Summary: Mr B complained about the way the Council handled a Safeguarding Adult Review (SAR), following a serious injury sustained by his brother, Mr C, whilst in residential care. The SAR found significant fault in the Council’s safeguarding investigation. We find fault in the way the SAR report was publicised and the way in which it involved Mr B in the process. This caused Mr B a significant amount of time and trouble and distress pursuing the issues raised. The Council has agreed to apologise to Mr B and Mr C, pay Mr B £1000, tell us and Mr B what improvements it has made to its safeguarding investigation process and arrange a meeting with the agencies involved in the SAR as the SAB originally intended to do.

The complaint

1. Mr B complains about West Sussex County Council’s (the Council) handling of the Safeguarding Adult Review (SAR) following a serious injury sustained by his brother, Mr C, whilst in residential care. Specifically, Mr B complains that:
• the Safeguarding Board investigation did not meet the agreed scope, especially regarding point one of the terms of reference. Following publication of the investigation report, the independent chair and the Board refused to address whether the injuries could have been prevented;
• the families of those affected were not involved in the investigation and did not have sufficient opportunity to consider the report and provide feedback;
• issues of collusion and cover up were not properly addressed by the investigation;
• conflicts of interest were not managed appropriately;
• the Director for Adult Services promised an independent investigation; but Mr B says they have only had a safeguarding investigation;
• the Council has not changed its culture and practice;
• the contracts team provided clear misinformation during the review;
• he has been wrongly labelled as vexatious, obsessed and unreasonably persistent in his communications with the Council; and
• the Safeguarding Adult Board (SAB) assured the families that it would meet with the agencies involved following the publication of the review, but has since refused to do so.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I have considered the complaint and the documents provided by the complainant, spoken to the complainant, made enquiries of the Council and considered the comments and documents the Council provided. I have written to Mr B and the Council with my draft decision and considered their comments.

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What I found

5. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)

Safeguarding process

Stage 1: Raising an alert

6. Everyone has responsibility to raise an alert if they have concerns for the welfare of a vulnerable adult. Concerns should be raised immediately with the person responsible for dealing with safeguarding alerts.

Stage 2: Referral

7. The decision to make a referral will normally be made by the person responsible for dealing with safeguarding alerts such as the care home manager and should be done promptly.

Stage 3: Strategy meeting / discussion

8. A multi-agency meeting should be coordinated by the Adult Safeguarding Manager in Adult Social Care. This should involve discussions with a range of professionals, including the police where a possible criminal offence has taken place.
9. The purpose of the meeting is to:
• consider the wishes and needs of the adult at risk;
• decide whether an investigation/enquiry will take place and if so, how it should be conducted and by whom;
• undertake a risk assessment;
• agree an interim protection plan;
• make a clear record of the decisions;
• record what information is shared;
• agree an investigation plan with timescales;
• agree a communication strategy; and
• circulate decisions to all invitees.
10. The meeting is usually just attended by professionals; the vulnerable adult, family and the alleged perpetrator are not typically involved at this stage.

Stage 4: Investigation / Enquiry

11. The scope of the investigation/enquiry is determined at the strategy meeting.
12. It will not necessarily be a council officer who undertakes the investigation depending on the circumstances of the case. For example the police will take the lead where allegations of a criminal offence have been made and a health professional may investigate allegations of abuse in a hospital.
13. The purpose of the investigation/enquiry is to:
• establish the facts about the incident(s) in which abuse is alleged or concerns raised;
• assess the support and protection needs of the vulnerable adult(s);
• determine who was responsible for the alleged abuse and what action should be recommended in relation to them; and
• review the management of the setting/service and consider improvements or sanctions;

Stage 5: Case conference

14. A case conference should then be held to:
• consider information obtained during the investigation;
• plan further action if the allegation is substantiated/partially substantiated/not substantiated/inconclusive;
• make decisions about the level of current risk and judgement about any future risk;
• agree a protection plan; and
• agree how the protection plan will be reviewed and monitored.
15. Usually all parties will be invited to the case conference. The case conference should reach a finding on whether abuse or neglect has occurred. This is one of the main functions of a safeguarding investigation.

Stage 6: Review the protection plan

16. The review should ensure that the actions agreed in the protection plan have been implemented and decide whether further action is required including any service improvements.

Stage 7: Closing the safeguarding process

17. The process can be closed at any stage if it is agreed that an ongoing investigation/enquiry is not necessary or if an investigation/enquiry has been completed and a protection plan put in place. Typically, the safeguarding process is brought to a close at the case conference or following a review of the protection plan.

Safeguarding Adult Boards (SAB)

18. These bodies are non-statutory partnerships. They have an independent chair appointed by the local authority whose role is to bring together local statutory and independent sector organisations, service users and carers to work together to safeguard adults from risk of harm.
19. The role of an SAB is broader than just protecting adults at risk. It is responsible for:
• ensuring multi-agency safeguarding adults policies and procedures are effective and prevent adults from experiencing significant harm;
• raising awareness and promoting the welfare of vulnerable adults; and
• carrying our safeguarding adult reviews.
20. In comparison to the local authority safeguarding investigation, a SAB has a wider and more general role to develop and implement local policies and promote awareness about adult safeguarding matters.

Safeguarding Adult Reviews (SAR)

21. Under the Care Act 2014, a SAB must decide when a Safeguarding Adults Review (SAR) is necessary, arrange for its conduct and if it so decides, implement the findings.
22. SARs replace serious case reviews. The SARs are about learning lessons for the future. They will make sure SABs get the full picture of what went wrong, so that all organisations involved can improve as a result. The purpose of a SAR is not to reinvestigate or apportion blame but to establish where and how lessons can be learned and services improved.
23. SABs must arrange a SAR when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult. SABs must also arrange a SAR if the same circumstances apply where an adult is still alive but has experienced serious neglect or abuse. SABs can also arrange a SAR in other situations where it believes there will be value in doing so.

Sussex Safeguarding Adult Boards SAR protocol May 2017

24. This document says that individuals and their families/carers will be notified that a review is being undertaken. Where appropriate the SAB will make arrangements for them to participate in the SAR, but their consent is not required for the SAR to go ahead. They should be kept updated at key stages of the review and notified of the publication of the report.
25. The protocol also says that the SAB will have discussions with the individual and their family/carer about publication where appropriate.

What happened

26. Mr B’s brother, Mr C suffers from severe physical and learning disabilities and requires help with every aspect of his personal care. He lacks capacity to make decisions about medication, clothes and food. Mr B is his representative and advocate. Mr C was living in a care home (the Home) run by Sussex Health Care (the Provider). He had been placed there by a different Council.
27. On 31 March 2015 Mr C suffered a serious injury (a leg fracture) at the Home. He was admitted to hospital the following day and the Council received a safeguarding alert. Another resident also received a similar injury at the same time and was admitted to hospital.
28. The hospital had concerns about how the similar injuries to two residents from the same care home had occurred. It considered they could be non-accidental and raised safeguarding alerts with the Council.
29. The Council agreed to gather information and review on 8 April 2015 to decide if a safeguarding meeting was needed. It asked the manager of the Home to undertake an investigation.
30. On 10 April 2015 the Council held a safeguarding enquiry meeting, involving the police. It did not invite the hospital. The Provider attended but Mr B was told he could not attend due to issues of confidentiality over the other resident. The Council also suspended the Home’s contract for new referrals.
31. On 14 April 2015, moving and handling advisors from the Council carried out a monitoring visit to the Home and a member of staff informed them that staff had moved Mr C on their own. A member of staff, who had worked with Mr C, was suspended. The Council identified concerns with the Home’s moving and handling procedures.
32. On 23 April 2015 the Council held a second safeguarding meeting, which Mr B attended. He said Mr C would not be returning to the Home. The hospital provided evidence from staff involved in treating the residents. This was inconclusive as to whether the injuries were accidental but suggested it was highly unusual to see two similar injuries from the same place at the same time.
33. On 21 May 2015 the Council interviewed a member of staff supporting Mr C. On 8 June 2015, the Council also interviewed nurses from the Home (who had previously provided statements). A draft report was produced. It concluded that the injuries were probably caused as a result of a manual handling episode which was not in line with the guidelines in place at the Home.
34. In June 2015 two further safeguarding meetings were held, one in respect of each resident, to discuss the report. Various Council staff were present along with the independent chair of the SAB. Both families challenged the findings, highlighting the contradictions and the lack of certainty that they needed to help the victims understand why they were injured. Mr B was also concerned about the factual accuracy of the report and some witness statements. Both families considered the police should have led the investigation and were requesting the police should investigate. After the meetings they both reported the incidents to the police who began an investigation. Mr B also complained to the Council.
35. A further safeguarding meeting was held in July 2015; its aim was to reach a conclusion as to what had caused the injuries to the two residents. Neither of the families were invited. The minutes said the families were satisfied with the enquiry and the identified outcomes. They understood that the enquiry did not discover what actually happened but that lessons have been learnt. The Chair noted that there were some unanswered questions and recommended that the safeguarding investigation remained open pending the police investigation.

Council complaint responses

36. The Council responded to Mr B’s complaint about the safeguarding investigation in October 2015. It agreed the interventions by the Council’s contracts team and the moving and handling advisors could have been more co-ordinated. It said the police had been fully involved in the process and were now investigating, but it would consider further whether clearer protocols were required in cases of potential willful neglect. It confirmed the suspension on new referrals to the Provider was still in place. It defended its decision not to invite Mr B to the meeting in July 2015, on the basis that a CQC inspection had just taken place and it was a sensitive period for the Provider. It also agreed the minutes of the meeting were not accurate in terms of the seriousness of the incidents and the responsibility of the Provider.
37. Mr B was dissatisfied with the response and sent a further complaint on 28 November 2015. The Council responded in December 2015. It defended its decision to invite the Provider to the initial planning meeting in April 2015 as necessary to ensure the safety of adults within the Provider’s homes. The Council did not consider it prejudiced the enquiry. The response covered many points and repeatedly referred to the ongoing police investigation. It said once this was concluded there would be a further safeguarding meeting to receive feedback, to learn the outcome of the police investigation and ensure the safeguarding plan was appropriate and robust. It said it would invite Mr B.

SAR process

38. In October 2015, the Council recommended the SAB should carry out a SAR. Initially the SAB said the case did not meet the criteria for an SAR. The independent chair disagreed and said in January 2016 that it would revisit the issue once the police investigation was complete.
39. The Council held a sixth safeguarding meeting in May 2016. Mr B was not present. The police provided an update and said the file had been sent to the Crown Prosecution Service. In July 2016, the Independent Chair commissioned a SAR. It found authors in September 2016.
40. In November 2016, the police investigation and safeguarding enquiry closed. The police investigation concluded there was insufficient evidence to reach a criminal threshold. Neither the safeguarding enquiry nor the police investigation was able to conclusively prove how the injuries occurred.
41. In December 2016, the original authors of the SAR withdrew due to disagreements with the methodology and scope of the review. In February 2017, a new author was found. In May 2017 the police carried out a separate review into issues at other homes run by the Provider so the SAR was suspended. It recommenced in August 2017 and the final report was published on 17 April 2018.

SAR report

Terms of reference

42. The SAR’s terms of reference consisted of 15 points. The first one was ‘whether or not the injuries to both men could have been predicted or prevented’. Although I note that later in the report it says: ‘One of the roles of the review is to consider if the injuries … could have been predicted and thereby prevented’.
43. The SAR also identified ten agencies had been involved in the care of the two men and asked each one to produce an individual management review detailing and assessing their involvement.
44. The report noted that the Council responsible for the other resident who was injured had last carried out a monitoring visit at the Home in March 2013 and no concerns were identified. The Council responsible for placing Mr C carried out a review in March 2015 and found that Mr C and his family were happy with the Home. CQC had last inspected the Home in 2014 and concluded it met the required standards.

