Summary: We upheld a complaint from Miss B about the Council’s management of her son’s social care needs during a disruptive period in his life in 2024. We considered fault by the Council contributed to his distress, and that of Miss B. A delay in resolving the question of whether he could consent to Miss B’s complaint also added unnecessarily to her time and trouble. The Council accepted these findings. At the end of this statement, we set out action it agreed to take to remedy this injustice.

The complaint

1. Miss B complained on behalf of her son, Mr C, a young adult with autism and ADHD. Her complaint to the Council, made in June 2024, covered events after August 2023 when Mr C left a supported living placement arranged by the Council. The complaint had 18 separate parts, all of which I address below. But in general, they concerned the care and support the Council had in place for Mr C at that time.
2. Miss B’s main concern in raising her complaint was that Mr C was at high risk of self-harm and would engage in high risk behaviour. She considered the Council had failed to provide a sufficiently individual package of care for Mr C and show understanding of his needs.
3. Miss B also said the Council unnecessarily prolonged investigation of her complaint, through disputing her right to bring the complaint on behalf of Mr C.

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The Ombudsman’s role and powers

4. 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)
5. 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)
6. 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(1), as amended)

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What I have and have not investigated

7. I did not consider I could investigate all parts of Miss B’s complaint. In particular, I considered there were parts of the complaint about health services Mr C received or should have had access to, which were not the responsibility of the Council. These were complaints that:

• Mr C would have benefited from more flexible arrangements in how he received prescribed medications. Miss B said there was an over-reliance on using a community pharmacy (point 10 of her complaint);
• Mr C struggled to access community mental health services after leaving his supported living placement in August 2023 (point 14 of Miss B’s complaint);
• Mr C had not had assessments to see if he had schizophrenia. Nor had he received an assessment from a specialist assessor with knowledge of psychological and emotional distress (point 15 of Miss B’s complaint).

8. I did not underestimate the Council’s involvement in Mr C’s life had some impact on all the above. As I explain below, during the events covered by this complaint Mr C experienced multiple changes of address and lived at different times, in different parts of the county. The Council took responsibility for arranging those moves. Those in turn impacted on his ability to access NHS services, due to how it delivers those across the county.
9. But the fundamental responsibilities to diagnose Mr C’s health needs, to prescribe medication in a way he would take it and to enable him to access mental health services all rested with NHS services. So, I did not consider these were parts of the complaint I could investigate as we have no power to investigate how the NHS delivers its services.
10. I also decided I could not investigate part of Miss B’s complaint about the actions of two housing providers who supported Mr C for a time (part of point 11 of her complaint). Miss B said neither provider gave her enough information to help her when she was trying to claim Universal Credit (UC) for Mr C. I noted UC is a benefit administered by the Department of Work and Pensions (DWP), not the Council. I considered any difficulties Miss B had in claiming UC were for the DWP and the housing providers to help her resolve. These organisations also fell outside our powers to investigate.

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How I considered this complaint

11. I considered evidence provided by the Council and Miss B as well as relevant law, policy and guidance.
12. I also gave Miss B and the Council a draft version of this decision statement and invited their comments. I took account of any comments they made, or further evidence they provided, before putting this decision statement in its final format. What I found

Relevant Legal & Administrative considerations

Assessing and providing for care needs

13. Sections 9 and 10 of the Care Act 2014 require councils to carry out an assessment for any adult with an appearance of need for care and support. The assessment must be of the adult’s needs and how they impact on their wellbeing and the results they want to achieve.
14. Following an assessment, if the Council is to meet someone’s care needs, it must find the following:

• first, that their needs arise from, or relate to, a physical or mental impairment or illness;
• second, that because of their needs, they cannot achieve outcomes in two or more of the following domains:
1. managing and maintaining nutrition;
2. maintaining personal hygiene;
3. managing toilet needs;
4. being appropriately clothed;
5. being able to make use of their home safely;
6. maintaining a habitable home environment;
7. developing and maintaining family or other personal relationships;
8. accessing and engaging in work, training, education or volunteering;
9. making use of necessary facilities or services in the local community including public transport, and recreational facilities or services; and
10. carrying out any caring responsibilities they have for a child;
• third, because they cannot achieve these outcomes, there will likely be a significant impact on their well-being.

15. Where the Council finds the eligibility criteria above met, then the Care Act 2014 also requires it to provide a care and support plan. This should consider:

• what needs the person has;
• what they want to achieve;
• what they can do by themselves or with existing support; and
• what care and support may be available in the local area. 

