Bracknell Forest Council (23 017 970)

Category : Housing > Homelessness

Decision : Upheld

Decision date : 05 Sep 2024

The Ombudsman's final decision:

Summary: Mr X complained about how he has been treated by the Council. He said: staff are discriminating against him because of his homelessness and disabilities; the Council has not supported him properly because he does not have access to the services; the Council asked him to sign a tenancy agreement without having the chance to see the property and said the Council’s communication has been poor. We find the Council was at fault for failing to respond to some of Mr X’s emails. This caused him significant distress. To remedy this injustice caused by fault the Council has agreed to apologise.

The complaint

  1. The complainant, Mr X, complains about how he has been treated by the Council. In particular he said:
      1. staff are discriminating against him because of his homelessness and disabilities;
      2. the Council has not supported him properly because he does not have access to the services;
      3. the Council asked him to sign a tenancy agreement without having the chance to see the property; and
      4. the Council’s communication has been poor.

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The Ombudsman’s role and powers

  1. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
  2. 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 has done. (Local Government Act 1974, sections 26B and 34D, as amended)
  3. If we are satisfied with an organisation’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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What I have and have not investigated

  1. I have investigated the period between July 2022 and March 2024.
  2. I have not investigated anything that occurred before July 2022, this includes part c of the complaint. As detailed in paragraph three we cannot investigate late complaints unless we decide there are good reasons. I think it would have been reasonable for Mr X to have complained to us sooner about previous matters.

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How I considered this complaint

  1. I spoke with Mr X about his complaint. I considered all the information provided by Mr X and the Council.
  2. Mr X and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Equality Act

  1. The Equality Act 2010 provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. It offers protection, in employment, education, the provision of goods and services, housing, transport and the carrying out of public functions.
  2. The Equality Act makes it unlawful for organisations carrying out public functions to discriminate on any of the nine protected characteristics listed in the Equality Act 2010. They must also have regard to the general duties aimed at eliminating discrimination under the Public Sector Equality Duty. The protected characteristics referred to in the Act includes disability.
  3. We cannot decide if an organisation has breached the Equality Act as this can only be done by the courts. But we can make decisions about whether or not an organisation has properly taken account of an individual’s rights in its treatment of them.
  4. Organisations will often be able to show they have properly taken account of the Equality Act if they have considered the impact their decisions will have on the individuals affected and these decisions can be challenged, reviewed or appealed.

Summary of the key events

  1. A medical letter from January 2022 states the hospital doctor agreed for Mr X to have a consultation for a review of his medication. The doctor encouraged him to seek support from his GP regarding his mental health.
  2. A further medical letter in June 2022 notes the doctor completed a review with Mr X. Mr X said he had pain in multiple areas since he was involved in a non-fault road traffic accident in 2016. It was noted Mr X did not have a prescription for any medication. But he said he was managing to get hold of some painkillers by alternative strategies. Mr X said due to issues with his GP, he had been forced to seek illegal medication.
  3. A medical letter in August 2022 stated the doctor was unable to complete the form requesting hospital inpatient information. This was because Mr X was not an inpatient. It was also noted that from the records Mr X had not had any inpatient hospital stays within the last year.
  4. A multi-disciplinary team (MDT) meeting was held in February 2023. This meeting was suggested by Mr X’s GP. The meeting minutes state:
    • Mr X was in a traffic accident seven years ago and this had resulted in him being in constant pain;
    • Mr X was currently rough sleeping in a secluded part of the woodlands and Mr X has said he prefers to be away from people;
    • all agencies agreed that Mr X required support to manage his health and housing needs;
    • the Council’s rough sleepers’ team had worked with Mr X since 2019 but had physically met him once. The team had tried to see him more but could not locate where he had been staying in the woods;
    • Mr X had been offered a flat. But Mr X declined this as he said it was not suitable for his needs. Mr X said he needed extra space due to being claustrophobic. He said he doesn’t want neighbours, nor does he want to be in an area with noise;
    • Mr X said his phone was not working well. The Council said it could provide a new one. But Mr X declined this; and
    • it was agreed the Council’s housing team would continue to reach out to Mr X regarding potential housing options.
  5. The Council’s adult social care team confirmed it was not actively involved with Mr X. It was noted Mr X did not have any specific eligible care and support needs.
  6. The Council spoke with Mr X in March 2023. It was noted that:
    • Mr X said he needed a suitable property in a rural location. He said a cottage in the country would be suitable for him;
    • the Council discussed Mr X completing a medical form. It said it would complete the form from the information Mr X had previously told it. It said it would send the form to Mr X to sign; and
    • Mr X agreed to check whether he had any identification cards (ID).
  7. In June 2023, the Council took a call from Mr X who said he wanted to speak with a team leader. The Council passed his details over to the relevant team.
  8. Shortly after, the Council sent Mr X a link to its complaints process and asked him to complete this. But Mr X requested a phone call and said he wanted to discuss a complaint about the department. He asked the Council to register his complaint as he said he did not have access to internet.
  9. The Council agreed to arrange a call. But Mr X did not want to speak with the officer who he said his complaint was about. The Council said it would speak with the complaints team to see if they could process the complaint with the limited information it had.
  10. Mr X’s complaint was lodged on the 2 July 2023. Mr X said there had been several issues against services within the Council. He said he had been ignored for the past eight years and lied to. He said he wanted a full investigation into his personal interactions with the team.
  11. The Council spoke with Mr X shortly after. He said as the Council could not provide him with what he needed it was not worth proceeding with the Council trying to work with him.
  12. The Council responded to Mr X’s complaint on 20 July 2023 following a recent phone call with him. The Council said:
    • as his complaint relates to contact made with the department over a number of years it had spoken with many people who had been involved. It was satisfied his complaints were dealt with at the time;
    • should Mr X wish to work with the team, it would allocate a housing officer;
    • due to annual leave the chair of the MDT meeting had not been available to speak with to see if there were any further actions to pursue;
    • Mr X was previously working with the team as somebody who was homeless. As part of that process, temporary accommodation was offered to him. This emergency accommodation was not owned by the Council and therefore it could not arrange any viewings;
    • it had tried to work with Mr X on a number of occasions. But the Council said it had not been able to fulfil his wishes. It said it was not always possible to fulfil every criterion of a person’s wish list;
    • Mr X was eligible for single person accommodation. It noted Mr X said he needed a 2-bed property. But it said exceptions could be made where there was a medical or care need as to why a person needs to have an extra bedroom;
    • if someone needs an extra room for a carer or on medical grounds, the Council would carry out an assessment of the customer’s needs and decide whether, or not, an extra room was required;
    • it has discussed housing and affordability with Mr X and noted Mr X would be able to claim housing allowance. But Mr X recognised that what he was asking for could be unrealistic and unplaceable. He made the decision that he would be better off remaining where he was;
    • it was working with a housing association in providing accommodation for rough sleepers and these properties could be viewed before any paperwork is signed. It said it understands that as these properties are flats, they would not meet what Mr X is looking for. But it wanted to evidence that it wants to prevent people from rough sleeping; and
    • Mr X was to let the Council know whether he wanted a new housing officer allocated.
  13. Mr X did not agree with the Council’s response and said:
    • he has been assessed and re-assessed time and time again;
    • as a single person, the Council ignores his needs;
    • he had not heard from the Council’s rough sleepers team; and
    • the temporary accommodation offered to him was discussed as a permanent offer. He said this property was forced onto him and when he turned it down, he received no further help.
  14. The Council said he had not been contacted by the rough sleeper’s team as he said he did not wish to work with them. It said if he has changed his mind, they could allocate a dedicated officer. It said the other option would be for him to join the housing register. Mr X told us he did not want to work with a department who had previously lied to him.
