Summary: There was no significant fault in the Council’s handling of a safeguarding enquiry. For this reason, we have completed our investigation.

The complaint

1. The late complainant, to whom I will refer as Mr J, is represented in his complaint by his daughter, to whom I will refer as Mrs G.
2. Mr J spent approximately two weeks at a Council-owned rehabilitation facility, Killelea House (to which I will refer as ‘KH’), in September and October 2019, before being admitted to hospital. After his admission, Mrs G made a combined safeguarding referral and service complaint about KH to the Council.
3. Mrs G complains:

• the Council’s initial set of findings was flawed, were based entirely on evidence gathered from KH, but the Council revised its findings when she submitted her own evidence;
• the Council still did not substantiate one safeguarding point – that Mr J had suffered a pressure sore – despite evidence from the hospital to support this;
• the Council failed to involve her in the safeguarding enquiry process;
• the Council pressured her into not making a complaint; and
• the Council has not taken adequate steps to improve its service.

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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 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)
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. I reviewed the Council’s safeguarding report, its case notes, and its correspondence with Mrs G.
7. I also shared a draft copy of this decision with each party for their comments.

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What I found

8. The following chronology gives an overview of key events relevant to this complaint. It does not detail every instance of correspondence between the various parties.
9. Mr J was admitted to hospital on 17 September 2019. On 20 September, he transferred to KH for a period of rehabilitation. He remained there until 3 October, when he was readmitted to hospital. In November, Mr J passed away.
10. Mrs G raised a safeguarding enquiry with the Council on 4 October. On 5 October, she submitted a written statement to the Council, raising other points of complaint about KH.
11. As recorded by the Council, Mrs G’s safeguarding allegations were that:

• Mr J had gone several days without pain relief at KH;
• he was not fed properly there;
• his food supplements had been locked away and not given to him;
• KH had failed to contact a dietician to discuss Mr J; and
• that he had developed pressure sores at KH.

12. Mrs G’s other points of complaint were that:
• she had been unable to meet a manager at KH;
• KH had not informed Mr J’s family the doctor had made an urgent referral for him;
• KH had not given the family a chance to attend his doctor’s appointments at the home;
• he had been served food which was too hot and presented a risk of scalding; and
• that Mr J had only showered once during his stay at KH.
13. The Council convened a strategy meeting on 8 October. The enquiry was allocated to an officer, to whom I will refer as Officer C. Officer C began making enquiries with KH and the hospital.
14. On 26 November, Mrs G emailed Officer C. Officer C replied on 28 November to express her condolences for Mr J’s passing. She said a meeting with KH had gone ahead as planned, but she had some further questions for both it and the hospital. Once she had received these, she would then be able to arrange an outcome meeting. Officer C asked if Mrs G would like to attend the meeting or receive a written response.
15. Officer C then entered a note on 2 December to say Mrs G had asked for a written response, before deciding whether to attend an outcome meeting.
16. There were several further exchanges of emails between Officer C and Mrs G in December, with Mrs G expressing concern about the length of time the enquiry was taking.
17. On 17 December, Officer C emailed Mrs G. She explained she had hoped to have finished the enquiry by this point, but due to ongoing concerns about the information she had received, and other urgent work in which she was involved, this had not been possible. Officer C said she was arranging a meeting with KH for the following day, but would explain her interim findings to Mrs G, to demonstrate the enquiry had not been neglected. Officer C also confirmed her work would be signed off by a senior officer before being finalised.
18. Officer C’s interim findings were:
• to uphold the concern about a lack of pain relief. She said KH had taken steps to address this issue, but she needed further clarification from the hospital and Mr J’s GP, as some of the evidence she had received was contradictory;
• the evidence showed Mr J ate regularly at KH, although not always well, and so she would not uphold the concern about meals being missed. However, KH had missed some information about Mr J’s food intake on the hospital discharge notification, which should have triggered some monitoring and possible contact with a GP or dietician;
• KH could not give Mr J the nutritional supplements as he had not been prescribed them. It had contacted his GP and had been awaiting a response. It was appropriate for the supplements to be locked away in the meantime, to prevent vulnerable residents from accessing them;
• KH had not contacted a dietician for the reasons Officer C had already explained, although KH had not formed any independent concerns about Mr J’s food intake. Officer C explained she was treating KH’s failure to properly process the discharge sheet as a serious concern;
• the hospital had confirmed Mr J had no pressures sores upon admission. KH had also commented that Mr J was independently mobile during his stay and was therefore not at high risk from pressures sores;
• records confirmed Mr J had only had one shower during his stay, but this was not a concern if a resident had regular personal care instead. KH had confirmed it offered residents a shower daily, but had not kept records to show when these were refused, which it was now rectifying. Officer C said she had seen Mr J was largely independent with personal care while he was at KH;
• the manager at KH had explained that, if family members wished to speak to her when she was unavailable, staff should take contact details to allow her to call them. Mrs G could not recall which staff member had failed to do this, so she could not investigate, but when Mrs G had asked to speak to her on 3 October, after she had left, an appoint was appropriately made for the following morning. There had also been some confusion about staff roles and the different types of manager at KH;
• KH had confirmed it could not discuss confidential health matters with family members where the resident had mental capacity, without their express permission, and so it was appropriate for it not to have informed Mr J’s family of the referral. However, it accepted this was a matter which could be discussed with residents on admission, and was considering making a change to its admission paperwork to this end;
• the GP’s visit to Mr J was part of a routine round, and so there was no appointment to notify the family of. KH had confirmed it would notify family members when the GP would be visiting the home, where residents had confirmed they wished this to happen, but there was no record whether this had been discussed with Mr J. This was another improvement to the admission paperwork KH would consider;
• KH had a policy for ensuring food temperature was in a safe range, but there were no records that temperatures had been checked for Mr J before his food was served. KH had addressed this with its staff and the Council would monitor to ensure this was implemented;
• records showed Mr J had only complained of pain twice during his stay, on one early occasion while he was received pain relief, and at the end of his stay when he spoke to the GP, prior to returning to hospital. The hospital had already made referrals about Mr J’s anaemia and so there was nothing further for the GP to do about this.
19. Officer C apologised for the time it had taken her to provide Mrs G with her interim findings, but said it was unavoidable due to her workload and that it was a busy period for the hospital and care home. She also explained she had not wished to give Mrs G information about her findings prematurely, as this may have caused her further concern. Officer C said she was still waiting for some details before she could formalise her findings, and asked Mrs G for her comments on the interim findings.
20. Mrs G emailed Officer C on 18 December. She said she had comments to make on the findings, and that she felt a “full review of [Mr J’s] documentation should have been a priority to allow [Officer C] to deal with [her] complaint” and that Officer C’s findings would change once she had done this. Mrs G said she would await Officer C’s full report so she could then discuss her concerns at a meeting. She also asked for a copy of the Council’s complaints policy.
21. Officer C replied the same day. She said her visit to KH would now take place in January, because there was no mutually available date for her to meet the relevant staff member there before then. Officer C confirmed she had reviewed a large amount of information, but there were additional points she wished to clarify before reaching a final decision, and as she was relying on information from the hospital and GP she could not give a firm date for when this would be. Officer C asked Mrs G to provide her comments now, so she could consider them, and gave her a weblink to the Council’s complaints policy.
22. Mrs C responded with a document explaining her disagreement with Officer C’s interim findings. She also quoted the timescales set out in the Council’s complaints policy and said the enquiry had not adhered to this. In response, Officer C explained this was a safeguarding enquiry, not a complaints investigation. She said another officer had explained the safeguarding process to Mrs G on 4 October, although she acknowledged Mrs G should have received an update after the strategy meeting, which she had said she was unable to attend.
23. Mrs G emailed again to ask how the matter was being handled, if not as a complaint. She also said she did not recall speaking to another officer on 4 October. Officer C again explained the difference between a safeguarding enquiry and a complaint and said she had seen a note of Mrs G’s telephone call with the other officer.
24. Officer C emailed Mrs G again on 6 January 2020 to update her, and explained she was hoping to visit KH on 13 January. Mrs G replied to complain that it had now taken three months since she made her referral, and that given this was a “complaint” this delay was not acceptable. In response, Officer C explained the Council would not consider three months to be unduly long for a safeguarding enquiry of such complexity, and reiterated the difficulty she had had finding a mutually available date to visit KH.
25. Further emails of this nature were exchanged between Officer C and Mrs G. Mrs G also approached the Caldicott Guardian, who discussed the matter with Officer C and agreed she would finalise her report within a week even if she had not received the necessary additional information, with a caveat to explain this.
26. On 13 January, Mrs G had a phone call with Officer C’s manager, to whom I will refer as Officer T, during which she discussed her complaints about Officer C. Officer T assured Mrs G the case had not been neglected, but explained safeguarding enquiries could be lengthy.
27. On 16 January, the Council provided a copy of the full draft safeguarding report to Mrs G. In summary, its findings were:
• it was a significant concern that Mr J’s pain relief had been missed. This was caused, in part, by contradictory information provided by the hospital and Mr J’s GP about whether he had been prescribed paracetamol or co-codamol. KH also wrongly believed Mr J’s prescription was ‘as required’ when in fact he was supposed to take paracetamol four times per day. Although his prescription had run out and KH was waiting for its to be refilled, paracetamol was available anyway and should have been given to Mr J. However, the records indicated Mr J was independent through his stay and it was believed he would have requested paracetamol if he had been in pain;