Faults identified

45. The report criticised the Home’s implementation of its moving and handling training and procedure. It also said that Mr C’s care plan should have highlighted a condition which increased his risk of injury from these procedures and the Home should have indicated what measures it was using to mitigate that risk.
46. The report identified fault in the staffing procedures at the Home which meant the police had been unable to establish who had actually been working with Mr C when the incident occurred. This was concerning, as an unknown individual had been working with vulnerable adults.
47. The report noted that the Council did not take any immediate action to safeguard other residents and did not immediately inform the police, until 9 April 2015 when it invited them to the first safeguarding meeting, despite government guidance recommending early contact with the police where abuse is suspected.
48. The report criticised the Council for involving the Home too heavily in the early stages of the investigation, for not involving the police early enough, for withholding from the first safeguarding meeting, key information from the hospital about the unusual nature of the two similar injuries and the possibility that they were non-accidental. The report said that because the injuries were unexplained criminal intent should not have been ruled out at this stage.
49. The report criticised the Council’s assumption formed very early on, that the injuries were caused by manual handling and noted this was only based on feedback from the Home’s management. The report criticised the investigation for not considering all options at this stage including the possibility that both incidents had been deliberate acts of abuse.
50. The report noted the inconsistent and contradictory evidence obtained from care home staff, the different people involved in obtaining the evidence and the lack of direction or organisation in carrying out this key role. It said the enquiry was uncoordinated, contradictory and supported by badly recorded information. It criticised the investigation for not establishing in either case, the exact time the injuries occurred or who inflicted them.
51. The report also criticised the Council for misrepresenting the families’ views in the draft report and in the minutes of the meeting in July 2015.

Previous concerns raised

52. In order to fulfil the terms of reference, the SAR needed to establish if there were opportunities to identify any concerns raised in respect of both the Home and any other organisations run by the Provider, prior to 1 April 2015 and specifically in respect of manual handling.
53. The Council’s individual management review stated it had no recorded indications of any significant safeguarding concerns about the Provider’s care homes prior to 1 April 2015. But at a later date the Council provided a copy of draft minutes of a meeting held in April 2014. This showed that the Council discussed concerns about recurring safeguarding issues with the Provider’s learning disabilities services, including unexplained injuries. This did not include the Home. An action plan was produced but there was no evidence of any follow-up monitoring. The report considered that the Council should have raised these concerns with the SAB.

Family views

54. The report noted it was important to highlight how the injuries and the subsequent investigation had impacted on the individual and his family. It said the author had spoken to Mr C’s family on a number of occasions and also visited Mr C.
55. Mr B said that Mr C had experienced a traumatic and very painful event, and while he had settled into a new care home, he missed the friends he made at the Home. He also endured great pain and a long stay in hospital.
56. The families had expressed concerns about how agencies have responded to the injuries, they were dissatisfied with the outcomes and sceptical as to how effective the SAR would be in providing answers. They believed that the agencies involved had not been open and honest with them and were potentially colluding to hide the truth from them.
57. The author of the report said he had worked with the families to explain the function of the SAR and to make them aware that the review might not be able to obtain answers to all their questions, especially how the injuries occurred.

Conflict of interest

58. The families’ main concern was the influence they believe the Provider has had on the process, because the Council’s cabinet member for Adult Services was also a director of the Provider’s company.
59. Given that the Provider was a significant provider of care home places in the area, the family questioned the ability of the cabinet member to be impartial in respect of issues relating to the Provider, including possibly influencing the safeguarding enquiry.
60. The report said the review had not examined the role of the individual cabinet member. However it had not identified in the information provided to the SAR any direct or indirect involvement of the cabinet member. The cabinet member had resigned following the police investigation. The report highlighted the need for the Council to ensure that there is no conflict or perceived potential conflict when considering cabinet member positions.