16. Section 27 of the Care Act 2014 says councils should keep care and support plans under review. Government Care and Support Statutory Guidance says councils should review plans at least every 12 months.

Mental Capacity Act and assessments of capacity

17. The Mental Capacity Act 2005 sets out what should happen if someone cannot act and decide for themselves because they lack the mental capacity to do so. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to decide for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to decide for someone else if they cannot decide themselves.
18. The law presumes a person aged 16 or over has capacity to make a decision unless it is known they lack capacity to do so. This means a council cannot treat someone as unable to make a decision:

• because they make an unwise decision;
• based simply on their age; appearance; assumptions about their condition, or any aspect of their behaviour; or
• before it has taken all practicable steps to help the person make their own decision.

19. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
20. An assessment of someone’s capacity is decision and time specific. When assessing somebody’s capacity, the assessor needs to find out the following:

• does the person have a general understanding of what decision they need to make and why they need to make it?
• does the person have a general understanding of the likely effects of making, or not making, this decision?
• is the person able to understand, retain, use, and weigh up the information relevant to this decision?
• can the person communicate their decision?

21. The person assessing an individual’s capacity will usually be the person directly concerned with the individual when the decision needs making. But more complex decisions may need more formal assessments.

Council complaint procedures

22. Government regulations (The Local Authority Social Services and National Health Service Complaints (England) Regulations 2009) set out the process local councils must follow when responding to complaints about adult care services.
23. The regulations say arrangements for dealing with complaints must ensure that councils:

• deal with complaints efficiently;
• investigate them properly;
• treat complainants with respect and courtesy;
• help complainants, so far as is reasonably practical to understand the complaint procedure;
• give complainants a timely and appropriate response.

24. The regulations say that a representative can complain for someone who receives care from the Council. This includes where they act for someone “unable to make the complaint themselves” because of a “lack of capacity within the meaning of the Mental Capacity Act 2005”. Or where someone has “requested the representative act on their behalf”.
25. Someone who does not receive care services can also complain if affected by an “action, omission or decision” of the Council in carrying out its adult care services.

Background and key facts

26. In August 2024 we issued a report following an investigation into a complaint the Council had failed to ensure an effective transition of social work services when Mr C turned 18. He had moved back to Devon, from outside the county in August 2022 and moved into a children’s home. But he had to leave that accommodation in December 2022, after turning 18.
27. We found fault because the Council did not do more to enable Mr C to stay in that placement, especially as it had found no suitable alternative accommodation nearby. Instead, the Council initially said Mr C would have to present himself as homeless to his local District Council. And while eventually this did not happen as the Council found Mr C supported living accommodation, this was over 30 miles from his previous placement and family. It was also nearly 60 miles from his college and resulted in Mr C missing education as the Council had not arranged transport for him.
28. We found the Council’s failings caused injustice to Mr C as he suffered unnecessary distress because of its failure to plan properly for his care beyond his eighteenth birthday. It had not listened to his voice and put him at risk of self-harm in moving him away from his family and college.
29. Mr C stayed in the supported living placement until August 2023. After that, he spent around two months living in a “shared lives” arrangement, living with a carer. That placement then broke down and Mr C lived in temporary emergency accommodation before spending time in a residential care home between January and March 2024. He then spent several weeks in different hotels before a short stay in another supported living placement before moving again between different hotels. During these moves, he lived in different towns in the Council’s area.
30. Miss B complained in June 2024. I set out the details of that complaint below. The Council replied to her complaint in December 2024. In between there were the following developments:

• Mr C continued to move between hotels up to August 2024. Hotel owners often asked Mr C to move as he did not keep his room in a hygienic state, often caused damage to hotel property and would sometimes disturb other guests through his behaviour;
• Mr C often contacted emergency services because of his mental health; he often indicated a wish to self-harm; he sometimes needed support because of risk-taking behaviours;
• the Council looked to identify a suitable specialist housing provider. A supported living provider in the County came forward in July and suggested it could meet Mr C’s needs. But it said it first needed to recruit specialist support staff. When this took too long, the Council decided not to pursue this option;
• the Council also discussed the possibility of Mr C presenting himself as homeless to his local District Council, which is a housing authority. He attended an interview with the housing authority in June 2024 with a personal assistant. During this Mr C became dysregulated and so his interview with a housing officer did not complete;
• the Council held regular multidisciplinary team (MDT) meetings;
• in July 2024 Miss B identified a care agency who could support Mr C in meeting his care needs, including prompts for personal care, with meals and in keeping a clean home environment. The Council agreed to commission the agency which provided some support for Mr C while staying in hotel accommodation in August;
• then, towards the end of August 2024, the Council identified privately rented accommodation Mr C could stay in, which he remained in beyond December 2024. The care agency provided enabling support for Mr C;
• during September 2024 the Council recorded ‘escalated behaviours’ by Mr C which resulted in more contact with emergency services;
• in October 2024 the Council agreed to begin weekly meetings with Miss B. It held these on Mondays, then professionals would meet to take forward any actions agreed on a Tuesday.