  15. Mr X contacted the Council in August 2023. He suggested discussing his case with an adjoining rural council who may have the location and adaptable properties suited to him. He also asked whether the Council could chase up the outcome of the MDT meeting.
  16. The Council said someone would be in contact with him soon. It also agreed to chase the outcome of the MDT meeting.
  17. The Council’s housing register and allocations team contacted Mr X on 25 August 2023.
  18. Shortly after the Council told Mr X it would find out more about the area Mr X had mentioned as detailed in paragraph 27. It also attached a medical information form for Mr X to sign. It said it needed his consent to access his medical records. It also highlighted parts of the form where it needed more information from Mr X.
  19. After speaking with Mr X, the Council sent him an updated medical information form in September 2023. This included information Mr X had shared about his medical conditions and well-being.
  20. The Council responded to Mr X’s complaint on 15 September 2023. It said:
    • an officer had recently been in touch who was providing support to Mr X;
    • regarding the MDT meeting, there were no outcome or actions;
    • an officer from the rough sleeper’s team was at the MDT meeting and it was noted they had tried to see Mr X more often but had not been able to find him;
    • Mr X likes to live out of sight of people. This has prevented the officer from visiting more frequently. But it said this should not have stopped the Council communicating with him to try and help with his accommodation needs;
    • the previous accommodation offered to Mr X was temporary. But it was noted Mr X declined this as he said it was not suitable;
    • it apologised if the offer was not appropriate and said it would work with him to find somewhere that meets requirements due to his disability;
    • it had no evidence to suggest the temporary accommodation was a permanent offer;
    • it apologised if Mr X felt he was not listened to at the MDT meeting. It said it was not the officer’s intentions and said it had reminded officers of the importance of listening to what customers say; and
    • it acknowledged that Mr X said he felt disadvantaged due to having no internet access. It said it would work around this by helping people to fill in forms over the phone, arranging face to face meeting and posting.
  21. Mr X requested his complaint be escalated on the same day. He said:
    • the property offered was inappropriate and was never suggested as temporary;
    • he had received very few calls or messages from the rough sleepers team; and
    • how was it acceptable to have no response or actions from the MDT meeting.
  22. The Council acknowledged Mr X’s request on the 25 September 2023.
  23. Mr X contacted the Council the next day and asked if his request to escalate his complaint had been processed. He chased a response on the 4 October 2023. He said he withdrew his request for housing assistance due to being ignored.
  24. The Council explained its timescales for responding to complaints. It said it was close to finalising his complaint. But it asked Mr X to confirm the outcomes he was seeking.
  25. Mr X signed the medical form sent to him by the Council. But he said he did not sign the permission to share as he said it was not clear how his data would be used.
  26. The medical form stated:
    • living outdoors affected Mr X’s health and mobility;
    • his medical conditions stem from a car collision;
    • Mr X had been sleeping in the woods for eight years;
    • due to disabilities including claustrophobia and agoraphobia, Mr X would not be comfortable living close to others. He needed level access and a property in a rural area;
    • Mr X had requested an enclosed garden and disabled parking should he drive again; and
    • since the car accident, Mr X had significant pain all over his body.
  27. In October 2023, Mr X sent the Council details around his conditions and his situation. He said:
    • his property requirements consisted of large rooms with high ceilings, a spare bedroom for carers for end of life and general support, adapted bathrooms and toilet areas, reduced internal doors, multiple doorways in all rooms, large opening windows in all rooms, private rear enclosed garden, isolated location, disabled access front and rear, disabled parking access and preferably a two-storey property with stairs;
    • he would need support with running a property and help with overall rehabilitation back into society;
    • he would need assistance in choosing another GP surgery; and
    • he was promised things from the rough sleepers unit a long time ago which never materialised, such as food vouchers.
  28. In response the Council said:
    • it may not be able to meet his needs in full but was prepared to do what it could to match as many needs as possible;
    • it had purchased a number of properties for use of those that are or had been rough sleeping. It asked Mr X if he was willing to consider this but said it was a flat which was near to the forest where Mr X currently sleeps. It asked if Mr X would compromise;
    • the property would be provided with the support from officers and services to help him transition. This would be for a period of up to two years following which the Council would work with him to gain permanent social housing that more closely met his needs; and
    • if Mr X moved to the property, he would be able to satisfy all requirements to be able to register fully on the housing list as formal ID is required. But it said he could decline the offer after viewing or moving in.
  29. Mr X was unhappy with the Council’s response and asked if it would ask a visually disabled person if they would compromise. He said the property ignored his needs.
  30. The Council said the offer was temporary to try and move him from where he is at the moment. It attached the sales brochure. But Mr X declined the offer as he said it was not suitable.
  31. Towards the end of October 2023, the Council told Mr X it had made a referral to the safeguarding team to see if they could offer him any support. It also gave him the details of other GP’s who offer drop-in services and mobile GP’s.
  32. Mr X asked the Council if he could get a grant for a disabled mobility motor home. He also said the GP offer proposed was a direct contradiction to his abilities of entering building and public spaces.
  33. The Council responded to Mr X’s complaint at stage two of its process in November 2023. It said:
    • it apologised for not making the notes of the MDT meeting available to him and attached a copy;
    • contact was made with Mr X numerous times from the rough sleepers team, with regular contact being between November 2019 and June 2021;
    • it had made offers of accommodation to Mr X previously which were declined;
    • it had not been able to establish if there were any statutory duties owed to him as he had always withdrawn any applications made;
    • it does not have any permanent housing stock; all offers of permanent housing would be made via the housing policy;
    • Mr X had withdrawn requests for assistance on each occasion he had approached since 2017;
    • services remain and have remained open to Mr X if he wishes to access;
    • it has referred his case to the adult social care team who are prepared to work with him and would make contact;
    • it offered to meet with Mr X in person at a site of his choosing to progress the application for permanent housing but said he declined;
    • it was unsure how some of Mr X’s property requirements would meet his needs. This was in reference to multiple doorways;
    • if Mr X wanted the Council to take a formal statutory homelessness application from him to establish if any duty was owed to him, he could contact a member of the team;
    • it did not have details of the type of bathroom adaptations he required; and
    • it did not offer grants for disability motor homes, but said this may be a matter to discuss as part of an assessment.
  34. In November 2023, the Council’s emails stated it would be speaking with Mr X and suggesting another risk framework meeting as it was unable to meet his expressed needs. It was noted it did not have evidence of a medical condition as when asked, Mr X was not able to provide anything.
  35. Mr X asked for his complaint to be escalated.
  36. Towards the end of November 2023, the Council’s emails stated it had attempted to arrange meetings to confirm what adult social care could and could not do. It was noted that:
    • it did not have any evidence of Mr X’s disabilities;
    • it had not been able to progress a statutory homelessness application as Mr X withdraws any request for assistance before it can formalise anything;
    • it has not established any housing or homelessness duties for Mr X and cannot confirm if he is homeless;
    • Mr X is considered to have capacity to make decisions and had a right to sleep rough;
    • previous offers of accommodation have been refused along with a current offer;
    • it does not currently have accommodation available to meet Mr X’s stated needs;
    • it has a long waiting list for the accommodation it does have available; and
    • it has not been able to locate Mr X on any of its outreach visits. It has also never received any notifications from the public, forest rangers, police or any other agency to advise that Mr X or anyone is rough sleeping in the woods.
  37. An email from forest rangers confirmed in November 2023 they had never noticed Mr X in rough sleeping. They said for Mr X to have lived in the woods for that length of time, it would mean he would have had to keep moving on a daily basis and move all his litter. The ranger thought this was unlikely.
  38. In December 2023 the social worker noted they had not had any input from Mr X. They said it did not look like he had identified eligible care needs.
  39. The Council responded at stage three of its complaints process. It:
    • apologised for the minutes of the MDT meeting not being provided. It said as the meeting was initiated by his GP, the GP should have provided him with a copy;
    • was satisfied actions from the meeting had been progressed;
    • would not reinvestigate matters from the stage two response;
    • said it had tried to help and engage with him;
    • said it appeared his complex issues needed consideration and would propose a meeting; and
    • directed Mr X to complain to us if he remained unhappy.
  40. Mr X asked the Council for an update on 21 December. He said since the accommodation offer, things had gone quiet. He asked for a further update on the 3 January 2024.
  41. The Council responded two days later and said Mr X’s email had gone into its junk folder. It said as stated in its stage two response, if he wanted to make a formal application for homelessness assistance, he would need to let the Council know.
  42. Mr X said he thought he had made the application last year. The Council said he made the application to join the housing register last year. But said he did not sign the medical form which would give the Council consent to speak with his GP. It explained that an application for homelessness was separate.
  43. Mr X provided his consent in January 2024 and the Council said it had agreed to accept the application to join the register dated from October 2023. It said it needed a copy of his ID and any income.
  44. The social worker spoke with Mr X in January 2024. The social worker agreed to contact the GP surgery to try and gain medical information and to ascertain whether a different surgery catering for someone living homeless was more appropriate. It was noted no direct care and support needs were identified.
  45. Mr X asked the Council if his medical information had been requested. He also confirmed he did not have any ID and asked how to proceed. The Council asked if Mr X held any bank cards for all benefits which are paid to him.
  46. The Council spoke with Mr X’s GP shortly after. The GP said Mr X was well known and ‘on strike’ from participating with the surgery. They said they rang him last week and suggested accessing a homeless charity where a GP attend once a month. But they said Mr X refused to engage with any health services. The GP also said they had offered to look into therapy services to assist with his claustrophobia but said Mr X does not want to engage with this. But Mr X said he was still waiting for a response from the therapy service.
  47. In early February 2024, the Council told Mr X it had spoken with the GP and said there was very little medical information on the NHS/GP data base with regard to letters or any open referrals/upcoming appointments. In regard to his ID it said he may wish to discuss this with the DWP as proof of benefits may assist.
  48. The Council told Mr X once it had accepted his housing application, it would backdate this to October 2023 which is when he applied to join. But said it needed ID. It also said the GP had informed it there was very little medical information on the data base. But said once the application was accepted, it could consider the information from the GP and any additional information.
  49. Mr X said he had asked for specific dates the Council had contacted his GP prior to recently. But said he had no response. The Council said the GP had provided letters on file from 2018 to date.
  50. In March 2024 the Council asked Mr X if he had confirmed his proof of identity for housing purposes.