SAR conclusions

61. The report summarised the failings of the safeguarding investigation in its conclusions:

The major lesson that comes from this Safeguarding Adults Review is the impact that failure to undertake a co-ordinated, evidence-led safeguarding and or criminal enquiry, has on the Adults who suffered the injuries, their families and in the long term to the reputation of agencies.

62. It said the safeguarding enquiry should have been able to provide an explanation as to how and why the injuries occurred. The failure to do so meant the families spent many hours seeking answers on behalf of the two residents. The Council should have involved the police at an earlier stage and considered other explanations beyond a moving and handling issue. It said the conclusions of the investigation report were not supported by evidence and were based on assumptions rather than fact.
63. It concluded that the serious traumatic injuries probably could not have been predicted.
64. The failings in the investigation also led the families to believe that there has been some form of collusion between agencies to supress the truth. This suspicion has caused a complete lack of trust in the process and prevented any closure for the families.
65. It also said the failure to follow-up the concerns raised in 2014 was a missed opportunity to introduce some oversight. But it found no evidence of collusion or improper influence on the outcomes of the investigation.

Recommendations

66. The report listed 14 recommendations for the SAB including:
• a four part specific recommendation ensuring the Provider improved its procedures and systems in respect of manual handling, responding to injuries and staffing;
• ensuring that policy, procedure, and training, highlights the need in potentially complex situations involving unexplained injuries to an adult at risk, that the police should be made aware as soon as possible.
• ensuring that all key staff involved in safeguarding enquiries have received specific training for the role of leading and coordinating effective enquiries, taking into account the evidence gathering requirements of organisations such as the police and the CQC and also taking into account the Person-Centred approach of the Care Act.
• ensuring that safeguarding enquiries are supported by clear action plans;
• ensuring that the adult or their representatives are fully engaged in a safeguarding enquiry in accordance with policy and procedures;
• ensuring that staff attending meetings review minutes to ensure that they accurately represent the meeting and the individuals’ input and challenge if they are not accurate.
67. The report also made two recommendations specifically for the Council:
• It should review the way it discharges its market management duty under the Care Act to ensure that it understands the quality of care being delivered in West Sussex and is able to support providers to improve where it identifies weaknesses.
• It should ensure that current governance arrangements in West Sussex County Council in respect of Members’ and Officers’ outside interests are consistent with Nolan Principles, and that safeguarding Lead Members should not hold outside interests with local provider organisations, that might appear to raise a conflict of interest with the post they hold.

SAR publication and involvement of Mr B

68. The SAB produced a timetable in February 2017 which originally intended the report to be published in July 2017. It included sharing the report with the families on 12 June 2017, meeting with the families the following week to receive feedback and discuss the report, arrange a meeting the following week between the agencies and the family members and then to publish the report on 3 July 2017. This timeframe was delayed due to a police investigation and changes of staff at the SAB.
69. On 28 March 2018 the SAB arranged a meeting to sign off and accept the SAR report. Representatives from the Council, the police, and the health service were present. Neither the Provider nor the families were invited. The author presented the report and much discussion was had around its content and conclusions. Amendments to the text were agreed at this stage.
70. The meeting also discussed the publication process. It planned to share the document with the Provider on 6 April 2018 on a confidential basis. It planned to hold a meeting on 17 April 2018 with family members to physically hand over the report and to publish the report later that day. There was significant discussion over this issue with differing views being expressed: the families should be given the opportunity read it and to correct inaccuracies, maybe a day; the Board had agreed the content of the report and it was not for the families to veto it; an opportunity should be given for them to ask questions. It was agreed that the families would be given the opportunity to meet shortly afterwards with senior officers, who are accountable and able to make changes, from all involved agencies.
71. The report was shared with the Provider on 5 April 2018. A meeting was held with the families at 10 am on 17 April 2018. The chair explained this was an opportunity for them to read through the report and ask questions. She said she was available for the next four hours for that purpose. She also confirmed there would be a wider meeting at a later date. Mr B raised concerns about possible conflicts of interest with the notetaker and the senior Council officer also present at the meeting. The chair explained why she would not accept Mr B’s offer of a notetaker. The report was published on the SAB website at 4 pm that day.