• KH had overlooked information to suggest Mr J needed additional support and monitoring with his food intake. However, there was no evidence this contributed to a deterioration in his health;
• it was appropriate for KH to have locked away the nutritional supplements which Mrs G had brought in. KH had sought advice from Mr J’s GP about whether he should have the supplements, but this was just before his readmission to hospital and so no reply was received. However, it was a concern there had been no information from the hospital about the supplements when Mr J was discharged from there;
• there was no evidence Mr J had pressures sores on his admission to hospital;
• there was no evidence Mr J’s personal hygiene needs were not met during his stay at KH, and it was his decision whether to shower or rely on washes instead;
• KH could not confirm whether any requests by Mr J’s family to meet a manager were not met, and would changes its processes to avoid this problem;
• KH would not normally share medical information, such as that a referral had been made, with family members, where the resident in question had mental capacity. This was the case with Mr J, and there was no reason to believe he was unable to discuss the referral with the family if he had wished. However, the GP’s notes did indicate he was expected KH to inform Mr J’s family, and work was necessary to reinforce information sharing procedures;
• it was not possible to confirm whether Mr J wished his family to be informed of the GP’s visit, and there was no evidence KH had failed to follow procedures, but it was acknowledged residents may forget to impart information about visits to their families;
• it could not be confirmed whether KH served food which was too hot. Its policy was only to check the temperature of food which had been frozen, but it was acknowledged all hot food should be checked to ensure it was a safe temperature;
• there was no evidence the GP had failed to act on Mr J’s reports of pain or his anaemia.
28. The report listed a range of improvements for KH to make.
29. On 6 February, the Council convened a safeguarding outcome meeting, which Mrs G attended. The findings on the various points were discussed, and Mrs G was invited to comment on them.
30. Officer C continued to make enquiries with the hospital and GP over February and March, to clarify the prescription and nutritional supplement matters. The safeguarding enquiry was formally closed on 31 March.
31. On 24 February, Mrs G emailed a senior Council officer. She said he had attended a safeguarding outcome meeting on 6 February, but had concerns about the conduct of the meeting, the accuracy of the minutes and the quality of the safeguarding enquiry. She also said she had received confirmation from the Patient Advice and Liaison Service (PALS) that Mr J had a pressure sore on admission to hospital on 3 October.
32. There followed some discussion between Mrs G and the Council whether she wished to appeal the outcome of the safeguarding enquiry, or pursue a complaint. In May and June, after delays the Council explained were due to the Covid-19 pandemic, it agreed a statement of complaint with Mrs G.
33. The Council formally responded to Mrs G’s complaint on 23 June. It provided a detailed investigation report, with a covering letter to summarise its key findings.
34. The Council said there was no evidence KH had lied or attempted to cover up any mistakes. It acknowledged there had been considerable difficulty in understanding what had happened with Mr J’s medication, but KH had now employed a pharmacist because of this.
35. The Council also said it considered KH had struggled to explain its policy on checking food temperatures, although it was satisfied it had followed the policy in place at the time. The policy had now been amended and staff had received further training.
36. The Council acknowledged KH had not informed the family of Mr J’s referral, for which it apologised.
37. The Council explained Mr J had been screened for possible malnutrition at KH, but staff had missed information from the hospital which should have led to a monthly monitoring of his food intake. Given Mr J was only at KH for two weeks, however, this made no substantive difference.
38. The Council reiterated the improvements it had made at KH, and that Mrs G’s concerns had been discussed with Officer C as part of a debriefing. The Council said it had brought in its safeguarding practice consultant to provide support and audits of the team’s work, and that further training modules had been arranged for team members.
39. The Council asked Mrs G to discuss the contents of its report with her family, and offered to arrange another meeting if there was anything else they wished to discuss.
40. On 9 July, Mrs G referred her complaint to the Ombudsman.

