Summary: Mrs B complains about the care her aunt received at a care home. The Safeguarding Adults Board (SAB) has decided to carry out a full Safeguarding Adults Review into the aunt’s case. The SAB is better placed to carry out this review than the Ombudsman and the Ombudsman has therefore discontinued its investigation.

The complaint

1. Mrs B complains on behalf of her aunt, Mrs C, who has died. Mrs B says the care home where Mrs C was living, failed to provide proper care to Mrs C. She says the Council failed to respond appropriately to the family’s concerns about the care home.

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The Ombudsman’s role and powers

2. 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’. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• there is another body better placed to consider this complaint.

(Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

3. I have considered the information Mrs B and the Council have sent me.

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What I found

Law and guidance

Safeguarding Adults Board (SAB)

4. Each local authority must set up a Safeguarding Adults Board (SAB). The main objective of a SAB is to assure itself that local safeguarding arrangements and partners act to help and protect adults in its area who meet the criteria.
5. The SAB oversees and leads adult safeguarding across the locality and will be interested in a range of matters that contribute to the prevention of abuse and neglect. These will include the safety of patients in its local health services, quality of local care and support services.
6. One of the duties of the SAB is to decide when a Safeguarding Adults Review is necessary, arrange for its conduct and implement any findings.

Safeguarding Adults Review (SAR)

7. SABs must arrange an SAR when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.
8. SARs replace serious case reviews. SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again.

What happened

9. Mrs C was an elderly woman who needed help and support. She moved to the Home in May 2017.
10. Mrs B says Mrs C deteriorated while she was at the Home and the Home did not adhere to Mrs C’s care plan. She says Mrs C lost weight, she was deprived of access to water and was not given assistance to eat. She was left socially isolated in her room and frequently did not have access to her glasses or hearing aid. The family says it raised these issues with the Council but the Council took no action.
11. The district nurses made a safeguarding referral to the Council as they said they found Mrs C soaked in urine when they went to treat her for a pressure sore on her sacrum.
12. The family moved Mrs C to a different home at the end of January 2018. They say Mrs C was dirty, dehydrated and had a bone deep pressure sore on her sacrum. She also had a grade 3 pressure sore on her heel which had not been recorded by either the district nurses or the Home’s staff. The new care home where Mrs C moved to made a safeguarding referral to the Council about the condition of Mrs C.
13. Sadly, Mrs C died in March 2018. A coroner’s inquest has found that the pressure sore on the sacrum was a contributory factor to Mrs C’s death.
14. The SAB has decided that it will carry out a full safeguarding adults review into Mrs C’s case. I will therefore discontinue my investigation as there is no point in having two investigations into the same matter running at the same time. Also, the SAB is better placed than the Ombudsman to carry out this review as it has powers to involve all the agencies, not just the Council and the care home. Therefore, the SAB can provide a broader investigation than the Ombudsman could.

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Final decision

15. The Ombudsman has discontinued its investigation as the SAB is carrying out a safeguarding adults review.

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Investigator's decision on behalf of the Ombudsman