Post-publication issues

72. Mr B asked for his own notes of the meeting on 17 April 2018 to be substituted for those of the SAB notetaker whom he had accused of having a conflict of interest. He then complained that the SAB had not responded to his emails raising issues with the process, including his point that the terms of reference had not been met: specifically the report concluded the injuries could probably not have been predicted but was silent on the issue of prevention. He also made a number of subject access requests of different agencies.
73. The SAB responded to Mr B’s complaint in June 2018. It said the SAR report had been accepted by the Board and could not be changed, it would not substitute his notes for those of the SAB’s notetaker and it could not arrange an investigation into collusion and cover-up as it was outside its powers.
74. Mr B then requested the date of the meeting with the agencies. A subgroup of the SAB considered this request in July 2018. It recommended that the families should put forward their questions in writing in advance to the agencies.
75. The families refused to accept any conditions on the terms of the meeting such as providing questions in advance. They saw this as the SAB moving the goal-posts and reneging on its previous commitment repeated by the chair on 17 April 2018.
76. In August 2018 the subgroup recommended to the SAB that the SAR protocol for engagement with the family had been met and there was no need for a meeting. The chair and the SAB confirmed this decision in September 2018 and notified Mr B.

Vexatious complainant

77. In July 2018 the Council sent Mr B a letter saying his behaviour in respect of the complaint had been unacceptable and unreasonably persistent. It said Mr B had:
• interfered in the progress and findings of the SAR and questioned the independence of the SAB;
• carried out a campaign of disruption against the Council and its officers, making multiple complaints and requests for information;
• refused to use the single point of contact provided by the Council;
• refused to attend a meeting with the Chief Executive to discuss his concerns;
• made repeated unreasonable demands for contact with staff, councillors and SAB members and their employers; and
• made unsubstantiated allegations of incompetence, inappropriate behaviour, collusion and cover-up which were without foundation.
78. Mr B disputes the actions were fair or reasonable. He said he was forced to take action to highlight the faults in the process and hold people accountable.
79. The Council said it would not enter into further correspondence or conversation with Mr B on these issues.
80. It has said in response to our enquiries that it will not consider meeting Mr B again due to his conduct but it would review the terms of the restriction on his contact in January 2019.
81. Mr B has more recently raised a complaint about the independence of the officer designated as Mr B’s single point of contact. Mr B has evidence that in August 2017 the officer expressed a view that Mr B’s communications should be treated as unreasonably persistent and vexatious. Mr B claims this has affected the way all his complaints have been dealt with.

Ombudsman complaint

82. Mr B first complained to the Ombudsman about the safeguarding investigation in December 2015. He asked for an independent review of the Council’s actions. We started an investigation but discontinued it in March 2016 due to the police investigation. We said he could come back to the Ombudsman when these processes were complete.
83. He contacted us again in February 2017 when the SAR started, asking us to reopen the complaint. We confirmed we would wait until the SAR process was complete.
84. We re-opened the complaint in April 2018 following the publication of the report and contact from Mr B.

Analysis

the Safeguarding Board Investigation did not meet the agreed scope, especially regarding point one of the terms of reference. Following publication of the investigation report, the independent chair and the Board refused to address whether the injuries could have been prevented