Analysis- was there fault by the Council causing injustice?

Complaint about how Mr X has been treated overall

  1. There was an MDT meeting held in February 2023 which was initiated by Mr X’s GP. Mr X attended the meeting. It was noted the Council had offered to provide Mr X with a new phone which he declined. It was also noted that the Council would continue to reach out to Mr X regarding potential housing options.
  2. In August 2023 Mr X chased up the outcome of the MDT meeting. The Council provided him with a copy of the minutes of the meeting in November 2023 and apologised for the delay. Whilst there was a delay in providing this, I consider the injustice to be limited. This is because Mr X attended the meeting and was aware of what was discussed.
  3. Mr X said he was unhappy with the fact there were no actions or responses from the MDT meeting. But from reviewing the minutes it was noted the actions were for the housing team to continue to reach out to Mr X regarding potential housing options and for a new phone to be provided to Mr X if he required one. It was also noted agencies were in place with a named person for Mr X to contact if he required advice.
  4. The housing register and allocations team contacted Mr X on 25 August 2023. The Council sent Mr X the medical form for him to sign and said it needed his consent to access his medical records.
  5. In September 2023, Mr X was advised by the Council to make contact if he wanted to make a homelessness application.
  6. Mr X withdrew his application on the 4 October 2023 as he said the Council had ignored him. I have reviewed the evidence and have not found fault in the Council’s communication during this time. Mr X later signed the medical form. But said he did not give permission to share his information.
  7. In November 2023 the Council’s adult social care team stated they had no evidence of Mr X’s disabilities. The forest rangers confirmed they had not been able to locate Mr X living in the woods.
  8. Mr X asked for an update in December 2023. The Council reiterated its previous response from November 2023 which is detailed in paragraph 45. The Council also explained Mr X had not given it consent to share information.
  9. Consent was provided in January 2024. The Council spoke with Mr X’s GP who said he had refused to engage with services. The GP also stated they had very little information on the data base with regard to letters or any open referrals/upcoming appointments.
  10. The Council advised Mr X it needed ID to progress his application. It said he may wish to discuss this with the DWP as proof of benefits may assist.
  11. From the evidence seen, the Council has not been able to establish any housing or homelessness duties owed to Mr X. This is because Mr X withdrew his housing application and did not make a homelessness application. Mr X also did not give the Council permission to share medical information. Therefore, we could not criticise the Council.
  12. Once Mr X did give his consent in January 2024, the Council liaised with the GP. I understand there was an issue with Mr X obtaining ID. The Council asked Mr X if he held a bank card for all benefits which are paid to him and was advised to discuss this with the DWP. Therefore, it is down to Mr X to contact the relevant people and update the Council so it can progress his application.