31. I noted that in Mr C’s case notes there were discussions between social workers and managers about Mr C’s capacity to understand actions which led to him losing hotel accommodation. Mr C’s social workers expressed the view that they did not have enough expertise to assess if Mr C had capacity to make decisions around his housing need. The notes often described his presentation as complex, as while Mr C could show some understanding it was unclear if this was enough to find he had capacity to understand his housing need. In August 2024 the Council agreed Mr C needed a specialist to assess his capacity in this area.
32. I also noted from October 2024 the Council began to keep a rolling ‘action plan’ setting out areas of concern affecting Mr C. Some of these action points related to the support provided by adult care services, such as with Mr C’s accommodation or in completing a Care Act assessment with him. Other action points were for other services, such as the education service.
33. By April 2025 the Council had completed a review assessment of Mr C’s needs under the Care Act 2014. This found he needed care services in several different areas, including to ensure he had adequate nutrition, to maintain his personal hygiene, his home environment and use his home safely. The Care and Support plan identified Mr C would continue to receive support from the care agency which had supported him since August 2024. Two of its care workers would visit Mr C each day of the week for three hours a day.
34. I could not investigate events beyond this time as this is when we accepted Miss B’s complaint for investigation.

Complaints about the case management of Mr C’s case

Summary of complaints

35. To investigate Miss B’s complaint, I grouped certain parts together, as I considered they raised matters closely related to each other or else which overlapped. First, I noted she made a series of complaints about the Council’s case management, as follows:

• that it did not sufficiently quality monitor its involvement in Mr C’s case given the complexity of his needs and the previous failings summarised above (point 1 of Miss B’s complaint);
• that its case records did not accurately record the multiple changes of address experienced by Mr C as summarised above (point 2 of Miss B’s complaint);
• that it did not sufficiently support Mr C’s accommodation needs. Miss B said Mr C had to report to his local district council as homeless each time his placement broke down (point 4 of Miss B’s complaint);
• that it did not have a contingency plan, or hierarchy of contacts, if Mr C was in a “spiralling situation” (point 5 of Miss B’s complaint);
• that it did not keep satisfactory records of MDT meetings she attended (point 7 of Miss B’s complaint);

Summary of the Council’s response

36. In reply to these points the Council responded as follows:

• that Mr C had a social worker assigned to his case who had line management support and oversight from a team manager and senior manager. It said managers took an interest in Mr C's case because there were “a lot of risks”. It noted Mr C also received support via his education provider and special educational needs case officer. And its children’s services met with Mr C every eight weeks as part of his continuing transition to adult care services. All those involved in Mr C’s case also took part in MDT meetings;
• that it had now put a chronology of Mr C’s multiple changes of address on its case records;
• that it recognised it had to support Mr C with housing as he was a “care experienced young person”. This could encompass approaching his local district council to try and access housing;
• that it could not plan for all circumstances where Mr C might need its help. It had set up a weekly rota of meetings and ensured Mr C had daily support from a care agency;
• that it had now begun keeping records of the meetings and holding them weekly;

