Summary: There was no fault in how the Council responded to a concern for the welfare of Mr Y. The evidence shows it took account of the available information it had, responded to the concern raised, and spoke to Mr Y to seek his views and preferences before deciding no further action was required.

The complaint

1. Ms X complained the Council’s response to a safeguarding concern for her now deceased father, Mr Y, was poor, did not consider any background information sufficiently, and did not involve the views of Mr Y’s family.
2. Ms X said this meant her father was at risk of physical harm as well as financial abuse and coercive control.

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The Ombudsman’s role and powers

3. 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)
4. 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)
5. 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 not investigated

6. Ms X highlighted in her discussion with us, that she believed the management at her father’s supported living complex did not properly consider its duty of care to her father. This was not part of her complaint to the Council and there are no reasons why Ms X cannot now make a complaint about these concerns and give the Council an opportunity to investigate and reply.

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How I considered this complaint

7. I spoke to Ms X and considered the information she provided.
8. I considered the Council’s comments and the documents it provided.
9. I considered the Care Act 2014 and the London multi-agency adult safeguarding policy which the Council follows.
10. Due to the sensitive nature of the subject and the third-party information provided by the Council, which I cannot share with Ms X, I have not included any details beyond those necessary to understand my decision.
11. Ms X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

What should have happened

Safeguarding

12. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)

Council procedures

13. The Council have a safeguarding adults policy and also operate under the London multi-agency procedures. The policy sets out the aims of adult safeguarding is to stop abuse or neglect wherever possible and to safeguard adults in a way that supports them to make choices and have control about the way they want to live.
14. The Council’s policy also highlights the key principle of ‘making safeguarding personal’ and ensuring its actions are ‘person-centred and outcome focused’. It also says it should consider the views, wishes, preferences, histories, circumstances, and lifestyle of the adult concerned.
15. The policy highlights a range of potential outcomes available to the Council when determining how to respond to a concern for someone’s welfare. It can either complete a statutory enquiry under section 42 of the Care Act 2014, where it believes someone is unable to protect themselves against abuse (the safeguarding criteria). The policy also highlights it carries out a non-statutory enquiry in the same way.

What happened

16. In mid-May 2023, a manager at Mr Y’s supported living complex told the Council it had a concern for Mr Y’s wellbeing and gave it reasons why this was the case.
17. The case notes show, over a week later, a social worker recorded brief facts about the Council’s knowledge of Mr Y, including his medical history. The social worker recorded that Mr Y was no longer in hospital by this point, was on medication and was being provided palliative care.
18. The notes also show the social worker spoke to the manager and recorded the manager’s views about the nature of Mr Y’s relationships, as well as the manager’s views on Mr Y’s mental capacity. The notes also have a record of the manager’s comments on these aspects of Mr Y’s life. The notes show the social worker intended to visit Mr Y that day, but initially delayed the visit, to give the manager time to update Mr Y about the referral they had made to the Council.

Initial visit to Mr Y

19. Four days after the initial call to the manager, the social worker visited and spoke to Mr Y at his flat in the complex. The case notes show Mr Y told the social worker he wanted to return to his previous home and ‘spend the rest of his days there’. The social worker asked Mr Y about his children, and he said his children were not involved in his care.
20. The social worker recorded their observations about Mr Y as follows:
• he was well looked after and able to communicate his views coherently, albeit slowly due to medication;
• there was nothing to suggest he was at risk of harm or that he was being coerced, and;
• Mr Y’s flat looked clean and he had fresh bedding.
21. The social worker recorded the safeguarding concern under the category of financial and material and domestic abuse. They also made a note that Mr Y did not need an advocate.
22. In their summary and recommendations, the social worker made a note that Mr Y had indicated he was happy with his care support and denied he was at risk of being exploited. The social worker also noted the reasons the manager had made the initial referral, because they wanted to act in Mr Y’s best interest. The social worker recommended closing the enquiry.
23. The case notes show a senior manager then reviewed Mr Y’s case and the social worker’s report. They noted the social worker had confirmed Mr Y had said none of his belongings were missing. They also noted Mr Y had discussed his relationship with his children and has recorded an update about this. The manager finalised the case notes saying the allegation was unsubstantiated and there was no requirement for further action.

Follow on contact to the Council by Ms X

24. Several days after this, the manager told Ms X about the social worker’s earlier visit and information about why it had made the initial referral; Ms X then contacted the social worker and raised several concerns of her own. She asked the social worker to investigate these concerns. She also told the social worker she had made a report to the police and said she believed Mr Y was not getting his pain killers.
25. The manager contacted the Council around the same time to highlight this recent conversation and in that message, said Mr Y had only hours remaining to live. The following day, Ms X and the social worker had an email exchange, and the social worker agreed to visit Mr Y that same day.
26. The case notes show the social worker went to Mr Y’s flat to visit him. The social worker had intended to speak to him again to see if he would consent to discussing his private affairs with his children. The social worker also noted he intended to explore the nature of Mr Y’s relationship with another person. The social worker was unable to speak to Mr Y because he died shortly before the visit.
27. The following day, the social worker closed the enquiry. The social worker and Ms X then had a follow-on exchange of emails, where the social worker gave Ms X an account of their contact with Mr Y in the previous two weeks.

My findings

28. Ms X said the sufficiency of the Council’s response in safeguarding her father was poor when it was initially aware of concerns, including that it did not contact her and her family.
29. From the evidence available, the Council initially responded in a proportionate way to the information it had at that point. It reviewed the information it knew about Mr Y and spoke to the person who made the referral. It also met with Mr Y to seek his views, and this included contact with his children. From the evidence I have seen and on balance, the Council responded in line with Mr Y’s wishes, and I cannot criticise its decision not to contact Ms X.
30. Our role is not to ask whether an organisation could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how it made its decisions. If we decide there was no fault in how it did so, we cannot ask whether it should have made a particular decision or say it should have reached a different outcome.
31. I have considered the steps the organisation took to consider the referral about Mr Y, and the information it took account of when deciding not to substantiate the allegation. There is no fault in how it took the decision, and I therefore cannot question whether that decision was right or wrong.
32. Additionally, I have not seen any evidence of fault in how the Council responded to Ms X’s contact in late May, when it was aware Ms X raised her concerns. The evidence shows it responded quickly, intending to carry out another visit the following day.

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Final decision

33. I have ended my investigation with a finding of no fault.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman