Privacy settings

LGO logogram

Review your privacy settings

Required cookies

These cookies enable the website to function properly. You can only disable these by changing your browser preferences, but this will affect how the website performs.

View required cookies

Analytical cookies

Google Analytics cookies help us improve the performance of the website by understanding how visitors use the site.
We recommend you set these 'ON'.

View analytical cookies

In using Google Analytics, we do not collect or store personal information that could identify you (for example your name or address). We do not allow Google to use or share our analytics data. Google has developed a tool to help you opt out of Google Analytics cookies.

Hertfordshire County Council (16 002 388)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 28 Sep 2017

The Ombudsman's final decision:

Summary: The Ombudsmen found that a Council and Trust failed to take appropriate action to prevent a vulnerable service user from abuse. The Council and Trust accepted that they had got things wrong and undertook extensive work to improve local policies and procedures. However, the Ombudsmen have made some further recommendations to address their outstanding concerns.

The complaint

  1. The complainant, who I shall call Ms N, is complaining about Hertfordshire County Council (the Council) and Hertfordshire Partnership University NHS Foundation Trust (the Trust). Ms N complains that the Trust and Council failed to safeguard her cousin, Ms D.
  2. Specifically, Ms N complains that:
  • The Council and Trust failed to put in place appropriate safeguards to protect Ms D from financial abuse by a support worker (Support Worker F).
  • The Council and Trust attempted to take Ms D into care without informing her family.
  • Staff from the Council were aware of the financial abuse, but took no action to prevent it. Ms N said this led to a delay before Support Worker F was suspended from duty. Ms N says another officer reported an incident of theft, but the Council took no action.
  • The Trust alleged that she had given Support Worker F a clue to Ms D's pin number, but this did not occur until after the thefts had taken place.
  • The Council and Trust failed to investigate her complaint appropriately resulting in lengthy delays.
  • The Trust's independent investigation report was flawed and inaccurate.
  • The Trust and Council have not taken appropriate remedial actions to prevent similar problems occurring for other service users.

Back to top

The Ombudsmen’s role and powers

  1. The Ombudsmen investigate complaints about ‘maladministration’ and ‘service failure’. We use the word ‘fault’ to refer to these. If there has been fault, the Ombudsmen consider whether it has caused injustice or hardship
  2. If the Ombudsmen find evidence of fault causing injustice, they may suggest a remedy. Recommendations might include asking the organisation to apologise or to pay a financial remedy, for example, for inconvenience or worry caused. We might also recommend the organisation takes action to stop the same mistakes happening again (Health Service Commissioners Act 1993, section 3(1) and Local Government Act 1974, sections 26(1) and 26A(1)).
  3. The Ombudsmen cannot question the merits of an administrative decision or professional judgment when there is no evidence of fault in how the decision was reached.

Back to top

How I considered this complaint

  1. In considering this complaint I had a telephone discussion with Ms N and considered the written materials she sent me. I made enquiries of the Council and Trust and considered their comments and supporting evidence, including the clinical records and staff comments.
  2. I took account of relevant law, statutory guidance, and local policy. I also considered comments from Ms N, the Trust and the Council on my draft decision.

Back to top

What I found

  1. The Mental Capacity Act 2005 (the MCA) applies to people who may lack mental capacity to make certain decisions. Section 42 of the MCA provides for a Code of Practice (the Code) which sets out steps organisations should take when considering whether someone lacks mental capacity.
  2. Both the MCA and the Code start by presuming individuals have capacity unless there is proof to the contrary. The Code says all practicable steps should be taken to support individuals to make their own decisions before concluding someone lacks capacity. The Code says people who make unwise decisions should not automatically be treated as not being able to make decisions. Someone can have capacity and still make unwise decisions.
  3. The Code says, at paragraph 2.11, there may be cause for concern if somebody repeatedly makes unwise decisions exposing them to significant risk of harm or exploitation. The Code says this may not necessarily mean the person lacks capacity but further investigation may be required.

Court of Protection

  1. If a person is deemed to lack capacity and there is a need for ongoing decision-making powers, the Court of Protection may appoint a deputy to make decisions for that person. It will state what kinds of decisions the deputy has the authority to make on the person’s behalf. The Office of the Public Guardian (OPG) produces detailed guidance for deputies.

Best interest decisions

  1. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be done, or made, in that person’s best interests. Section 4 of the Act provides a checklist of steps that decision-makers must follow to determine what is in a person’s best interests. This includes considering the views of other people close to the person lacking capacity.
  2. If there is a conflict about what is in a person’s best interests, and all attempts to resolve the dispute have failed, the Court of Protection might be asked to decide what is in the person’s best interests.

Key facts

  1. Ms D had Alzheimer’s Disease and came under the care of the Trust’s Specialist Mental Health Team for Older People (SMHTOP). This integrated team provided health and social care for people with Alzheimer’s Disease. At that time, all staff within the team were employed and managed by the Trust.
  2. Ms D lived alone at home and received daily care visits from a domiciliary care agency. In addition, a support worker (Support Worker F) from the SMHTOP began to visit Ms D regularly. Ms D also saw another officer from the SMHTOP regularly until 2010.
  3. Ms D was able to go out in the community accompanied by friends and also received regular visits from Ms N.
  4. On 13 January 2010, Support Worker F recorded that she had visited Ms D and found her looking at a bank statement. She said Ms D seemed confused about several large debits, including one of £1,000.
  5. As a result, a social worker (Social Worker P) visited Ms D on 5 February 2010 accompanied by Support Worker F. Social Worker P reported that Ms D told her she often paid for things (such as meals) when she went out with her friends.
  6. On 8 February 2010, the Council convened a safeguarding strategy meeting. The meeting agreed Social Worker P or Support Worker F would ask Ms D’s permission to involve the police. However, it is unclear whether this happened.
  7. The Council subsequently received contact from Ms D’s bank manager on 20 August 2010. He reported that Ms D’s friend had accompanied her to the bank and been very aggressive towards her. The bank manager also reported that the husband of Ms D’s friend had asked bank staff for Ms D’s PIN number. He said her condition seemed to be declining and that he was concerned she may be vulnerable to financial abuse.
  8. Social Worker P visited Ms D on 3 September 2010. She was again accompanied by Support Worker F. Social Worker P assessed Ms D’s capacity to manage her finances and found she did not have full capacity. She recorded that Ms D ‘was not able to acknowledge the risk of financial abuse.’
  9. The Council convened a further safeguarding strategy meeting on 16 September 2010. This meeting agreed Ms D no longer had capacity to manage her finances and that the Council would apply to the Court of Protection (CoP) to become her Deputy.
  10. On 23 September 2010, the Council asked the bank to impose restrictions on Ms D’s account while Deputyship was pending. The bank agreed to cancel Ms D’s debit card and ensure that she would be unable to withdraw money unless accompanied by Social Worker P or Support Worker F.
  11. However, in November 2010, Ms N said she would be prepared to become Ms D’s Deputy. This process was eventually completed in 2012.
  12. In September 2012, Ms N noticed a number of suspicious transactions on Ms D’s bank statements. She was concerned that these could only have been made by Support Worker F. This was based on Ms N’s belief that only Support Worker F had regular, unsupervised contact with Ms D and access to her bank card. She contacted Social Worker P on 18 September 2012 to express concern that Ms D may be the victim of financial abuse.
  13. In the meantime, responsibility for social care for older service users with dementia was transferred back to the Council from the Trust. As a result, Ms D’s case was allocated a new social worker (Social Worker T).
  14. Ms N met with the police on 27 September 2012 to discuss her concerns.
  15. Ms N’s concerns led to a safeguarding strategy meeting on 26 October 2012. The police reported a number of suspicious transactions going back over a year. The meeting concluded that Ms D had been the victim of financial abuse, but that ‘there is currently not enough evidence to point to any one person.’
  16. However, the meeting heard that Ms D no longer had mental health needs and that there was no longer any reason for Support Worker F to visit her. The meeting agreed Social Worker T would ‘conclude [Support Worker F’s] involvement with [Ms D].’ Despite this agreement, Support Worker F continued to visit Ms D.
  17. A professionals meeting on 20 December 2012 heard that some of the transactions related to equestrian supplies and that Support Worker F owned a horse. The meeting agreed to provide this information to the police.
  18. This led to a further safeguarding strategy meeting on 2 January 2013. The police said there were sufficient grounds for an investigation. The police said they would interview Ms D and, if necessary, her domiciliary carers and Support Worker F.
  19. The Council subsequently advised the Trust (Support Worker F’s employer) that her actions were subject to investigation. Shortly after this meeting, the Trust placed Support Worker F on paid leave.
  20. At a further safeguarding meeting on 11 January 2013, the Trust confirmed that Support Worker F would be suspended from duty shortly.
  21. On 1 December 2014, Support Worker F was convicted of theft. The charges related to four service users, including Ms D. She was subsequently given a 10 month prison sentence.
  22. On 22 December 2014, the Trust dismissed Support Worker F.