85. Mr B is concerned that in respect of point one of the terms of reference the report only considered the question of whether the injuries could have been predicted (it concluded they could not have been predicted). But it did not consider whether they could have been prevented.
86. The Council says that the report could not conclude whether the injuries could have been prevented because it could not establish how they occurred. Mr B does not understand how the report can reach a conclusion on prediction but not prevention. The report’s author indicates his view is that the two issues are interlinked by his phrasing: ‘One of the roles of the review is to consider if the injuries … could have been predicted and thereby prevented’. But the conclusions only refer to the issue of prediction and were silent on prevention.
87. From the later explanations, it follows that the lack of certainty over how the injuries occurred meant the report could not reach a view on prevention. The injuries could have been caused by a manual handling fault or by a deliberate act of abuse and the issue of prevention would be very different in each of those scenarios, so I consider the Council’s explanation is not unreasonable. But I accept this was not explicitly stated in the report and it has left uncertainty for Mr B.
88. This was fault but I do not consider it was the main cause of the injustice to Mr B and Mr C. The SAR was a review not an investigation; its purpose was not to establish how the injuries had occurred, but to review the safeguarding investigation. Due to significant fault in the safeguarding investigation, it failed in its key role of clearly establishing, when, how and why the injuries occurred. This is the fault which has caused Mr B and Mr C significant injustice. The SAR clearly identified the fault but could not ‘correct’ it by establishing a cause at this late stage. I do not consider there is any benefit in continuing to investigate this issue: as it is very difficult to reach a safe conclusion so long after the events occurred and it will always be a matter of speculation.
89. Moving to the second part of this head of complaint I do find fault in the way the SAB handled the publication issue. If the families had been allowed a longer period to read and digest the report as was originally intended, they could have raised this issue with the SAB and the SAR author, and the text could have been amended to clarify the conclusion on prevention. This caused injustice to Mr B which I shall discuss in greater detail below.

the families of those affected were not involved in the SAR investigation and did not have sufficient opportunity to consider the report and provide feedback

90. The families were involved in the SAR in accordance with the protocol. I have seen two versions of this protocol: one from May 2017 and the second from June 2018. Both have the same requirements in respect of the involvement of families. I cannot find fault with the involvement in the investigation. It is clear from the report that the author spoke to the families, including Mr B and Mr C on several occasions and took their views into account in the final report.
91. But I agree that they did not have sufficient opportunity to consider the report and provide feedback. The original intention was to give the families the report one to two weeks before publication. This would have been in line with the time given to the Provider and would have given the perception that the families were being treated as an important part of the process. Several hours was insufficient time. The failure to allow at least a day, meant they had no opportunity to properly digest the content, formulate questions, provide feedback or suggest amendments to the text.
92. Mr B emailed the SAB within days of its publication to query the prevention/prediction issue. If he had been give more time prior to the publication it is likely this issue could have been addressed, by way of explanation and amendment.
93. The failure also compounded Mr B’s perception that the process was weighted against the families and led to his conviction that collusion and cover-up have influenced the outcome of the safeguarding investigation and the SAR.

issues of collusion and cover-up were not properly addressed by the Investigation and conflicts of interest were not managed appropriately

94. Although it was not specifically part of its scope, the SAR report said it had not found any evidence (either direct or indirect) of collusion or cover-up during the course of the investigation. In respect of the conflict of interest issue regarding the cabinet member it said there was no evidence that the member had been directly or indirectly involved in any way and noted that the member had resigned once the police investigation was underway. It also made a recommendation that the Council should carefully consider the appointment of cabinet members and the outside interests of safeguarding lead members. I cannot find fault with this approach.
95. Mr B has not presented any evidence to me to support his view that collusion, cover-up or conflicts of interest affected either the original safeguarding investigation or the SAR. He said the fact that the Council did not initially disclose relevant information to the SAR regarding concerns about the Provider, which the Council had raised in 2014, was evidence of cover-up. The Council said this fault was more to do with a misunderstanding about the requirements of the SAR. Without any additional evidence of deliberate withholding of the information or intent to do so, I cannot conclude there has been collusion or cover-up.

the Director for Adult Services promised an independent investigation; but Mr B says they have only had a safeguarding investigation

96. I note that Mr B raised this issue in December 2015 when he first complained to us. He said he was shocked that the Council in its complaint response had not recommended an independent investigation as that was what he had been promised by the Director for Adult Services at the time.
97. Since then the Council has completed a safeguarding investigation and the SAB has carried out an independent SAR. The police have also investigated and carried out a wider review of the Provider. The SAR acknowledged the failings in the original safeguarding investigation. I consider the SAR has remedied the injustice and I do not consider any further investigation is warranted or would provide any more answers.

the Council has not changed its culture and practice

98. The Council has acted on the findings of the SAR. Ongoing audits by the SAB regarding future safeguarding matters will provide opportunities to check that safeguarding alerts and investigations are dealt with properly.

the contracts team provided clear misinformation during the review

99. I have covered this issue above at paragraph 95. It was fault not to provide this information initially. But the key issue is the SAR had the information before it concluded and was able to include it in the report.