My finding

37. I did not find fault with the general case management arrangements made by the Council to monitor and review services to Mr C. It was right those sat with a qualified social worker and I noted during the events covered by this complaint, the Council arranged for two social workers to oversee Mr C’s case. They handed over fortnightly and this way the Council ensured it did not leave Mr C without someone covering his case because of leave. I thought this showed a high commitment by the Council to stay vigilant to Mr C’s needs, given the exceptionally disruptive period he was living though at the time.
38. I also noted social workers frequently involved managers in discussion of Mr C’s case. For example, when considering his capacity to understand the consequences of his actions and in reviewing his accommodation.
39. But that said, while the case management structure in place appeared sound I could understand Miss B’s concerns around the overall approach taken by the Council towards planning for and responding to Mr C’s needs. It was not until after Miss B complained the Council began to record more thoroughly its meetings where it discussed Mr C’s case or keep an action plan. Miss B also pointed out it was she, not the Council, who began keeping minutes of the MDT meetings. And while previously it had recorded Mr C’s frequent changes of address it did not keep a single record of the multiple changes he experienced.
40. So, the impression I gained was that before October 2024 the Council primarily engaged in ad-hoc crisis management to respond to Mr C’s needs. Its responses were not inappropriate simply because of this, as clearly Mr C was in crisis being in regular contact with emergency services because of his poor mental health, risk taking behaviour and increasingly chaotic way of life. He also found himself at risk of becoming street homeless as he could not keep hotel accommodation for more than a few nights at a time.
41. The Council rightly accepted it had a responsibility to secure accommodation for Mr C and clearly worked hard to ensure he kept a roof over his head. But I questioned why it did not also try to take a more systematic approach to address not just the crisis, but the causes. I found it disappointing that it did not make more effort to consider what kind of support Mr C needed to remain in whatever accommodation it could find, including hotels. Placing Mr C repeatedly in hotels without support to keep him safe, and the rooms in reasonable condition, was only setting him up to fail time and again. This in turn could only increase his chaotic lifestyle and neglect of his self-care.
42. There was also the associated question of what capacity Mr C had to understand the consequences of his actions which led him to repeatedly lose the accommodation the Council found for him. I noted above that it was not the Council’s job to ensure Mr C had the right mental health support, as that would be a clinical led decision. But the Council could and should have been raising his case more frequently with mental health practitioners.
43. It was not the Council did nothing to address these matters. It searched for a supported living placement for Mr C and eventually found the rented accommodation he moved into. It also discussed his capacity and more than once tried to reach out to mental health services. But I found it did not take these actions in a consistent way or with enough urgency. I considered contributing to this approach was its failure to keep adequate records of its meetings and discussions. It did not have a consistent and clear action plan to pull together the various strands of the support Mr C needed.
44. I considered the value of taking this more systematic approach demonstrated by what happened after the Council secured accommodation for Mr C. This coincided with the Council keeping better records of its meetings (with encouragement from Miss B) and maintaining action plans. The evidence showed that over time, and with support, Mr C settled in his accommodation. While I understood Miss B still had doubts about its long-term stability, Mr C remained settled there long enough that the crises of Summer and Autumn 2024 passed and some stability returned to his care.
45. But I still had to find fault for the way the Council managed Mr C’s case before October 2024 given the concerns set out above.
46. It was hard to quantify the injustice caused to Mr C and Miss B because of this fault. I could not say to what extent the overlapping crises Mr C experienced resulted from historic failings of the Council we have previously sought to remedy, the events covered by this complaint or because of Mr C’s underlying neurodiversity and mental health needs. But I considered the Council’s fault would have contributed to some extent. As the degree was unknown, there was uncertainty; but we consider this a form of distress. So, I recommended action I wanted the Council to remedy that distress, caused primarily to Mr C. But I also recognised the distress caused to Miss B, although to a lesser extent. She experienced heightened concern for her son’s welfare because of the Council’s fault.

Complaints about the care and support given to Mr C

Summary of the complaints

47. The next group of complaints were more specific and covered aspects of the care and support given to Mr C. Miss B’s complaint raised concerns the Council:

• had not ensured daily welfare checks of Mr C (point 3 of the complaint);
• had, in January 2024, within the course of eight days, issued four different versions of a Care Act assessment of Mr C’s needs (point 9 of the complaint);
• that it had not undertaken a “longitudinal assessment” of Mr C’s needs (point 17 of the complaint)

Summary of the Council’s response

48. I summarise the Council’s response as follows:

• that it was now providing Mr C with three hours care and support every evening and an extra six hours a week to help him maintain his home, family contacts and stay safe in the community. It recognised that when Miss B made her complaint, Mr C did not receive direct support. But it said it had kept in touch with him via his personal assistant, the care agency, its social worker and education provider;
• that it agreed it was unhelpful it had repeatedly amended Mr C’s Care Act assessments;
• that it considered the assessment sought was a matter for the NHS.