  1. Ms N complained that the Council and Trust failed to put in place appropriate safeguards to protect Ms D from financial abuse by Support Worker F. In addition, Ms N complained some staff were aware of the financial abuse, but took no action to prevent it. Ms N said this led to a delay before Support Worker F was suspended from duty. Ms N says another officer reported an incident of theft by Support Worker F, but no action was taken. Furthermore, Ms N complained that both organizations failed to take appropriate remedial action to prevent similar problems occurring for other service users.
  2. The Trust’s investigation identified several significant areas for improvement. The Trust acknowledged and apologised for the impact this had on Ms D and Ms N. I have considered these issues below, along with Ms N’s other complaints. I have also considered the appropriateness of the actions arising from the Trust’s investigation.

Attempt to gain control of Ms D’s finances

  1. Ms N complained that the Social Worker P and Support Worker F did not consult her before taking measures to gain control of Ms D’s finances. She said these officers began the process of applying for Deputyship through the Court of Protection without involving Ms D’s family. Ms N said this left Ms D increasingly vulnerable to financial abuse. Furthermore, Ms N disputed the Trust’s view (as set out in the investigation report of September 2015) that the thefts could have been prevented if the Council had applied for Deputyship in 2010 as originally planned.
  2. On 20 August 2010, Social Worker P received a call from Ms D’s bank manager. She noted ‘staff have noticed recently [that] when [Ms D] has come into the bank she has been with a friend that they feel is very aggressive towards [her] and getting money out.’ Social Worker P went on to note that ‘[t]he friend’s husband also went into the bank asking for the PIN number to the account.’
  3. This led Social Worker P to carry out a capacity assessment the following month. She concluded that ‘[Ms D] does not have full capacity to manage her finances…She was not able to acknowledge the risk of financial abuse’.
  4. On 16 September 2010, the Council convened a safeguarding strategy meeting. As those present were concerned Ms D may be at risk, they decided Social Worker P would apply for Deputyship through the CoP via the Council. In the meantime, Social Worker P asked the bank to impose restrictions on Ms D’s account to prevent her from accessing her account unless accompanied by her or Support Worker F.
  5. The case records show the professionals involved in Ms D’s care were understandably concerned about her vulnerability to financial abuse. In the context of ongoing concerns about the behaviour of Ms D’s friends, it was appropriate for the professionals to initiate safeguarding proceedings and to assess Ms D’s capacity to manage her finances.
  6. However, I found no evidence to suggest the Council or Trust involved Ms N in decision-making around Ms D’s finances at that stage, even though she visited Ms D regularly and was known to those caring for her. Nor did they inform Ms N of their intention to apply for Deputyship at that stage. This is fault on the part of both the Trust and Council.
  7. Ms N subsequently became aware of the situation and offered to take on the Deputy role herself. This process was eventually completed in 2012. I am satisfied the decision to apply for Deputyship had no significant impact on Ms D, therefore, as this did not ultimately come to fruition.
  8. In 2014, the Council undertook an audit of its processes for managing Deputyships and Appointeeships in the area.
  9. Following this, in 2015, the Council introduced guidance entitled Deputyship and Appointeeship Guidance For Care Management Staff. This guidance contains a section on whether it is necessary for the Council to become a Deputy. This clarifies that ‘[s]afeguarding is not a reason to apply for Deputyship or Appointeeship. Other measures to assist the service user to safeguard their funds should be taken.’ The guidance goes on to say ‘If there is a relative, friend, or another organisation…If there are any other options it is not appropriate for [the Council] to take on the role. [The Council] should always be considered as the last resort.’ The Council also explained that it now monitors staff compliance with these protocols.
  10. The Council and Trust failed to involve Ms N in decision-making around Ms D’s finances following a safeguarding meeting in August 2010. I partly uphold Ms N’s complaint in this area and have recommended that they apologise for this.
  11. However, I am satisfied the Council now has guidance in place for staff to prevent similar problems occurring in future.

