Summary: There was fault in the way the Council carried out safeguarding investigations and in its communications with Ms B and Mr C. The Council has agreed to apologise to Ms B, to make a payment of £750 to Ms B and to make a service improvement to ensure the same fault does not happy again.

The complaint

1. Ms B complains about the Council’s failure to properly carry out safeguarding investigations into the care for her adult son, Mr C. She also says the Council did not properly involve her or Mr C in the process and its communications were poor.

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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. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)

4. 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

5. I have discussed the complaint with Ms B and I have considered the documents she and the Council have sent and the Council’s comments on the draft decision.
6. I have investigated events going back to 2016 as it was not until 2018 that Ms B’s complaints from 2016 onwards had gone through the Council’s full complaints process.
7. I have not investigated the actions of the agencies which supported Mr C. The agencies are funded by the NHS, not the Council and are therefore outside of the Ombudsman’s jurisdiction. I have only investigated whether the Council has carried out its safeguarding role in line with its duties.

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What I found

8. The Care Act 2014 section 42 says the Council must make enquiries or cause others to do so, if it believes that an adult with care and support needs, is experiencing or is at risk of abuse or neglect and is unable to protect themselves because of those needs.
9. If the adult at risk lacks mental capacity to be involved in the process, the local authority should provide an advocate to that person.
10. The Council has its own adult safeguarding policy which sets out the process.

Strategy meeting

11. If the section 42 duty to carry out an enquiry is triggered, then the Council will hold a strategy meeting to decide how the enquiry will be carried out. The strategy meeting will take place within 5 days of the receipt of the referral.
12. The strategy meeting can be one meeting or a series of meetings or telephone calls. It should set out the plan and specify:
• What enquiries are needed?
• Who will carry out the enquiries?
• What are the timescales?
• How will agencies work together?
13. The coordinating manager should decide who to include in the distribution of the minutes of the strategy meeting.

The enquiry/investigation

14. The policy says the Council can cause another agency to undertake the enquiry/investigation but the Council remains the lead and is responsible overall for the coordination of the process and for checking the quality of the other agency’s enquiry. If it is not satisfied, it can ask for a further enquiry to be undertaken.
15. There will be a coordinating manager (from the Council) and an enquiry officer (from the Council or the agency which is carrying out the enquiries).
16. The coordinating manager should:
• Assess any immediate risk to the person involved and any other adults and formulate an interim safeguarding plan.
• Ensure that the relevant agencies are involved in the strategy discussions.
17. The enquiry officer should seek information for the enquiry. This includes, among other things;
• Examination of the files, daily records and accident and incident reports.
• Interviews with the adult at risk, witnesses and person(s) alleged to have caused the harm.
18. The enquiry officer will write the enquiry report.
19. The coordinating manager should check the enquiry report against the enquiry plan to ensure that all enquiry activities have been undertaken as planned. They should check that the report’s recommendations are based on the analysis of evidence obtained, that the report is robust and will stand up to scrutiny. If the coordinating manager is satisfied this is the case, they will sign off the report.
20. If an adult safeguarding conference is planned, then the report should be sent to the chair of the conference three working days in advance.
21. The adult at risk should be kept central to the investigation. Everyone, including the adult at risk should be clear about the roles and actions taken.

Safeguarding conference meeting

22. The purpose of a multi-agency conference is to review the findings of the enquiry, to review the safeguarding plan and to assess the level of any ongoing risk.

Case conclusion

23. The focus of the entire procedure is to safeguard people. It should establish whether, on the balance of probabilities, abuse has occurred, in order to assess the extent of any ongoing risk.
24. There are four possible outcomes:
• Substantiated.
• Not substantiated.
• Inconclusive.
• Investigation ceased at individual’s request.

Background

25. Mr C had physical disabilities, a severe learning disability and suffered from epileptic seizures. He was unable to walk or communicate and needed 24-hour care. He was transferred from his bed to his wheelchair via a hoist. He received care and support from care agencies funded by continuing health care (NHS funded).

