Summary: Mr B says the Council failed to provide any intervention or support for Ms C despite his family repeatedly asking for help. There is no fault by the Council.

The complaint

1. The complainant, whom I shall refer to as Mr B, complained about the way the Council dealt with his sister, whom I will refer to as Ms C. Mr B says the Council failed to provide Ms C with any intervention or support despite his family repeatedly asking for help.
2. Mr B says this meant his Ms C was left abandoned and alone and could not cope, which led to her death.

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The Ombudsman’s role and powers

3. The Ombudsman investigates complaints of injustice caused by maladministration and service failure. I have used the word fault to refer to these. The Ombudsman cannot question whether a Council’s decision is right or wrong simply because the complainant disagrees with it. He must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3))
4. 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

5. As part of the investigation, I have:
• considered the complaint and Mr B's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
6. Mr B 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

What should have happened

7. The Council’s Safeguarding Adults Policy (the policy) makes clear there is a presumption that adults have mental capacity to make informed decisions about their lives. If someone has been assessed as not having mental capacity to make decisions about their safety decision making will be made in their best interests as set out in the Mental Capacity Act 2005 and Mental Capacity Act Code of Practice.
8. The policy says where an individual is not able to protect themselves without support, the aim should be to support them to make their own informed decisions which preserve their safety. However, people involved in safeguarding need to acknowledge that there is a balance to be struck between risk and an individual’s right to make their own informed decisions, even if others consider the decision to be unwise or puts the individual at risk. The importance of their right to make decisions about their own life, which is part of an individual’s well-being, needs to be considered as well as the safeguarding concern(s).
9. The policy says where a local authority has reasonable cause to suspect that an adult in its area:
• has needs for care and support (whether or not the local authority is meeting any of those care and support needs); and
• is experiencing, or is at risk of, abuse or neglect; and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse and neglect.
• the local authority must make (or cause to be made) whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult’s case. This is referred to as a Statutory Section 42 Enquiry (under the Care Act 2014).
10. The policy says local authorities are not required by law to carry out safeguarding enquiries on behalf of adults who do not fit the criteria outlined in Section 42 of the Care Act 2014; they do so at their own discretion. These enquiries would relate to an adult who:
• is believed to be experiencing, or is at risk of, abuse or neglect; and
• does not have care and support needs (but might have just support needs).
11. The policy says for high risk domestic abuse cases a Multi-Agency Risk Assessment Conference (MARAC) meeting may be held. MARAC meetings include representatives of local Police, probation, health, children and safeguarding adults, housing practitioners, substance misuse services, independent domestic violence advisers (IDVA) and other specialist organisations from the statutory and voluntary sectors.
12. The aims of a MARAC are as follows:
• To safeguard adult victims who are at high risk of future domestic violence and abuse;
• to make links with other public protection arrangements in relation to children, the perpetrator and people at risk;
• to safeguard agency staff; and
• to work towards addressing and managing the behaviour of the perpetrator.
13. The policy refers to five statutory principles that underpin the work with adults who lack mental capacity set out in the Mental Capacity Act (the MCA):
• Every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is proved otherwise;
• a person is not to be treated as unable to make a decision unless all practicable steps to help him/her to do so have been taken without success;
• a person is not to be treated as unable to make a decision merely because he/she makes an unwise decision;
• an act done or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his/her best interests;
• before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action.
14. The policy says the requirement to apply the MCA in adult safeguarding enquiries challenges many professionals and requires utmost care, particularly where it appears an adult has capacity for making specific free and informed decisions that place them at risk of being abused or neglected, even if this decision is considered to be unwise.
15. The Mental Health Act 1983 (the Act) says a patient may be admitted to a hospital and detained there. The Act says an application for admission for assessment may be made in respect of a patient on the grounds that:
• (a)s/he is suffering from mental disorder of a nature or degree which warrants the detention of the patient in a hospital for assessment (or for assessment followed by medical treatment) for at least a limited period; and
• (b)s/he ought to be so detained in the interests of his/her own health or safety or with a view to the protection of other persons.
16. The Act says an application for admission for assessment shall be founded on the written recommendations in the prescribed form of two registered medical practitioners.