My finding

49. I considered the point Miss B made about the lack of welfare checks related closely to those complaints considered above. But the gap in care Mr C experienced, rightly highlighted by Miss B (when she did not know how long the gap would last), was symptomatic of his circumstances then. It was fault, the Council could not provide a consistent level of care and support for several months to Mr C. Although I cannot say this caused any separable injustice to that I identified above.
50. I found it disappointing the Council did not explain more to Miss B about the circumstances which led it to send out repeated similar copies of Mr C’s Care Act assessment. She highlighted this matter concerned at the time she spent, and the Council spent, in correcting the assessments. But given the Council had still recognised it had been at fault, I did not consider further investigation of this matter needed. Also, I did not consider the matter had any significant bearing on Mr C’s care, although it caused some understandable frustration for Miss B.
51. I did not uphold the complaint the Council should have arranged for a ‘longitudinal assessment’ of Mr C’s needs. This was not an expression I was familiar with, nor did I find it one commonly referred to in social care. Nor did I find it a phrase used regularly in medicine, so I thought the Council wrong to say it was a matter for the NHS.
52. Miss B told me an NHS employee suggested she ask the Council for such an assessment. She says in April 2024 she therefore discussed the request with Mr C’s then social worker who recognised the phrase but suggested he could not complete the assessment because of workload.
53. I approached this matter by looking at what the Council had a duty to provide. As the social services authority the Council had to regularly assess Mr C’s eligibility for care services using the Care Act framework. This meant it had to carry out assessments in a way compatible with Mr C’s needs, so he could take part (for example, by providing advocacy if he needs it). It then had to ensure he had an up-to-date care and support plan. I could not fault the Council for failing to provide any additional assessment that went beyond these requirements.

Complaints about communication with Miss B

Summary of the complaint

54. Parts of Miss B’s complaint, and relevant also to the Council’s complaint handling, concerned the Council sharing information about Mr C with her. Specifically, she complained the Council:

• did not consistently share information about Mr C with her, despite Miss B having a power of attorney to act for Mr C for both health and welfare and finances (point 8 of Miss B’s complaint);
• did not have a record of Mr C’s mental capacity issues for which he needed a “full assessment” (point 13 of Miss B’s complaint).

Summary of the Council’s response

55. I summarise this as follows, the Council:

• did not consider the power of attorney documents conferred an automatic right on Miss B’s involvement in all decisions affecting Mr C’s care. Being a health and welfare attorney only entitled Miss B to make decisions around life sustaining treatment. It had delayed replying to her complaint while it commissioned an independent advocate to meet with Mr C and confirm he consented to Miss B making her complaint. The advocate met with Mr C in November 2024, where he expressed general dissatisfaction with the support he received from the Council, both historically and at that time.
• that all decisions around Mr C’s capacity were ‘decision specific’. It would always assess Mr C’s capacity if it had any doubt that he could make a decision for himself.

My finding

56. I started from the position that I saw nothing to suggest Miss B had not acted throughout other than through genuine concern for what she considered was in Mr C’s best interests. Her concern, whether dealing with social workers or when making her complaint, was to see that he received services to meet his complex needs. She had concerns about his behaviours associated with his needs and the potential consequences of those on him and others.
57. That said, I accepted the Council could not necessarily investigate a complaint made by Miss B on this basis alone. If her complaint concerned a decision, action or omission by the Council that affects only Mr C and not her, then the Council could decide not to investigate if:

• it had evidence Mr C did not want to complain about the decision, action or omission complained about; and
• he had capacity to decide that, if it concerned his health and welfare.

58. This was because even though Miss B held two Power of Attorneys for Mr C, only the power of attorney for finances took affect if the donor (Mr C) retained capacity. So, the Council had to consider the issue of Mr C’s capacity to complain or consent to a complaint, before it could investigate a complaint about his health and welfare. If Mr C provided a consent for Miss B to act on his behalf, the Council could only question that if it considered Mr C did not have capacity to give such consent. But if that was so, then it followed that Miss B could rely on her power of attorney to make the complaint.
59. I therefore could not fault the Council for pausing to reflect if it could properly investigate Miss B’s complaint. But I questioned why it could not resolve this sooner. It should not have taken seven months to settle the question that Mr C consented to Miss B’s complaint.
60. It was not clear to me why the Council did not ask its social workers to assess if Mr C had capacity to consent to Miss B’s complaint. I considered the use of an advocate to make such an assessment in this case was arguably unnecessary. But in any event, the delay in resolving this issue was unacceptable and this caused injustice to Miss B adding unnecessary time and trouble to her pursuit of her complaint.
61. I considered next the wider issue of information sharing with Miss B. I noted that after October 2024 the Council began regular meetings with her and seemed content to share information about Mr C (although Miss B told me the Council scaled back the MDT meetings over time). It was not appropriate for me to suggest the Council could adopt blanket rules about what it should or should not share with Miss B. As what it could share and when always had to take account of Mr C’s ability to consent.
62. I also noted the matter of Mr C’s capacity to take some complex decision specific choices was something that had clearly exercised his social workers during the events covered by this complaint. Their dilemma was they did not know the true extent to which Mr C always understood the consequences of his decisions and actions around matters such as his housing and care. It was understandable the Council sought specialist advice therefore. Unfortunately, the scope of that, and its potential impact on dealings with Miss B, was something that fell outside the scope of this investigation. But I trusted if Miss B had cause to complain again, the Council would be able to reply much sooner through having a better understanding of Mr C’s needs in this area. Although that said, I also recognised that because capacity is a ‘decision specific’ question, the Council would always have to consider the question of Mr C’s consent if Miss B complained about his care. But it should aim to do so in a more efficient way following the principles set out in this statement.

Complaints about other specific incidents

Summary of the complaint

63. Finally, Miss B also raised complaints about the following specific matters, that the Council:

• had ‘manipulated’ the reasons given by an agency that had supported Mr C with care and accommodation, to blame her for the breakdown of that support (point 6 of Miss B’s complaint);
• had not kept rental agreements or contracts of Mr C’s stays in shared lives or with one of the supported living providers (part of point 11 of Miss B’s complaint);
• kept poor records which resulted in Mr C receiving inaccurate invoices for the time he spent with the residential care provider (point 12 of Miss B’s complaint);
• had not undertaken a serious case review to look at Mr C’s case, something she understood it had said it would do at the end of 2023 (point 18 of Miss B’s complaint).

Summary of the Council’s reply

64. The Council said that:

• it apologised to Miss B that she felt blamed in the notice letter given by the care agency;
• did not keep rental agreements or contracts as part of its care records;
• it wanted to resolve any dispute over the charges made to Mr C. It invited Miss B to provide more details;
• it had no record of where it had promised a serious case review.

My finding

65. I did not pursue further investigation into any of these matters. I considered the apology provided by the Council would remedy any injustice caused to Miss B by how it summarised the notice letter she referred to.
66. I also agreed with the Council that it was not necessary to keep all tenancy or similar agreements a user of its services enters into, as part of its social care records. This would only be appropriate where the Council itself was the one commissioning services.
67. I considered it offered a satisfactory route for Miss B to pursue any outstanding grievance with the invoice Mr C received for his time in residential care.
68. Finally, I could not see the Council was under any obligation to hold a serious case review. These reviews take place when a child dies or suffers serious harm because of abuse or neglect. Their focus is therefore more on the role of children’s care services rather than adult care services. Because they aim to identify how local professionals and organisations can improve the way they work together to safeguard children.
69. As I noted above we found the Council at fault previously, in part due to the actions of its children’s care services, when planning for Mr C’s adulthood. But while those failings were serious, they did not cross the threshold where I would expect the Council to hold a serious case review. It was also unlikely we would investigate where a serious case review had taken place given its role is also an investigatory one. I could not therefore see any basis why the Council would have suggested holding a serious case review, nor why it may have suggested one.
70. So, while I did not doubt Miss B’s recollection or understanding that such a review would happen, I could not recommend the Council visit this matter again.

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Agreed Action

71. The Council accepted the findings set out above. To remedy the injustice caused to Miss B and Mr C it agreed that within 20 working days of this decision, it would:
1. provide apologies to Miss B and Mr C, accepting the findings of this investigation. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The Council would consider this guidance in making the apologies recommended;
2. make a symbolic payment to Mr C in recognition of the distress caused to him by its fault of £500;
3. make a symbolic payment to Miss B in recognition of the distress caused to her by its actions and for putting her to unnecessary time and trouble because of its complaint handling, of £500 (£250 for each).
72. I decided not to recommend the Council take any further specific action in connection with Mr C’s case. Since the events covered by this complaint, there was work done with Mr C to assess his capacity in specific areas to help inform his care planning moving forward. I also noted the review of Mr C’s care and support plan which completed in April 2025 and could see no grounds to recommend the Council revisit that before it would next schedule a review (around April 2026).
73. The Council understood it needed to provide us with evidence to show compliance with the actions agreed in paragraph 71.

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Final Decision

74. For reasons set out above I upheld this complaint finding fault by the Council caused injustice to Miss B and Mr C. The Council agreed to take action that I considered would remedy that injustice. So, I completed my investigation satisfied with its response.

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Investigator's decision on behalf of the Ombudsman