Lack of action by Social Worker P

  1. On 30 August 2012, Social Worker P recorded that she had spoken to Ms N. She noted that Ms N had found spending on a bank card that had supposedly gone missing and so ‘advised her to cancel card and call Police.’
  2. On 18 September 2012, Ms N visited Ms D’s bank and requested copies of account statements. She identified a number of suspicious transactions. Ms N was concerned that Support Worker F may be responsible as only she had regular unsupervised access to Ms D and her bank card during this period. She reported her concerns about the transactions to Social Worker P shortly after this, though she did not voice her suspicions about Support Worker F at time. Ms N says this is because she was concerned Social Worker P may also be implicated.
  3. Social Worker P passed Ms N’s email to Support Worker F requesting an explanation for the expenditure on Ms D’s account.
  4. On 27 September 2012, Ms N approached the police with her concerns, this time making clear her suspicions about Support Worker F. The police made a safeguarding referral that day. Also on that day, Support Worker F responded to Ms N’s email, providing various explanations for the expenditure.
  5. The Trust’s investigation considered Social Worker P’s handling of Ms N’s concerns. The investigation criticised her decision to pass Ms N’s initial concerns to Support Worker F for comment. It found Social Worker P failed to initiate safeguarding proceedings, despite Ms D’s vulnerability and her previous safeguarding history. In addition, the investigation found Social Worker P failed to escalate the matter to her line manager, even though Ms N had by this point contacted the police with her concerns.
  6. This represents fault on the part of both the Trust and Council (as Social Worker P’s employment transferred from one agency to the other during this period). I uphold Ms N’s complaint that the Social Worker P failed to take appropriate action when she raised concerns that Ms D was the victim of financial abuse.
  7. Nevertheless, it is important to be clear that it is not for the Ombudsmen to decide whether a crime has been committed. This is for the police to determine. I note the police interviewed Social Worker P as part of their investigation and decided not to take any action against her.

Lack of action by Social Worker T

  1. The Trust’s investigation also considered the actions of Social Worker T to whom Ms D’s care was transferred in September 2012. The investigation found Ms D’s case had been discussed at an initial safeguarding strategy meeting on 26 October 2012. This was attended by representatives of the Council (including Social Worker T) and a police officer. However, the Trust was not invited to attend.
  2. The meeting agreed that there was no clear suspect for the thefts. However, the meeting noted that Ms D no longer required mental health support and that Social Worker T would conclude Support Worker F’s involvement with Ms D. The Trust was Support Worker F’s employer and the commissioned provider of mental health services in the area. Despite this, Social Worker T did not refer the matter to the Trust for action.
  3. It was not until a further safeguarding meeting on 20 December 2012 that professionals began to feel that Support Worker F may be implicated in the thefts. Following another meeting on 2 January 2013, the Council contacted the Trust.
  4. The Council convened a further safeguarding meeting on 11 January 2013. This meeting heard that Social Worker T had made a ‘softly softly’ approach to Support Worker F in an attempt to end her involvement with Ms D, but that she ‘had no direct authority to stop [Support Worker F] from seeing [Ms D].’ The Trust advised that Support Worker F had now been placed on paid leave, but that it would explore whether suspension would be more appropriate.
  5. As a direct result of the Council’s failure to refer the matter to the Trust, Support Worker F remained involved in Ms D’s care and continued to visit Ms D unsupervised until December 2012. This is fault on the part of the Council and placed Ms D at continued risk of abuse. I uphold this aspect of Ms N’s complaint.
  6. Ms N also complained that the Social Worker T failed to visit Ms D at all from the point that she took over the case in September 2012.
  7. The Trust addressed this issue in a complaint response dated 5 April 2016. The Trust explained that Social Worker T had been allocated to Ms D’s case as lead investigator in the safeguarding process. It said that, in that capacity, she would have visited Ms D only if care workers or family raised concerns.
  8. The records suggest Social Worker P only became significantly involved in Ms D’s case as a result of her bank manager raising concerns. There is no indication that she required social worker support as part of her day-to-day care. Similarly, I have seen no evidence to suggest the situation had changed by the time Ms D’s case transferred to Social Worker T.
  9. Social Worker T participated appropriately in the safeguarding process and I found no evidence in the case notes to suggest Ms D required a visit. I consider the Trust’s response to be reasonable in this respect.
  10. Social Worker T completed a risk assessment for Ms D in October 2012. This noted that Ms N had LPA for Ms D’s finances and that this reduced the risk to her. However, the police agreed to approach Ms N to ask her to limit the amount of money that could be withdrawn using Ms D’s cards.
  11. There is evidence in the records to suggest Social Worker T made efforts to reduce the risk of abuse in Ms D’s case, therefore. However, I accept this was counterbalanced by her failure to notify the Trust about the emerging safeguarding concerns.
  12. The Trust’s investigation report acknowledged that the safeguarding response was inadequate in Ms D’s case. The Trust’s investigator recommended the Trust arrange an event to provide staff with detailed feedback from the report and encourage shared learning. The investigator also recommended that the Trust and Council work together to take learning from the failure of staff to comply with the safeguarding process (by failing to escalate Ms N’s concerns and failing to involve the Trust (as Support Worker F’s employer).
  13. On the face of it, these recommendations are reasonable. However, I found no evidence in the complaints correspondence to suggest the Trust and Council shared the outcome of their work in these areas with Ms N. I have made recommendations to address this, therefore.