What happened

17. Ms C was suffering from alcoholism and had several hospital admissions in May and June 2020. Ms C had been offered a referral to mental health in May 2020, which she had declined. The women’s centre had also offered Ms C three appointments in June 2020 to discuss support they could offer which Ms C had declined.
18. Ms C contacted the police about her ex-partner controlling her on 8 June 2020. The police visited but no offences were disclosed. Ms C subsequently said her partner had not assaulted her and she had made it up because he would not let her have a drink.
19. The Council’s safeguarding team considered the case at a MARAC on 10 June. The meeting noted Ms C was attending probation which would explore her current circumstances with her and what support could be offered without her partner being there. The police said if anything further was disclosed it could look at getting a domestic violence protection order to separate the parties for 28 days.
20. Ms C was due to attend probation on 10 June. The independent domestic violence adviser (IDVA) attended that appointment to try and engage with Ms C but she did not attend. The appointment was rearranged for 17 June. Ms C cancelled the second appointment.
21. In July 2020 Ms C was admitted to hospital with injuries and heavily in drink and had seizures while in hospital. Ms C reported being assaulted by her partner. A Council officer visited Ms C and spoke to her. Ms C made clear she was aware of the risk to her and that people were concerned and said she would not drink again. Ms C discharged herself from hospital.
22. The Council referred the case to the domestic abuse hub. At the next MARAC meeting probation agreed to carry out a doorstep visit each week.
23. A member of the domestic abuse hub visited Ms C as part of a welfare check on 27 July. Ms C told officers the bruising was from her being clumsy when drunk and falling over and she denied her partner was responsible.
24. The IDVA attended Calderdale Recovery Steps on 6 and 20 August in the hope of meeting Ms C when she attended for her appointment but she did not attend.
25. The Council discussed the case at the next MARAC on 7 September. Probation reported that when meeting with Ms C on 3 September she had appeared scared of her partner but did not want to make any reports to the police. Probation therefore decided to invite her into the probation office despite Covid 19 restrictions so the probation officer could discuss the concerns with her without her partner being present and encourage her to talk to an IDVA. It was intended that the police would be at that appointment as well. Those at the meeting hoped the probation officer would be able to encourage Ms C to access support.
26. In October 2020 the police attended A&E when Ms C attended with some injuries. The police sorted out emergency accommodation for her. The IDVA attended the accommodation and met with Ms C. Ms C was under the influence of drink.
27. The Council discussed the case at the next MARAC in November. The IDVA attended that meeting and reported back what had been discussed when she met Ms C. The meeting noted Ms C had struggled to engage with the probation service. It was agreed to contact housing to find out what options Ms C had for accommodation. The police asked about detox and was advised that funding for that would be through the NHS. The police were advised though that Ms C needed to be on board for that to happen. It was agreed the IDVA would offer support to see if Ms C would agree to a non-molestation order application.
28. The domestic abuse hub met later in November. The IDVA told the meeting Ms C had said she was safe although still drinking. The IDVA said Ms C had been advised to contact Recovery Steps for support, which she had agreed to do. Probation reported Ms C’s engagement continued to be poor and they would assess whether face-to-face weekly appointments could be offered while further accommodation was being sought.
29. Ms C was admitted to hospital in December 2020. The Council asked to be notified when she was discharged. When the Council contacted the hospital in January 2021 it advised it had already discharged Ms C.
30. The Council received a safeguarding referral in January 2021 as Mr B had contacted another organisation after being unable to contact Ms C for two days. A Council officer visited and spoke to Ms C who advised she had been staying at somebody else’s flat and they had locked her in the flat for the last two days. Ms C reported an assault. The officer took Ms C to hospital.
31. The Council received a further safeguarding alert in February 2021. The Council made several attempts to contact Ms C. Despite leaving a message on each occasion Ms C did not return the Council’s call. The Council subsequently obtained a telephone number for Mr B’s mother who advised she had spoken to Ms C and she was fine. Mr B’s mother provided a new telephone number for Ms C. Mr B’s mother did not have any concerns.
32. The Council received another safeguarding alert in April 2021. The Council did not have much information at that point and tried to contact the referrer but did not get a return call. The Council did not consider it had sufficient information at that stage to support the threshold for section 42 being met. The Council sent the person that had made the referral an email for further information. The Council explained the provisions within section 42 of the Care Act 2014 and explained that if the criteria was not met the threshold to begin an adult safeguarding investigation would not be met. The Council said it had information that Ms C was using substances and when doing so concerns had been raised about vulnerability and harm but the Council had no evidence to suggest Ms C had needs arising outside of substance use. The Council explained on that basis it did not consider the threshold for safeguarding was met. The Council explained though this did not mean suggestions about support could not be offered and suggested some options which would require working with Ms C.
33. Mr B made a referral to the Council about Ms C in May 2021. Mr B reported having concerns for her mental health as she was alcohol dependent, suicidal and possibly pregnant. The Council tried to telephone Ms C but the call could not be connected. The Council contacted Mr B and left a message suggesting if he had immediate concerns he should contact the police and request a welfare visit. The Council later spoke to Mr B who advised he had no new concerns but they were ongoing. Mr B reported Ms C was deteriorating and suggested a mental health assessment. The Council said it would need to consider less restrictive options and that based on what he had described a Mental Health Act assessment was not required. The Council also said it could make a referral but Ms C would need to consent to any services.
34. Shortly after that Ms C sadly died.

Analysis

35. Mr B says the Council failed to provide any support to Ms C despite his family repeatedly asking for help. Mr B says Ms C was not in a position to look after herself and he believes the Council should have made appropriate referrals for rehab or sectioning. I have carefully considered the documentary evidence. That shows there was regular involvement from various services, including the Council, between June 2020 and Ms C’s sad death in 2021. That included regular discussions at multiagency meetings where the police, probation, NHS, social services and other external organisations input into what was happening with Ms C. It is clear from those discussions that professionals had concerns about Ms C but also had concerns about her willingness to engage with services. There are regular reports, for instance, of Ms C not engaging with probation or the IDVA. I am satisfied though that services were provided to Ms C where she was willing to accept those services. I therefore could not say the Council failed to provide any intervention or support.
36. In reaching that view I recognise Mr B wanted the Council to arrange for Ms C to be sectioned to enable her to be provided with support given she was not engaging. I understand why Mr B would have wanted that to happen. However, the decision to section a person has to be made by an appropriately qualified mental health professional. The evidence I have seen satisfies me Ms C was regularly seen by NHS professionals at hospital. It is evident from the recordings I have seen that nobody considered it necessary to section Ms C. That is not a matter I can comment as the Ombudsman does not have jurisdiction over the NHS. Given NHS professionals did not consider it necessary to section Ms C though I cannot criticise the Council for not identifying the need for such an action to take place. As I said in the previous paragraph, I am satisfied NHS professionals as well as the other services involved in Ms C’s life attended multiagency meetings and there is nothing in the notes of those meetings to suggest anybody considered either that Ms C did not have mental capacity to make her own decisions or that a section under the Mental Health Act was required. In those circumstances, although I completely understand Mr B’s concern given the loss of Ms C, I have found no evidence of fault by the Council.

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Final decision

37. I have completed my investigation and do not uphold the complaint.

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Investigator's decision on behalf of the Ombudsman