Mr B has been wrongly labelled as vexatious, obsessed and unreasonably persistent in his communications with the Council and the single point of contact is not independent

100. The Council is entitled to restrict contact in accordance with its policy where it considers a person’s behaviour is unacceptable in manner, frequency or degree. The Council’s letter to Mr B explained in detail the reasons for the restrictions.
101. However, I consider the Council has failed to acknowledge that a major driver of Mr B’s behaviour has been his perception that the Council has ‘got away with something’ due to the flawed nature of the original safeguarding investigation. As this failed to fulfil its purpose to find out what happened to Mr C on 31 March 2015, Mr B has been driven to continue to search for answers. This has led to approaches to members of the SAB (which the Council considers are inappropriate) and public accusations of conflicts of interest against people without any substantiating evidence of an adverse impact.
102. I note that despite the numerous failings identified by the SAR in the safeguarding investigation (which may have altered the Council’s views expressed in its original complaint responses in 2015), the Council has not written to Mr B to apologise or explain what steps it has taken to improve.
103. This search for answers has also been fuelled by Mr B’s perception of unequal treatment from the start of the process: for example by the inclusion of the Provider in the early stages of the investigation, the erratic gathering of information, the misrepresentation of Mr B’s views in the original safeguarding report, the failure to involve Mr B in the closure of the safeguarding investigation and the failure of the SAB to give Mr B adequate time to read the report before publication. The failure of the Council to acknowledge these issues and their impact is fault.
104. I do not consider the comments by the single point of contact officer are inappropriate or have affected the way in which the Council has dealt with Mr B’s complaints. Mr B has not provided any evidence to show how his complaints have been affected and the single point of contact primarily directs the complaints to the correct person to respond.

the SAB assured the families that they would meet with the agencies involved following the publication of the review, but has since refused to do so.

105. When the SAB decided to give the families only hours to read the report prior to publication, it agreed that it would also offer a meeting with senior representatives from the agencies involved in the SAR shortly afterwards.
106. It did not do so and as a defence said that its protocol had been met. This was an inadequate and unfair response, which yet again contributed to Mr B’s perception of bias against the families. It would have provided a much-needed opportunity for the agencies at fault in the original investigation, including the Council, to take responsibility for the failings and apologise. That may not have been a function of the SAR but the fact it was a gesture above the bare bones of the protocol would perhaps have helped Mr B accept the process and the outcome. It appears to have been agreed originally to make up for the inadequate time given prior to publication and there was no good reason given for the SAB’s failure to follow through with the meeting.

Injustice

107. The significant flaws in the safeguarding investigation meant that Mr B and Mr C will never know how or why Mr C was injured. This has caused them, and Mr B in particular, a significant degree of distress and uncertainty. The subsequent delays and failings in the SAR process have contributed to that sense of injustice and unfair treatment for a prolonged period of time.

Agreed action

108. In recognition of the injustice caused, particularly to Mr B, I asked the Council to:
• provide an apology to Mr B and Mr C, in writing from the Chief Executive;
• pay Mr B £1,000;
• provide to us and Mr B, evidence of how it has improved its role in safeguarding investigations as a result of this process; and
• ask the SAB, to hold (within three months) the promised meeting for the families with the agencies involved in the SAR with clear terms of reference on content and conduct, to be agreed with the families beforehand.
109. The Council has agreed to my recommendations. In the event that the SAB declines to hold the meeting the Council has agreed to arrange it.

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Final decision

110. I consider this a fair and reasonable way of resolving the complaint and I have completed my investigation on this basis.

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Investigator's decision on behalf of the Ombudsman