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Legislative background

Adult safeguarding

41. Local authorities must make enquiries, or ensure others do, if it reasonably suspects an adult who has care and support needs is, or is at risk of, being abused or neglected, and is unable to protect him- or herself because of those needs.
42. The local authority is the lead agency for making enquiries but can ask others to undertake them.
43. An enquiry is the action taken or instigated by the local authority in response to a concern that abuse or neglect may be taking place.
44. An enquiry could range from a conversation with the individual who is the subject of the concern to a much more formal multi-agency arrangement.
45. The purpose of an enquiry is to decide whether or not the local authority or another organisation, or person, should do something to protect the vulnerable adult from any actual, or risk of, abuse or neglect.

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Analysis

46. Mrs G has raised several points of complaint, which I will address in turn.
47. First, I must make clear it is not my role to reinvestigate the substantive safeguarding issues Mrs G raised as part of her referral, or draw my own conclusions on the evidence the Council gathered as part of its safeguarding enquiry. These are matters of professional judgement. My role is instead to look at the procedures the Council followed during the enquiry, to identify any possible administrative fault, and to determine whether that fault may have caused an injustice.

The Council’s initial set of findings were flawed, were based entirely on evidence the Council gathered from KH, and were revised when Mrs G submitted her own evidence

48. There were, in effect, three different points in the process where the Council discussed its findings with Mrs G – Officer C’s email with her interim findings in December 2019, the formal draft report in January 2020, and the outcome meeting in February.
49. It is evident that Officer C’s findings in December were heavily summarised. Her email makes clear the enquiry was ongoing, that she was still waiting for evidence to be returned to her, and that Mrs G was able to make comments on the findings (and in fact, she encouraged her to do so then, rather than waiting for the full draft report to comment, as Mrs G had said she would do).
50. The draft report then provides an extremely detailed account of the evidence Officer C had gathered, her interpretation of it, and the rationale for her findings. The minutes of the outcome meeting show these findings were discussed, and Mrs G’s comments were noted and recorded.
51. I appreciate Mrs G had some criticism of the interim and draft findings; but, fundamentally, I do not see there was any significant change in the substance of the Council’s decision between the different stages. It had substantiated virtually everything Mrs G had raised as part of her referral (with the exception of the question of pressure sores, which I will discuss separately), and proposed a lengthy list of improvements to be made to avoid these issues arising again. Although the formal report included some additional consideration and commentary on the evidence, I do not consider it is right to say the Council changed its findings simply because of evidence Mrs G had provided.
52. I also do not accept Mrs G’s criticism the Council’s initial findings were based purely on KH’s view. It is inevitable that any enquiry of this nature will involve asking the relevant person or organisation for their records, as well as their recollections of events – and investigations by the Ombudsman usually work in a similar way – but there is no reason to believe the Council simply, and uncritically, accepted KH’s opinion on the matter.
53. In fact, the evidence shows the opposite to be true. Officer C went to significant lengths to process the evidence she received, and made further enquiries with each of the bodies involved where she was not yet satisfied with their responses. This is precisely what the Ombudsman would expect. I see no reason to criticise the Council here.
54. There is one small issue, where I must question the Council’s decision. Right at the beginning it identified that approximately half of the issues Mrs G had raised were not safeguarding matters, but actually service complaints about KH – for example, those about the availability of management, and the failure to pass on information about Mr J’s referral. This being the case, I find it unusual the Council did not separate these issues off and deal with them as a normal complaint, which would appear to be the more logical approach.
55. This is not, in my view, a significant point, and so I do not propose to find fault on this basis. Nor do I consider there is any possible injustice arising from this, as the Council thoroughly investigated these points anyway, and provided Mrs G with (presumably) the same responses it would have done under its complaints procedure. But I do note Officer C commented on the complexity of the enquiry, and I am left questioning whether it could have been simplified by separating it into safeguarding and non-safeguarding matters.
56. Despite this, I find no fault here.

The Council did not substantiate the point about pressures sores, even after the hospital confirmed this

57. As part of her safeguarding referral, Mrs G said Mr J had had pressures sores on arrival at hospital.
58. Officer C made enquiries with both the hospital and KH about this. The evidence she received from the hospital was that no pressures sores had been noted when Mr J was admitted to hospital. KH also confirmed it had no record Mr J had developed pressure sores, and commented that, as he was independently mobile, he was not at high risk of this anyway.
59. However, after the end of the safeguarding enquiry, Mrs G provided evidence she had received from PALS, which said the hospital’s records showed Mr J did have a pressure sore on arrival. The Council acknowledged this discrepancy during the complaints process, and said it would follow it up with the hospital.
60. As part of my enquiries, I asked the Council for any further evidence it had received about the apparent pressure sore. In response, the Council gave me a copy of an email it received from the hospital in June.
61. The hospital confirmed it had initially identified a red area on Mr J’s sacrum (the area of skin at the base of the spine) as a ‘grade 1 pressure sore’. However, nurses subsequently decided this was instead an area of redness or a moisture lesion, not a pressure sore. This appears to explain the contradiction in the evidence the hospital provided.
62. The Council has also provided a copy of KH’s daily log from 3 October, shortly before Mr J’s admission to hospital. This records in detail an incident where staff had changed his incontinence pad and completed personal care, and recorded specifically there was no evidence of “marks” in this area.
63. Taking this together, the Council decided there was no further action it needed to take on the pressure sore issue.
64. It is unfortunate the hospital provided contradictory evidence, but I cannot criticise the Council for relying on this information in the first instance; and, as soon as it had reason to question the evidence, it made appropriate follow-up enquiries. This is good practice and I see no reason to find fault.
65. My only criticism here would be that the Council does not appear to have updated Mrs G, when it received the further evidence from the hospital in June. This may be because both the safeguarding and complaints processes were complete by that point, and so there was no active investigation involving Mrs G, but either way, it would have been better if the Council had informed her of the new evidence it had received. However, I do not consider this point to be so significant as to justify a finding of fault.
66. I find no fault here.