Lack of effective supervision

  1. The Trust’s investigation identified numerous failings in terms of staff supervision during this period. The investigator found that management arrangements within the SMHTOP were largely in a state of flux from 2010 until September 2012.
  2. During that period, the Trust’s investigation found Support Worker F was able to operate largely without line management oversight as the manager with responsibility for this was seconded or on sick leave for a protracted period. The investigation also found that Social Worker P should have been supervising Support Worker F’s caseload but that she was largely content to delegate responsibility for managing Ms D’s finances to Support Worker F.
  3. The Trust’s findings reflect a wider lack of supervision and accountability that allowed the support worker to act with impunity. It is likely, in my view, that more effective supervision would have identified irregularities in Support Worker F’s approach and given the Trust an opportunity to take action. This was a missed opportunity and represents fault on the part of the Trust. I uphold this aspect of Ms N’s complaint.
  4. The Trust’s investigation found that the Trust had done considerable work to improve line management and clinical supervision in recent years. The investigation noted that a clear ‘supervision tree’ is now in place and that all staff have named supervisors.
  5. I share the Trust’s view that it is difficult to entirely prevent determined criminal activity. Nevertheless, I consider the improved supervisory arrangements to be an important step to prevent similar problems occurring in future. I have recommended that the Trust provide further information about how it will audit this improved structure on an ongoing basis.

Previous incidents

  1. The Trust’s investigation report identified two incidents that demonstrated how Support Worker F’s practice differed from that of her colleagues. On one occasion, two colleagues (Support Worker B and Support Worker C) described having witnessed Support Worker F withdrawing a service user’s money unaccompanied. In the other incident, a service user’s money had gone missing from the office safe. The Trust’s investigation reported that a member of staff had told a senior manager he had seen Support Worker F using the office safe unsupervised. The report said no further action was taken. Ms N said these incidents represented missed opportunities to identify poor practice earlier.
  2. I obtained further information from the Trust in relation to both of these incidents. Neither Support Worker B nor Support Worker C could recall when the first incident took place. They said they had felt it was not a good idea for Support Worker F to be alone with a service user’s money for her own protection. Support Worker B and Support Worker C did not report the incident to a manager as there was no procedural requirement to work in pairs at that time.
  3. The second incident took place in December 2009. On this occasion, Support Worker B and Support Worker C went to put some money in an envelope in the office safe only to discover the envelope was missing.
  4. At this time, the office safe key was kept in the desk draw in the secretaries’ office. Although the draw was kept locked at night, this was not always the case if the secretaries were absent for periods during the day. The procedure at that time was for staff to sign the keys out in a book kept by a member of the secretarial team.
  5. The Support Worker B and Support Worker C reported this to a manager who completed an incident report form and referred the matter to the police. Support Worker B also reported an occasion on which he had seen Support Worker F with the keys to the safe despite not having signed the book.
  6. The police investigation did not locate the money and found insufficient evidence on which pursue a criminal case. However, the Trust told me it tightened security procedures to prevent staff taking the keys without signing for them. The procedural changes were also intended to prevent staff opening the safe unless in the presence of witnesses.
  7. Support Worker B and Support Worker C both said that, while they considered Support Worker F’s working practices to be irregular, they did not feel her behaviour was suspicious.
  8. These incidents show the Trust did not have suitably robust procedures in place at that time for the management of service user’s finances. In addition, they represented missed opportunities to address Support Worker F’s unconventional working practices through supervision. This is fault and I uphold Ms N’s complaint on this point.
  9. It is important to note that responsibility for managing service user’s finances has now passed back to the Council. Nevertheless, the Trust has taken action to improve supervisory arrangements. I am satisfied these improvements should prevent a situation occurring by which a member of staff is able to operate without effective supervision for such a protracted period.
  10. In response to my enquiries, the Trust also provided me with a copy of its Service User Finance Policy (2016). Part 1 of this policy sets out certain compulsory conditions for staff managing service user finances.
  11. Under this policy, staff are not permitted to retain service user bank cards or PIN numbers and must not hold cash for a service user (unless asked to do so by the service user).
  12. The policy also includes compulsory guidance for the use of safes. This sets out that access to safes and secure storage will be limited and a list maintained of all staff who will have access. The guidance says that combination codes and keys must not be accessible to staff who are not on this list. The guidance says PIN numbers must not be stored with bank cards and that the contents of the safe must be reconciled on a weekly basis.
  13. In my view these are robust measures that should minimise the chance of similar procedural abuses occurring in future.

Decision to place Support Worker F on paid leave

  1. The Trust’s investigation noted that the decision to place Support Worker F on paid leave was in keeping with Trust suspension policy of the time. However, the investigator acknowledged that this meant Support Worker F was able to continue to access Trust systems and records unchallenged. Nevertheless, the investigator concluded that this was reasonable given that the Trust had not by that point seen all of the evidence implicating Support Worker F.
  2. Council managers met following the safeguarding meeting on 2 January 2013. It was at this meeting that the Council decided it would be appropriate to involve the Trust. The meeting also agreed that action would be taken to block Support Worker F’s access to the care notes.
  3. Shortly after this, the Trust placed Support Worker F on paid leave pending a further safeguarding meeting. This took place on 11 January 2013 and resulted in the Trust suspending Support Worker F.
  4. Section 7(1) of the Health Service Commissioners Act 1993 (the legislation that governs the work of the Health Service Ombudsman) prevents the HSO from considering complaints about ‘[a]ction taken in respect of appointments or removals, pay, discipline superannuation or other personnel matters.’ For this reason, I am unable to reach a view on how the Trust dealt with this issue under its personnel procedures.
  5. However, I will comment in the broader safeguarding context. The decision to place Support Worker F on leave meant she was faced with fewer restrictions than would have been the case if she had been suspended immediately. This meant there was a period of several days during which she was free to access Trust premises and visit service users, including Ms D. This placed vulnerable service users at risk and potentially risked compromising the ongoing police investigation.
  6. Given the seriousness of the allegations, the Trust and Council should have carried out a risk assessment. This would have allowed professionals to consider whether any further action was necessary to prevent Support Worker F having access to service users, colleagues or work premises during this period of leave. That they did not do so is fault, in my view.
  7. The records suggest Support Worker F did not visit Ms D again during the period of leave. With this in mind, I am satisfied there was no substantial injustice arising to her from this fault.
  8. The Trust addressed this issue in its investigation report. The investigator recommended that the Trust should support any safeguarding or police investigation, but should also carry out a parallel investigation to ‘ensure prompt action is taken to safeguard and protect the interests of service users and establish whether there are any potential disciplinary consequences for individual members of staff.’
  9. In January 2017, Hertfordshire Safeguarding Adults Board produced revised safeguarding guidance entitled Safeguarding adults at risk (2017). This includes details of the local Serious Concerns Process to be used ‘when the care and support being delivered by a specific provider is, or may be, causing a service user, or a number of service users, abuse or neglect.’ This process emphasises the importance of holding an urgent multi-agency professionals meeting (or, if this is not possible, a telephone conversation) to discuss any serious concerns. The process also sets out that a risk assessment must be completed at every such meeting and clearly recorded. In my view this should minimise the possibility of similar problems occurring again in future.

Lack of remedial action

  1. Ms N complained that, despite the Trust’s investigation findings, the Trust and Council have not taken appropriate remedial action to prevent similar problems occurring for other service users.
  2. I have largely addressed this in my consideration of Ms N’s various complaints above. However, Ms N also raised more general concerns about the suitability of local procedures for the management of finances for service users with cognitive impairment (such as dementia).
  3. Sections 4 to 7 of the Trust’s Service User Finance Policy (2016) set out clear directions for staff managing service users’ finances. This includes the process for supporting those service users considered to have capacity to manage their own finances. This emphasises that staff should support a service user to make purchases where possible and that any staff-supported purchases should be documented in the service user’s case records.
  4. The policy recommends that an Appointee or Deputy should be sought where the service user is considered to lack capacity. As I have previously explained, the Service User Finance Policy (2016) makes clear that the Trust or Council should not undertake this role unless all other options have been considered.
  5. The policy also recognises that there may be ‘exceptional situations’ whereby either a service user has capacity but requires extra protection, or the service user lacks capacity but an Appointeeship is not yet in place. The policy states that staff should only handle a service user’s money if ‘there is no other viable alternative’ and that staff should hold a service user’s cash only for immediate or short-term needs (no longer than seven days).
  6. It is not possible to eliminate the risk of determined criminal activity entirely. However, I am satisfied that, taken with the work it has undertaken to improve staff supervision, the Trust has put in place appropriate measures to reduce this risk.

PIN number

  1. Ms N complained that the Trust’s investigation suggested she had given Support Worker F a clue to Ms D's pin number and that this had facilitated the thefts. Ms N said she had given a clue to the PIN, because she was afraid Ms D would forget the number and be unable to access her money. However, Ms N said she did not give Support Worker F the clue until after the thefts had taken place.
  2. The Trust told me this had simply been intended as a factual statement and that it had not intended any offence.
  3. The Trust’s investigation report states that ‘[t]here is no evidence that [Ms D] or [Ms N] ever actually gave [Support Worker F] the PIN but she knew how to prompt [Ms D] to remember the number, from the advice given by [Ms N].’
  4. This suggests Support Worker F was able to access Ms D’s money more easily as a result of information provided by Ms N.
  5. However, while Ms N did advise Social Worker P how to prompt Ms D if she forgot her PIN number, she did not do so until 1 September 2012 (by email). By this point, Support Worker F had already been stealing from Ms D for over a year.
  6. The Trust’s report is misleading in this respect, therefore. This is fault and I uphold this aspect of Ms N’s complaint.
  7. I do not believe the Trust intended to deliberately imply that Ms N was culpable in any way for Support Worker F’s actions. Nevertheless, Ms N understandably found the Trust’s comments distressing. I have addressed this in the ‘recommendations’ section of this report.

Flawed investigation

  1. Ms N complained that the Trust's independent investigation report was flawed and inaccurate. Ms N also queried how independent the report was given that it was commissioned by the Trust.
  2. Ms N shared in detail her concerns about the report in an email to the Trust on 29 November 2015. I have addressed the key issues above in my consideration of Ms N’s specific points of complaint. In addition, I took Ms N’s comments into account when compiling the ‘key facts’ section of this decision statement.
  3. However, I do not consider it necessary to comment on all of the concerns Ms N outlined in her detailed submission to the Trust. In my view, it would not be proportionate to do so.
  4. As I have explained above, I have identified some fault in addition to that highlighted in the Trust’s investigation report. I also identified some areas where the Trust and Council could provide some further information to Ms N. I have addressed these areas in my recommendations.
  5. The Trust’s investigation identified significant failings on the part of both the Council and Trust. I have seen no evidence that lead me to doubt the impartiality of the investigation, albeit I appreciate Ms N was dissatisfied with the report.

