Summary: There was fault by the Council as its social care assessments contained inaccurate information about the source of a medical diagnosis. This caused Mr X avoidable distress. The Council will apologise, make Mr X a symbolic payment and rectify its records.

The complaint

1. Mr X complained a social care assessment by Surrey County Council (the Council) wrongly attributed the source of information about his diagnosis of Post Traumatic Stress Disorder (PTSD) to his GP. This caused Mr X avoidable distress and a loss of trust in social workers

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The Ombudsman’s role and powers

2. We normally expect someone to refer the matter to the Information Commissioner if they have a complaint about data protection. However, we may decide to investigate if we think there are good reasons. (Local Government Act 1974, section 24A(6), as amended)
3. Mr X could refer the case to the Information Commissioner to consider taking enforcement action, but I have exercised discretion to investigate because I have investigated and upheld other complaints from Mr X about the Council’s social care assessment process and this complaint is closely linked.
4. 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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. If we are satisfied with a council’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

6. I considered Mr X’s complaint to us, the Council’s response to the complaint and records set out in this statement. I discussed the complaint with Mr X.
7. Mr X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Relevant law and guidance

8. Our Principles of Good Administrative Practice is guidance we expect councils to consider and we use it as a benchmark for the standards we expect when we investigate a complaint. We expect councils to be open and accountable. This includes keeping proper and appropriate records.
9. The UK General Data Protection Regulation (‘GDPR’) sets out the principles, rights and obligations for processing of personal data. Article 5 says personal data should be accurate. Under Article 16, people have the right to have inaccurate personal data rectified.
10. Personal data is inaccurate if it is incorrect or misleading as to any matter of fact. (Data Protection Act 2018, section 205)
11. A council completes a social care assessment for an adult who appears to need social care. (Care Act 2014, section 9)

What happened

12. Mr X is an adult with autism. He complained to us previously about the Council’s social care assessments, care plans and care funding and about incorrect information about him in a risk assessment. We upheld some of those complaints and recommended remedies to remedy his injustice. Mr X finds it stressful and anxiety-provoking to accept inaccuracies and errors in information held by the Council. He is already distrustful of the Council based on its previous performance.
13. Mr X’s GP patient summary lists his medical conditions. The summary does not say he has PTSD.
14. A letter from Dr Y (a psychiatrist) says Mr X has PTSD.
15. A social care assessment in October 2020 (page 2) lists Mr X’s health conditions including PTSD. While page 2 does not say where the information about PTSD came from, page 4 says ‘taken from patient summary at Mr X’s GP …..2015- Post Traumatic Stress Disorder’ Page 4 of the assessment summarises information in the letter from Dr Y.
16. A social care assessment dated February 2021 (page 2) lists Mr X’s health conditions including PTSD and says ‘this information was taken from the patient summary’. Later, at page 3, the social care assessment goes on to set out the GP patient summary and to list Mr X’s health conditions, but not PTSD. Page 4 of the assessment summarises the information in Dr Y’s letter.
17. The Council’s response to Mr X’s complaint said the diagnosis of PTSD on the social care assessment was taken from a letter by Dr Y. The response went on to quote from Dr Y’s letter.
18. The Council told me its assessment ‘clearly identifies which information came from the GP records and which information came from Dr Y. It clearly states the information came from Dr Y’. The Council went on to say it was willing to complete a new assessment for Mr Y and he could have support from an advocate.

Was there fault causing injustice?

19. Both social care assessments of Mr X attribute his PTSD diagnosis to the GP patient summary. Yet the GP patient summary did not mention PTSD as one of Mr X’s health conditions. My view is the Council’s records are therefore misleading and incorrect as to a matter of fact according to the definition in section 205 of the Data Protection Act 2018 because the source of the information was not the GP patient summary.
20. I consider the Council failed to act in line with Article 5 of the GDPR by keeping inaccurate records. This was also a failure to act in line with our expected standards of record-keeping. It caused Mr X avoidable anxiety.

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Agreed action

21. Within one month of my final decision, the Council has accepted my recommendations and will:
• Apologise to Mr X
• Pay him £250 to reflect his avoidable distress
• Remove references in the October 2020 and February 2021 (as set out in paragraphs 15 and 16 of this statement) to the diagnosis of PTSD being from the GP’s patient information summary and provide me with new copies.
22. I will require evidence of compliance.

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Final decision

23. There was fault by the Council as its social care assessments contained inaccurate information about the source of a medical diagnosis. This caused Mr X avoidable distress. The Council will apologise, make Mr X a symbolic payment and rectify its records. I have completed the investigation.

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Investigator's decision on behalf of the Ombudsman