Summary: Mrs C complains the Council carried out an inadequate safeguarding investigation into the circumstances surrounding the admission of her father-in-law into hospital in April 2020. We uphold the complaint as the Council failed to carry out a safeguarding investigation in the way it promised. However, we do not consider that fault affected the outcome of the investigation. The injustice caused to Mrs C is therefore that the Council raised her expectations unnecessarily. The Council has agreed to apologise.

The complaint

1. I have called the complainant ‘Mrs C’. She complains on her own behalf and that of her husband ‘Mr C’. Mrs C complains the Council carried out an inadequate investigation into the circumstances surrounding the admission of her father-in-law (Mr B) into hospital in April 2020. Mr B subsequently passed away.
2. The circumstances around Mr B’s death have caused great distress to the family. Mrs C considers the Council’s failure to carry out a more thorough investigation has compounded that distress.

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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 cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. We cannot investigate complaints about the provision or management of social housing by a council acting as a registered social housing provider. (Local Government Act 1974, paragraph 5A schedule 5, 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. Before issuing this decision statement I considered:

• Mrs C’s written complaint to the Ombudsman and any supporting information she provided; including that gathered in a telephone conversation with her;
• correspondence sent by the Council to Mrs C which pre-dated our investigation;
• information provided by the Council in response to written enquiries;
• information provided by a hospital trust and ambulance service in reply to enquiries;
• relevant law and guidance.

7. I gave Mrs C and the Council opportunity to comment on a draft decision statement where I set out proposed findings. I considered any comments or new evidence received in reply, before issuing this final decision.

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What I found

Relevant law and guidance

8. Section 42 of the Care Act 2014 says a local authority must make enquiries to “enable it to decide whether any action should be taken” if it has “reasonable cause to suspect” that an adult in its area:

• has needs for care and support;
• is experiencing, or is at risk of, abuse or neglect;
• as a result is unable to protect himself or herself against the abuse or neglect or the risk of it.

9. Guidance says neglect can include acts of omission such as ignoring medical, emotional or physical care needs. Also, the failure to provide access to appropriate health services.
10. Local authorities can make their own enquiries or “cause others to do so”. The purpose of such enquiries is to protect the adult. They should make enquiries wherever abuse or neglect are suspected.
11. The objectives of an enquiry into abuse or neglect are to:

• establish facts;
• ascertain the adult’s views and wishes;
• assess the needs of the adult for protection, support and redress and consider how such needs might be met;
• protect from the abuse and neglect, in accordance with the wishes of the adult;
• make decisions as to what follow-up action should be taken with regard to the person or organisation responsible for the abuse or neglect;
• enable the adult to achieve resolution and recovery.

12. Guidance says that in carrying out enquiries local authorities can consider the consequences for others if they may also be at risk.

Key Facts

13. Mr B lived in a Council owned complex it describes as an Independent Living Community managed by its housing services. Residents have their own flats and there are communal facilities such as gardens and a common room. All flats are connected to a community alarm system. Residents can operate this via a pully cord and they may also carry a pendant alarm. Their flats have an intercom which links them to the office of an on-site warden. At times when the warden is unavailable the alarm system links to the Council run ‘Be Independent’ service. This is a 24/7 telecare service that responds when residents have an emergency or need assistance.
14. In addition to this service, residents can choose to receive a daily call from the on-site warden to check on their welfare. Some residents may also receive care services provided or arranged for by the Council. For example, to assist with personal care tasks like washing or dressing.
15. Mr B had lived at the complex since 2013. He did not receive daily checks from the warden having opted out of that service. He did not receive any care services provided or arranged for by the Council. Mrs C has reported that Mr B was active and left his flat most days and was well known to his neighbours.
16. Mr and Mrs C lived around 20 miles from Mr B and would visit him regularly. However, after the Government introduced ‘lockdown’ measures because of COVID-19 they could only maintain contact with Mr B via phone. They spoke to Mr B on 4 April and arranged to speak to him again on 8 April 2020.
17. Mr and Mrs C failed to make contact with Mr B on 8 April. And when they could still not contact Mr B on 9 April they attempted to contact the housing service without success before contacting North Yorkshire Police. The police contacted the ‘Be Independent’ service. That service says one of its call handlers contacted Mr B and he told them he was fine. This information was then relayed to Mr C. The ‘Be Independent’ service has a specific record of the time of that call and the name of the call handler who spoke to Mr B. During this investigation it also provided a transcript of that call.
18. On 11 April 2020 the call handler from the ‘Be Independent’ service says they made a follow-up call to Mr B. They again recorded the specific time of this call. They recorded that Mr B again told them that he was fine. During this investigation the Council has also provided a transcript of this call.
19. On 14 April 2020 a housing officer (‘Officer X’) was at the complex carrying out weekly safety checks. The regular warden was not on site as they were absent from work. A resident approached Officer X saying they were concerned for Mr B’s welfare as they had not seen him outside his flat or heard him in his flat for two to three days. Also, when they had last seen Mr B he looked unwell. Officer X said she initially tried knocking the door of Mr B’s flat but he did not answer. She then rang Mrs C who explained she was concerned for Mr B’s welfare having not spoken to him since 4 April. Officer X says she then used the intercom to contact Mr B. He answered but was short of breath. Officer X says she asked Mr B if he needed assistance and he answered yes, at which point she called 999 and requested an ambulance.
20. When ambulance services arrived Mr B was found lying on the floor in his flat. He was admitted to hospital. When Mr and Mrs C arrived at the hospital they were told Mr B was dehydrated and malnourished. He had pressure sores which were ‘ungradable’ suggesting he had lain in one position for a long time. He was not able to speak. He had likely suffered a stroke and was unlikely to recover as he was going into multiple organ failure.
21. Mr B passed away in hospital on 16 April 2020.

The Council safeguarding response

22. On 15 April 2020 Mrs C contacted the Council expressing concern about how Mr B had been found. At this stage he was critically ill in hospital and not expected to recover. Mrs C believed he must have been lying in his flat for several days to account for his condition. Mrs C set out that her concerns were:

• that Mr B had lain unconscious in his flat for a long time before being discovered; Mrs C said Mr B had multiple pressure sores, included some considered “past Grade 4” which are the most serious; Mrs C did not consider Mr B’s skin could have deteriorated to that extent without him lying in one position for several days; he was also malnourished and dehydrated;
• that she understood neighbours had expressed concern for Mr B’s wellbeing but no action was taken;
• that the housing warden service had not been making checks on Mr B as she would expect.

23. The Council immediately made enquiries with its housing service. It replied the same day and it explained the facts around Mr B’s tenancy and the services he received, as I described at paragraph 15. It explained the contacts its ‘Be Independent’ service had with Mr B on 9 and 11 April 2020 and provided copies of the notes of those calls (although not the transcripts). It also relayed Officer X’s account of events on 14 April 2020.
24. The Council initially decided that in the light of this information the referral did not meet the threshold where it should conduct a safeguarding investigation. Its officer recorded that they had considered if there was evidence of neglect on the part of the housing service. But that it had “demonstrated appropriate steps were taken at the appropriate time to check [Mr B] was OK and to seek medical assistance once he became unwell”. The Council decided this on 16 April, which was the day Mr B passed away.
25. Mrs C was dissatisfied with this decision believing the Council should carry out a more thorough investigation into the circumstances around Mr B’s hospital admission. In particular, Mrs C cast doubt on whether Mr B could have spoken to the Be Independent service and Officer X as claimed given how he was found.
26. On 17 April 2020, the Council therefore decided to undertake a review of its decision the case did not meet the threshold for a safeguarding investigation. An internal email says this was because it considered it important to “check records”. A note on 20 April 2020 said the investigating officer had contacted Be Independent and asked it to provide further records to demonstrate it made the calls it had logged. The officer also asked if there was any ‘log’ of the contact Officer X said she had with Mr B on 14 April.
27. In response the Be Independent service sent through the same records it had previously in response to the initial safeguarding enquiry on 15 April 2020. The investigating officer then asked if it was possible to get “full transcripts” of the call rather than just the call handler’s notes. The officer followed up this enquiry on 27 April and was advised the Be Independent service was still looking into whether it could provide this.
28. On 29 April 2020, the Be Independent service again sent through a copy of the call handler’s notes. This was the same information it had provided on 15 and 20 April 2020. The investigating officer referred this information to the manager who had agreed to review the case and asked for their advice on how to progress enquiries. There is no record of their reply.
29. But in early June 2020 the Council concluded its review and again decided the case did not meet the threshold for further investigation. It decided there was no evidence of neglect on the part of its housing services and no further action it should take. Mrs C went on to complain about this decision and asked the Council to investigate further, continuing to doubt the accuracy of the communications between 9 and 14 April 2020 which the Council referred to. The Council declined to carry out any further investigation and referred Mrs C to this office.

My investigation

30. I asked for, but was not provided with, full information of how the Council carried out the review which culminated in June 2020. To my knowledge all the Council did was approach the Be Independent service for more details of its calls to Mr B which that service failed to provide. The Council did not, during its investigation, approach either the local ambulance service or hospital to ascertain details about Mr B’s condition when he was admitted. I obtained that information direct.
31. I listened to the 999 call made by Officer X on 14 April 2020. Officer X and a colleague I will call Officer Y called from the Warden’s office. Neither was physically present with Mr B during the call. Officer X explained to the call operative that she had been approached by neighbours as no-one had seen Mr B “for two to three days” and was told when he was last seen he had looked unwell. Officer X said she had checked with family (Mrs C) who were also concerned for his welfare. Officer X said she had spoken to Mr B and he had “very shallow breathing” and had asked for help. Officer X passed the phone to Officer Y and he said to the operator that Mr B was “struggling to speak”; he had said ‘help’ and “that was a struggle for him”.
32. During the call the operative asked one of the officers to contact Mr B via the intercom and reassure him an ambulance was on the way. While Officer Y spoke to the operative, Officer X could be heard speaking in the background through the intercom. Mr B cannot be heard on the recording. But Officer X’s responses suggest that Mr B was talking to her in a limited way. For example, when she asked if Mr B could still hear her and if he understood help was on the way. There were several of these brief exchanges during the call which lasted 22 minutes in total.
33. I noted that when the ambulance arrived paramedics completed various checks with Mr B. This included recording observations against what is known as the ‘Glasgow Coma Scale’ or GCS. This observes patient’s eye opening, motor and verbal responses when a brain injury is suspected. The paramedics took three sets of observations in a 30 minute period. Each time they recorded Mr B as having a verbal response at ‘3’ on the scale which corresponds to him making intelligible single words.
34. I noted that when later, similar observations were undertaken at the hospital, Mr B’s score on this scale had declined. Those notes also confirm all that Mrs C has said that the hospital treated Mr B on the understanding he had been lying on the floor for some time. It recorded him having ‘ungradable’ pressure sores on one elbow and knee.

My findings

35. Mr B was not in receipt of any adult care services before he passed away. As such, any contact he had with the Council was only in its capacity as his social landlord. I am unable to take any view on the actions of the Council housing service in this case for the reasons explained in paragraph 4. It is therefore outside the scope of this investigation to comment on the services Mr B received as a tenant.
36. However, I can take a view on the response of the Council’s adult care services when Mrs C contacted it with concerns. I think it appropriate the Council considered whether to carry out a safeguarding investigation. Potentially Mr B was an adult with a need for care and support even though the Council was not providing any care services. Mrs C also suspected actions by the housing service which could have amounted to neglect. And any failing there could have implications for other residents at the Independent Living Community. There were reasonable grounds therefore for the Council to make initial enquiries and decide if these would justify a more thorough safeguarding investigation.
37. I note at this stage the circumstances in which Mr B was found must have been very distressing for Mrs C and her family. For Mrs C this distress is compounded by the knowledge that due to lockdown rules she could not pay her regular visit to Mr B. I can understand why she had questions about how long Mr B may have been in distress in his flat without help. And whether more might have been done to summon aid to him more quickly and potentially saved his life. On Mrs C’s account I find there were four key lines of enquiry the Council needed to consider:
• First, was the housing service checking on Mr B’s welfare as a matter of routine and had it failed to do so?
• Second, had it failed to make enquiries when alerted to concerns from neighbours?
• Third, had it responded properly to the contact from the police on 9 April?
• Fourth, had it responded properly on 14 April?
38. In considering these questions in turn, I note the Council quickly established Mr B was not receiving daily care visits or welfare checks from the housing service. So, there could be no question of neglect in that regard. There was no fault in the Council’s consideration of that matter.
39. The Council also received no information from the housing service to suggest any neighbours had raised concerns before 14 April. None has come to light subsequently. So again, the question of neglect does not arise, and I am satisfied there was no fault in the Council’s consideration of this matter.
40. On the issue of the contact on 9 April 2020 the Council was provided details quickly which suggested the Be Independent service had responded appropriately to the contact from the police. I note here the notes provided by the service were specific in terms of the time of call and named point of contact. I see no reason why they would, as a matter of routine, be queried by the Council.
41. However, when Mrs C challenged if the record could be consistent with how Mr B was found in his flat, I can also understand why the Council decided to undertake further checks. It is then apparent the Council failed to complete those checks. It was provided with the same information by the Be Independent service three times. It never completed checks to find out if it could listen to the calls between the call handler and Mr B or get an itemised print out to demonstrate the calls were made. It is not clear why having decided to seek this information the Council abandoned the effort. I consider the lack of a clear audit trail around this point is enough to justify a finding of fault. Because having made the commitment to Mrs C to carry out a more thorough review, the Council should have carried this out.
42. Turning to events on 14 April there was nothing which pointed at neglect by the Council in the housing service’s initial account. It said its officers were made aware of concerns for Mr B’s welfare and duly called an ambulance when contact with him established he needed help. The account provides no evidence of neglect. But for Mrs C this account raised an understandable question. She could not understand how the officer’s account could reconcile with how Mr B entered hospital.
43. I consider as part of its commitment to review the initial decision not to open a safeguarding investigation the Council could have sought more facts about what happened. In particular obtaining information from the ambulance service to see if that suggested any contradiction of its officer’s account. Which in turn may have cast doubt on the Be Independent records.
44. But having now gathered that information I find no contradiction. I am satisfied that on 14 April, Mr B was still capable of limited verbal communication and this is demonstrated by the 999 call and the paramedic notes. I find the housing officer statements consistent and credible. They do not suggest any cover-up which may have led the Council to think there had been neglect here. I also consider in the light of this evidence the accounts of the Be Independent service of their contacts with Mr B on 9 and 11 April 2020 are credible. I am also grateful transcripts of those calls have now come to light.
45. In summary therefore I am satisfied there is no evidence which casts doubt on the Council’s decision that it did not need to pursue any further safeguarding investigation into the circumstances around Mr B’s hospital admission. However, the Council should have done more to gather such evidence itself when it committed to undertake further enquiries on 16 April 2020. Its commitment led Mrs C to believe it would undertake a more thorough investigation. It raised her expectations, which it then failed to fulfil. That was her injustice.

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Agreed action

46. The Council accepts these findings. To remedy the injustice set out in paragraph 45 it has agreed that within 20 working days of this decision it will apologise to Mrs C accepting the findings of this investigation; recognising the distress caused to her and her husband by its actions.

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Final decision

47. For reasons set out above I have upheld this complaint finding fault by the Council causing injustice to Mrs C. The Council has agreed action that I consider will provide a remedy for that injustice. Consequently, I am satisfied I can complete my investigation satisfied with its response.

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Investigator's decision on behalf of the Ombudsman