Summary: We will not investigate Mr and Mrs X’s complaint about the action taken by the Council and the ICB after they raised safeguarding concerns about a Care Home. This is because further investigation by the Ombudsmen is unlikely to add to the Council and the ICB’s joint investigation. Further, we cannot achieve the outcomes Mr and Mrs X are seeking.

The complaint

1. Mr and Mrs X complain that Leeds City Council (the Council) and NHS West Yorkshire Integrated Care Board (the ICB) failed to take appropriate action when they raised safeguarding concerns about Mrs X’s mother, Mrs Y’s, care in a care home (the Care Home). Mr and Mrs X say the Care Home was not properly monitored despite multiple concerns being raised. Mr and Mrs X are unhappy with the outcome of the Council and ICB’s joint report and say the recommendations are insufficient.
2. Mr and Mrs X say that failure to properly monitor the Care Home caused Mrs X’s mother unnecessary pain and distress when she died. They say the family has also been caused a great deal of distress.
3. Mr and Mrs X are seeking a formal review of the joint report, a repeated formal safeguarding investigation, formal action to be taken against individuals and a significant financial payment in recognition of distress.

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The Ombudsmen’s role and powers

4. The Ombudsmen have the power to jointly consider complaints about health and social care. Since April 2015, these complaints have been considered by a single team acting on behalf of both Ombudsmen. (Local Government Act 1974, section 33ZA, as amended, and Health Service Commissioners Act 1993, section 18ZA)
5. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use 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. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A (1), as amended).
6. We provide a free service but must use public money carefully. We may decide not to start an investigation if we believe:

• we could not add to any previous investigation by an organisation; or
• further investigation would not lead to a different outcome; or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, sections 34B(8) and (9))

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How I considered this complaint

7. I have spoken with Mr and Mrs X and considered the information they provided. I shared my draft decision with Mr and Mrs X, who had an opportunity to comment. I did not receive any comments.

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What I found

What happened

8. In 2011, Mrs X’s mother, Mrs Y, moved into the Care Home. Four years later, the Care Home was put into special measures and became subject to ongoing monitoring by the Council and the ICB.
9. In February 2019, Mr and Mrs X raised safeguarding concerns about Mrs Y’s care. In November 2019, an outcomes meeting took place where poor record keeping was identified. It was agreed that Mrs Y’s care would be reviewed in a few months.
10. In December 2019, Mrs Y died. Mr and Mrs X raised further safeguarding concerns, particularly about Mrs Y’s care during her final days.
11. In September 2021, the Care Home closed permanently.
12. In June 2022, the Council and the ICB issued a joint investigation report into Mr and Mrs X’s complaint that their contracts and commissioning teams had not taken adequate action to monitor the Care Home following their safeguarding concerns. Six out of seven points were either partially upheld or upheld.

Analysis

13. The Council and the ICB have produced a thorough and detailed report. I am satisfied that they have taken Mr and Mrs X’s concerns seriously. The report accepts multiple failings including
• delay in sharing information with other organisations
• unclear information sharing, poor communication and lack of clarity of roles between the safeguarding and contracts/commissioning teams; and
• the decision not to handle matters more formally when the Care Home was failing to provide the required information.
14. The Council and ICB’s joint report made 14 recommendations, including multiple systemic improvements to their processes, to assist Mr and Mrs X in any further investigation by the Care Quality Commission (CQC) or police, and a total of £2,500 to recognise the stress and inconvenience caused by the handling of both safeguarding reports and subsequent delays. The Council has provided evidence that it is actively taking steps to implement the recommendations.
15. Mr and Mrs X are unhappy with the recommendations, which they do not feel go far enough to address the number and severity of the failings identified. They say the policy changes mean little to them and the financial sum offered is insulting as it fails to recognise the level of distress caused.
16. Mr and Mrs X have wider concerns about the quality of care generally in the Care Home. As explained above, when considering complaint, the Ombudsmen must see whether the person raising the complaint has been caused an injustice. Therefore, we would consider those matters which have directly impacted on Mrs Y and Mr and Mrs X. Wider monitoring of the Care Home would be the responsibility of the CQC.
17. Mr and Mrs X feel that there has been no personal professional accountability for individuals, such as the Care Home manager and the Clinical Lead. They also believe formal action should be taken against individuals within the Council and the ICB. They are unhappy that no one has faced formal disciplinary or legal proceedings.
18. This is not something the Ombudsmen can achieve. The Ombudsmen cannot recommend disciplinary action against individuals. It would be for the appropriate regulator to consider complaints about individual misconduct.
19. Further it would be for the police to decide whether to pursue legal proceedings against individuals. We cannot influence this process, nor can we commence legal action on a complainant’s behalf.
20. Mr and Mrs X would like their concerns referred back to the police as they consider the Care Home’s actions amount to a criminal matter. The police are aware of the matter complained about and are able to request further information if required. Again, we cannot influence this process.
21. Mr and Mrs X are seeking a substantial financial remedy, in recognition of distress which they consider was a result of gross misconduct and negligence. The Council and ICB’s joint report has offered £2,500 for distress. I recognise that Mr and Mrs X consider this inadequate. However, I also note that the Council and ICB considered the Ombudsmen’s guidelines when deciding on this amount.
22. Deciding about whether an organisation has been negligent usually involves looking rigorously, and in a structured way, at evidence as only the court can to make its findings. In addition, only a court can decide if an organisation has been negligent and so should pay damages.
23. We cannot decide whether an organisation has been negligent and have no powers to enforce an award of damages. If we were to find fault and decide that fault had a detrimental impact, we may recommend a nominal financial remedy in recognition of that impact. However, we do not make recommendations at the same levels the courts might where a person is seeking compensation for the actions of an organisation. Any amount recommended by the Ombudsmen is unlikely to be significantly more than the amount already offered by the Council and the ICB.
24. I note that Mr and Mrs X still have outstanding questions about Mrs Y’s care in the 48 hours prior to her death and this is causing them significant distress. Unfortunately, the Care home has since closed and Mrs Y’s relevant care records are missing. As such, any further investigation by the Ombudsmen is unlikely to resolve this point.

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Final decision

25. There is no basis for the Ombudsmen to investigate the complaint. Further investigation by the Ombudsmen is unlikely to achieve any more than the Council and ICB have already offered. We are also unable to achieve most of the outcomes sought by Mr and Mrs X.

Investigator’s decision on behalf of the Ombudsmen

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Investigator's decision on behalf of the Ombudsman