Part a and b of the complaint

  1. Mr X said he suffers with chronic pain, claustrophobia and agoraphobia. From the evidence seen, the Council liaised with Mr X and his GP and no medical evidence was provided in relation to his disabilities. The GP said Mr X had refused to engage with any health services.
  2. Mr X advised the Council of his property requirements. This is detailed in paragraph 39. He said the Council failed to consider this when it offered him an unsuitable property.
  3. In October 2023 the Council explained it may not be able to meet Mr X’s needs in full but said it was prepared to do what it could. It asked Mr X if he was willing to consider a flat that the Council had purchased for rough sleepers. The Council said this was a temporary offer to try and move Mr X from where he was. It also said the property would be offered with support from officers.
  4. In considering Mr X’s property requirements, the Council said:
    • the property offered had large rooms and a very large living room/dining room area which could have been used as a spare bedroom;
    • it did not have details of bathroom adaptations Mr X required;
    • it was not sure how reduced internal doors/multiple doorways met Mr X’s needs;
    • the property offered had allocated parking, but said it was not aware Mr X currently had a car; and
    • the property was very close to the woodland where Mr X was residing.
  5. The Council has previously explained to Mr X the reasons it is unable to offer him a property that satisfies his very detailed and specific requirements. In my view the Council has considered Mr X’s needs well given his detailed and specific requirements, his documented needs and the type of properties available.
  6. From the evidence seen the Council has provided reasonable adjustments to accommodate Mr X’s disabilities. This includes:
    • accommodating Mr X’s communication preferences by using emails or pre-arranged phone calls;
    • the medical information form was copied into the body of an email for Mr X to sign and confirm;
    • adapting its complaint responses form to suit Mr X’s needs. These responses were incorporated into the body of the email;
    • offering to work around Mr X’s lack of internet access and suggested alternative solutions to ensure his access to service was not limited; and
    • offering to meet Mr X in public spaces or near to the woods where he reported to sleep on several occasions. But Mr X declined this offer.
  7. Therefore, in my view, there is no evidence to suggest the Council has discriminated against Mr X. The Council has evidenced it adapted its approach to meet Mr X’s needs where possible. The Council has properly taken account of the Equality Act and I do not find fault.

Part d of the complaint

  1. I have reviewed the evidence, and, in my view, the Council has responded to Mr X within a reasonable timeframe throughout. Mr X asked for an update on his case on the 21 December 2023. He asked again on the 3 January 2024. The Council responded two days later and reiterated its stage two response where it was noted it was down to Mr X to make contact with it.
  2. The Council has acknowledged there was a slight delay in responding. It said this was due to staff taking leave during the Christmas and new year holidays. It responded within eight days instead of the usual five working day timescale. But I do not consider this slight delay to have caused significant injustice to Mr X.
  3. Mr X gave the Council permission to access his GP records in January 2024. He was advised on the 23 January 2024 that the Council was waiting for a response from the GP.
  4. Two days later, Mr X asked the Council if he had received the GP’s response. The Council reiterated its previous response. Mr X asked again the following day whether the Council had received the medical information. The Council responded within one day and explained it had spoke with the GP.
  5. In February 2024, Mr X asked the Council when it received his medical records. The Council replied to Mr X the following day and said the GP said there was very little information on the data base. Therefore, there is no evidence to suggest the Council’s communication has been poor during this time.
  6. But in February 2024, Mr X sent three separate emails on the 4, 5 and 10 of February 2024. The Council responded on the 21 February 2024. It explained the delay was due to the officer being away from the office. The Council has acknowledged that this response was outside of its preferred response timescale. But this did mean Mr X spent unnecessary time and trouble in contacting the Council.

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Agreed action

  1. To remedy the injustice caused by fault, within one month of my final decision the Council has agreed to apologise to Mr X for the fault identified in this statement.

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Final decision

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

Investigator’s final decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman

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