Complaint delays

  1. Ms N said the Council and Trust failed to investigate her complaint appropriately resulting in lengthy delays.
  2. The records show Support Worker F was convicted in December 2014 and sentenced in February 2015. A Trust manager advised Ms N in an email on 21 January 2015 that the Trust would be undertaking a Root Cause Analysis to explore whether it could take any learning from the situation. He explained the Trust had not yet done this work as it was awaiting the outcome of the legal process. The manager also explained that he was in the process of drafting the terms of reference for the investigation.
  3. Following the suspension of Support Worker F in January 2013, it took over two years for the legal process to come to a conclusion. Nonetheless, I find no fault with the Trust’s decision to delay its substantive investigation pending the outcome of the legal process, particularly given the serious allegations involved.
  4. In a subsequent email on 5 March 2015, the manager advised that he had allocated the case to an investigator. He then contacted Ms N again on 8 May 2015 to explain that he had reallocated the case to an external investigator.
  5. There was a delay of around four months following the manager’s email of 21 January 2015 before the case was allocated to a suitable investigator and the investigation began. The manager acknowledged in his emails that this process took longer than hoped and apologised for this.
  6. The complexity of the case and the fact that it involved several service users inevitably contributed to this delay. In the circumstances, I consider the manager’s apology to be a reasonable response to Ms N’s evident frustration.
  7. The Trust’s investigator issued her report in September 2015, around four months later. In my view this was a reasonable timescale for completion of what was an extremely detailed report. I find no fault on the part of the Trust in this regard.
  8. Ms N’s concerns were registered as a formal complaint on 2 February 2016. The Trust provided a substantive response on 5 April 2016, just over two months later. Again, I consider this timescale to have been reasonable given the detail contained in the Trust’s investigation report and Ms N’s counter-response of 29 November 2015.
  9. The Trust’s consideration of Ms N’s complaint was not ultimately completed until April 2016, almost three years after the conclusion of the original safeguarding investigation. It is understandable that Ms N found this delay frustrating.
  10. Nevertheless, a large part of this delay was attributable to the protracted legal process. I agree it would not have been appropriate for the Trust to pre-empt or circumvent this process. There were further delays, as explained above, but I consider these to have been understandable in the context of what was a very large and complex complaint.

Back to top

Agreed actions

  1. I found two areas of fault in addition to those identified in the Trust’s investigation report. The first of these relates to the Trust’s inference that Ms N facilitated Support Worker F’s thefts by providing her with a hint to Ms D’s PIN number. The second area is the Council’s failure to involve Ms N in discussions around Ms D’s finances in August 2010.
  2. In addition, in my view the Trust and Council could share some further information with Ms N about the work they have done to improve local procedures in the years since the events she is complaining about took place.
  3. The Council and Trust have agreed to share this information now. They will work together to provide Ms N with a joint response incorporating the following agreed actions:
  4. Within three months of my final decision statement, the Trust will:
  • Apologise to Ms N for incorrectly implying that Support Worker F was able to steal from Ms D as a result of Ms N sharing a hint about Ms D’s PIN number.
  • Write to Ms N to explain how it will audit line management and supervision structures on an ongoing basis to ensure these remain robust and that staff are familiar with supervision arrangements.
  1. Within three months of my final decision statement, the Council will:
  • Apologise to Ms N for their failure to involve her in decision-making around Ms D’s finances following a safeguarding meeting in August 2010.
  1. Within three months of my final decision statement, the Trust and Council will:
  • Arrange a reflective practice event to discuss the report findings and share learning. The Trust and Council will share the outcome of this event with Ms N, along with any learning taken from it.
  • Explain to Ms N any actions they have taken, or will take, to ensure staff compliance with local and national safeguarding guidance. This should include details of how they monitor staff compliance with this guidance. In the case of any outstanding actions, the Trust and Council should provide a clear timescale for completion.
  1. The Council and Trust will copy the Ombudsmen into their further correspondence with Ms N.

Back to top

Final decision

  1. The Trust’s investigation report identified several significant failings in the care provided to Ms D and the conduct of the subsequent safeguarding investigation. These reflect fault on the part of the Trust and Council.
  2. However, I am broadly satisfied that the actions taken by the Trust and Council to remedy matters are appropriate and proportionate.
  3. I identified two further areas of fault that were not addressed in the Trust’s investigation report. The Trust and Council have agreed to take action that I consider will remedy the injustice arising from this fault.
  4. I have now completed my investigation on this basis.

Back to top

Parts of the complaint that I did not investigate

  1. Ms N complained that a Council manager contacted her in October 2012 to persuade her that Support Worker F was innocent and ask her to ‘move on’. The Trust did not address this issue during the local resolution process.
  2. The Council manager did make a contemporaneous note of a conversation with Ms N on 9 October 2012. However, this makes no reference to the comments Ms N describes. Rather, the manager’s note suggests the discussion focused on the actions of Ms D’s friends (who had been the subjects of the initial safeguarding alerts).
  3. There is a clear disparity between Ms N’s recollections and the manager’s notes. In the absence of any independent evidence to help me establish what took place, I do not consider an investigation would be likely to resolve this matter. For this reason, I have not included this issue in the scope of my investigation.

Back to top

Investigator's decision on behalf of the Ombudsman

Print this page