a young person’s individual healthcare plan. While there may be a practical overlap in the responsibilities imposed, the Council’s duty to secure a suitable education under Section 19 of the Education Act 1996 remains separate and distinct from duties arising under Section 100 of the Children and Families Act 2014. I have therefore found the Council at fault for misadvising Mrs X in its initial response to her complaint.
69. This caused Mrs X an injustice. I recognise the Council later did note the Section 19 duties it owed to Z in its final complaint response. However, its initial response was incorrect and Mrs X was caused avoidable frustration when trying to seek amendment.
70. When Mrs X tried to escalate her complaint, the Council did not accept this and logged the matter again as a new stage one complaint. I am not persuaded by the Council’s rationale. Throughout the complaint, Mrs X consistently maintained the substance of the complaint was the same and that the Council had not found a resolution. The Council also accepted it had not managed the complaint properly, in accordance with its complaints procedure. The evidence shows it repeatedly mischaracterised Mrs X’s complaint, in part leading to its decision to consider the complaint as a new issue, when it was not.
71. I have found the Council at fault for not managing Mrs X’s complaint properly, in accordance with its complaints procedure.
72. This fault caused Mrs X an injustice. The Council not accepting Mrs X’s complaint escalation meant Mrs X had to repeat steps already taken. This delayed progress in seeking a resolution and delayed Mrs X’s right to approach the Ombudsman. This caused Mrs X avoidable frustration and time and trouble.

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Agreed action

73. Within four weeks of the final decision being issued, the Council has agreed to:
1. Provide a written apology to Mrs X and Z for the faults and injustice identified in this statement. The Council should have regard to the Ombudsman’s guidance on “Making an effective apology", set out in our Guidance on Remedies document.
2. Share a copy of this decision and the Ombudsman’s Focus Report Out of school, out of sight? with relevant officers, to emphasise the Council’s Section 19 responsibilities and identify wider points of learning.
3. Remind officers of the timescales that apply when the SEND Tribunal decides the Council must complete an EHC needs assessment.
4. Pay £4660 in recognition of Z’s lost educational provision. This is a figure of £1400 across three academic terms (the spring and summer terms in the 2022/23 academic year, and the autumn term of the 2023/24 academic year), plus part of the autumn term in the 2022/23 academic year. I have considered the Ombudsman’s Guidance on Remedies when recommending this figure. In particular, I have considered:
1. Z is a child with diagnosed conditions, but where SEN needs have not yet been identified through assessment.
2. Z received some provision in the periods investigated, though this was minimal, intermittent and lacked in core subjects.
3. Z is a child in secondary education, but not in a transition year or taking public exams.
4. Future provision is likely to be able to remedy some of the provision lost.
5. Pay Mrs X £500 in recognition of faults in complaint handling and the avoidable distress she experienced. This is broken down as follows:
1. £150 for avoidable time and trouble incurred due to faults in the Council’s complaint handling.
2. £350 to recognise the avoidable uncertainty, frustration and distress Mrs X otherwise experienced.
74. Within six weeks of the final decision being issued, the Council has agreed to:
1. Review the processes it has in place for seeking Occupational Therapy assessments for EHC Plans, to identify and address any avoidable delays in these procedures.
2. Decide whether it will issue an EHC Plan to Z, if it has not already done so, and inform Mrs X of this. The Council should ensure Mrs X receives any right of appeal to the SEND Tribunal relevant to its decision.
75. The Council should provide us with evidence it has complied with the above actions.

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Final decision

76. I have completed my investigation with a finding of fault causing injustice. I have made recommendations to remedy the injustice caused.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman