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Coventry City Council (19 010 863)

Category : Adult care services > Residential care

Decision : Upheld

Decision date : 11 Feb 2020

The Ombudsman's final decision:

Summary: The Council failed to respond to Mrs X’s concerns about the outcome of a safeguarding investigation into the care her late mother received at a care home. It also failed to respond to Mrs X’s repeated correspondence about this.

The complaint

  1. Mrs X complains about how the Council responded to her concerns about the outcome of a safeguarding investigation into the care her late mother received in a care home.

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The Ombudsman’s role and powers

  1. 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)
  2. 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

  1. I have:
  • considered the complaint and discussed it with Mrs X;
  • considered the correspondence between Mrs X and the Council, including the Council’s response to the complaint;
  • offered Mrs X and the Council an opportunity to comment on a draft of this document.

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What I found

What happened

  1. Mrs Y went into a care home in 2013. In 2015, Mrs X became concerned about the care Mrs Y was receiving.
  2. Mrs X first raised a complaint with the Council in February 2016. More complaints followed and the Council held a safeguarding strategy meeting in April 2017. One of the concerns related to the actions of a nurse at the care home. The outcome being that the nurse should be reported to the relevant professional body. The manager of the care home was tasked with this. It was agreed the NHS Clinical Commissioning Group (CCG) would follow up with the care home to ensure it had been done.
  3. Mrs X received the minutes of the safeguarding meeting in May 2017. She did not feel the minutes were a true reflection of discussions had at the meeting, so she complained to the Council. The Council amended the minutes and Mrs X received an amended copy in January 2018.
  4. Mrs Y sadly passed away in 2017.
  5. Mrs X expected the Council would confirm the actions agreed at the safeguarding meeting had been completed. She did not receive confirmation that the nurse had been reported to the professional body, so she contacted the professional body to enquire if it had received a report. It said it had not. Mrs X felt particularly strongly about this and says there is little point in a safeguarding investigation if the agreed outcomes are not acted on.
  6. Mrs X has been chasing the council for the last two years about this. She has written 19 letters in total.
  7. Mrs X received a response from the Council on 29 March 2019. I have seen a copy of this letter. The author confirms a safeguarding investigation was completed, and several issues were considered, one of which related to the actions of a nurse, who should be reported to a professional body.
  8. The author said a social worker contacted the care home and was told this action had been carried out, but it had since discovered it had not. The author said, “I appreciate the Local Authority could and should have been more proactive in following up in respect of your ongoing concern that this action had not been completed and I know that this has been distressing for you”. The author apologised to Mrs X.
  9. The author partially upheld Mrs X’s complaint saying, although the Council was not directly responsible for nursing standards, it expected this would be monitored by the CCG. She went onto say “However, the Local Authority does have an ultimate responsibility to ensure that the outcomes of the safeguarding proceedings were carried out, and should have been more proactive in confirming that the then manager of the nursing home had made the report and that the CCG were following up with NMC to confirm their actions”. The author said the Council had now contacted the care home and the professional body to confirm its actions.


  1. The Council accepts it had a responsibility to ensure the outcomes from a safeguarding investigation were completed, and that it failed to do so. It apologised to Mrs X.
  2. Mrs X has been put to significant time and trouble chasing the Council for a response for over two years. This is wholly unacceptable and has had a profound effect on Mrs X. I note the Council failed to apologise for this.

Agreed action

  1. The Council will within four weeks of the final decision:
  • provide Mrs X with a written apology for its failure to respond to her concerns about the outcome of the safeguarding investigation and its failure to respond to her repeated correspondence about this. In acknowledgment, the Council should pay Mrs X £500
  • pay Mrs X £250 for the time and trouble she has been put to pursuing the complaint with the Council and the Ombudsman.

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Final decision

  1. There is evidence of fault in this complaint. The Council failed to respond to Mrs X’s concerns about the outcome of a safeguarding investigation into the care her late mother received at a care home. It also failed to respond to Mrs X’s repeated correspondence about this.
  2. The recommendations above are a suitable way to settle the injustice caused to Mrs X.
  3. It is on this basis; the complaint will be closed.

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Investigator's decision on behalf of the Ombudsman

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