The Council failed to involve Mrs G in the safeguarding process

67. Mrs G raised the safeguarding referral on 4 October. On 5 October, she submitted a detailed written statement, elaborating on the referral, as well as adding new points.
68. The Council held its strategy meeting, where it considered Mrs G’s referral and statement, and decided enquiries should be made, on 8 October. I can see Mrs G was invited to this meeting, but unfortunately she was unable to attend.
69. Thereafter, it was for the Council to gather evidence from the various relevant bodies, interpret this evidence, and draw its conclusions and prepare a report. Although I appreciate Mrs G was anxious to know what the Council was doing, there was nothing for the Council to involve her in at this stage, especially given the detail she had already provided in her original referral and written statement.
70. It is unfortunate the evidence-gathering process was somewhat drawn out here. However, as I have said, the matters Mrs G had raised were complex, and required Officer C to make repeated enquiries with a number of different bodies. The length of the enquiry appears only to reflect the thoroughness with which the Council looked into the referral.
71. I note Mrs G considers Officer C neglected the enquiry, and hoped Mrs G would drop the matter when Mr J died. I find these allegations to be without foundation. Mrs G began chasing the matter towards the end of November, after the enquiry had been ongoing only for six or seven weeks. This is an entirely reasonable timeframe for a complex safeguarding enquiry, as is the three to four months it eventually took for it to be completed.
72. I also note again Officer C gave Mrs G the opportunity to make comments on her findings even before she had issued a draft report.
73. I must say I am not convinced this was necessarily wise; the purpose of making draft findings is to allow interested parties to comment on the full detail of the proposed decision, and providing a summarised version in advance – which does not fully examine or explain the evidence – may cause confusion.
74. But, either way, I do not consider it can reasonably be said the Council failed to involve Mrs G in the enquiry process.
75. I find no fault here.

The Council pressured Mrs G into not making a complaint

76. Mrs G says, at the end of the outcome meeting, a senior Council officer asked her to stay behind. She says the officer then asked her not to make a complaint about the safeguarding team, as team members were new and still learning.
77. I was not present for this conversation, and there is no objective record of it, so I cannot make a finding on this point. Either way, I am satisfied Mrs G was able to submit a complaint, which the Council took seriously and to which it provided a very detailed response.
78. I make no finding here.

The Council has not taken adequate steps to improve its service

79. There are two aspects here – the improvements which have been put in place at KH, as a result of the findings of the safeguarding enquiry, and improvements the Council has made to the safeguarding process itself, as a result of Mrs G’s complaints.
80. With regard to the improvements at KH, I asked the Council to summarise these for me. In response, it said it had:
• employed two pharmacists to monitor medication daily;
• instituted 24hr nursing cover to review residents on admission, as well as providing daily GP visits;
• put in place a clinical lead to provide assurance to the CQC;
• trained all staff in food hygiene, and recording the temperature of all food;
• instituted monthly file audits and daily rounds by managers;
• instituted weekly weighing of residents;
• instituted monthly assurance meetings to review incidents, and improve and update processes where necessary;
• provided a new electronic incident recording system; and
• arranged further training for staff on medication and vital signs.
81. As I have said, it is not my role to draw my own conclusions on the safeguarding matter, and by extension this means it is not for me to decide what specific improvements need to be made. I am satisfied, however, the changes described here are very comprehensive and thorough. It is very difficult to see what more the Council could do to prevent recurrences of the issues which arose at KH.
82. With regard to the safeguarding process itself, the Council says its staff have undergone new training on various aspects of the process; and that it is also in the process of updating its standard safeguarding paperwork, including its enquiry checklist, and an information sheet for people about whom a safeguarding referral has been made, explaining how the process works.
83. I must say, and despite the Council’s acknowledgement of various points Mrs G has raised, I actually do not consider there is anything of significance to criticise in its handling of the enquiry. It made extremely thorough enquiries, drew logical conclusions from the evidence it gathered, took the problems it had identified seriously, and has produced a comprehensive list of improvements. It also provided Mrs G with various opportunities to contribute, and considered her comments.
84. This being the case, it is unlikely I would independently recommend any of the changes the Council has made here. Despite this, it is positive to see the Council decided to take Mrs G’s complaint as a prompt to refresh and reinforce staff training anyway. Again, the range of improvements it has made / is making appear comprehensive, and I do not see what more could reasonably be expected.
85. I find no fault here.

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Final decision

86. I have completed my investigation with a finding of no fault.

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Investigator's decision on behalf of the Ombudsman