Safeguarding enquiry 1

26. Ms B raised the first safeguarding alert on 12 November 2015. This related to the care Mr C received from Agency K during two respite stays. The concerns related to neglect of personal care, poor documentation and poor manual handling. Ms B said, among other things, that Mr C was in the incorrect position in his wheelchair when she went to pick him up after the second respite stay. She said he had urine and dried faeces in his groin and leg areas. His carers had not properly completed the documentation and not used the appropriate equipment (an adapted commode). His toothbrush had not been used.
27. The Council arranged a strategy meeting for 4 December 2015 and it was agreed that the Health Team would carry out the enquiry. The Health Team provided a safeguarding report dated 24 February 2016. This upheld the concerns relating to the record keeping. It said staff had not followed the guidelines in supporting Mr C in eating and drinking. Mr C was not appropriately dressed on one occasion and his wheelchair straps had not been threaded through properly.
28. The Council held an initial adult protection conference on 24 February 2016 which Ms B attended. The attendants had not seen the Health Team’s report before the conference.
29. The report said there was no evidence of Mr C’s condition at handover in terms of the soiled groin and leg areas. Ms B questioned this at the conference as she said a senior person at Agency K, Ms J was in the room and should have witnessed it. Ms J said she was in the room but although she saw that Mr C was wet she did not see any faeces. She added that Mr C had been changed before Ms B arrived.
30. Ms B felt the concerns constituted wilful neglect. The conference concluded that nothing had been identified to evidence poor practice but there were concerns about Agency K’s documentation. A plan was put in place and it is my understanding that the matter was then to be closed.
31. Ms B contacted the Council on 9 March 2016 as she was not satisfied with the Health Team’s report. She had cross-referenced the report with Agency K’s care notes and had found discrepancies and mistakes. She was concerned that the investigator had not interviewed all the staff members involved in Mr C’s care.
32. In response to Ms B’s concerns, the chair agreed to organise a meeting between Ms B, the Council, the investigator who wrote the report and Agency K to further discuss her concerns.
33. Ms B met the investigator and Mr C’s learning disability nurse on 22 April 2016 and further discussed her concerns. The investigator agreed that the report should have been discussed in more detail at the conference. The social worker said she would speak to the chair to see if the safeguarding conference should be reopened or the concerns dealt with as a complaint.
34. Unfortunately, Ms B’s complaint about safeguarding investigation 1 was then overtaken by safeguarding investigation 2 which started in June 2016. Ms B contacted the Council in July 2016 to chase them about what was happening with safeguarding investigation 1.
35. The meeting that was planned in March 2016 took place on 8 September 2016. The manager of Agency K acknowledged that the member of staff was in the room when the faeces were discovered on Mr C’s groin. She acknowledged that there had been insufficient time to train staff sufficiently to ensure that they could meet Mr C’s complex needs. She apologised to Ms B and said that, had she not been on leave at the time, she (the manager) would have ensured concerns would have been dealt with promptly. The outcome of the meeting was that there would be an investigation into how the safeguarding case was conducted and a report would be provided within 28 days.
36. The report was not completed, as far as I can see.
37. There was a report relating to Ms B’s complaint into the safeguarding enquiry 1 dated 21 February 2017. However, this report was confusing and mixed up some of the complaints regarding the two safeguarding enquiries.

Safeguarding enquiry 2

Incident on 13 June 2016

38. There was an incident on 13 June 2016 when Mr C was at home.
39. Two carers from Agency L provided care to Mr C from 2 to 7 pm. The records show Mr C suffered a drop seizure after 5 pm although the time of the seizure (5.35 or 5.40) and the length of time of the seizure (30 seconds or 3 minutes) differ on the two records that were made that day. A drop seizure is a seizure that consists of a partial or complete loss of muscle tone which causes the person to go limp.
40. The carers say that, when they hoisted Mr C to bed, they noticed that Mr C was in severe pain in his left leg. They informed Ms B. There was no indication, from the carers’ account, that there had been an accident or that Mr C had suffered an injury. The carers said they could not explain why Mr C was in such pain.
41. The GP was called the following day. He saw that Mr C was in a lot of pain. As there was no indication that Mr C had suffered an accident, he thought the cause may be gout.
42. As the pain continued over the following days, Mr C was taken to hospital on 20 June 2016 where he was diagnosed with a spiral fracture in the left tibia (shin bone).
43. Ms B spoke to Agency L on the same day and informed them of what had happened. Agency L said it would make a safeguarding referral to the Council.
44. Ms B made a safeguarding referral regarding physical abuse on 21 June 2016. She said she was concerned how the fracture could have happened as Mr C was unable to move himself. The staff at the hospital told Ms B that the type of fracture Mr C suffered would have been the result of him hitting his leg with extreme force. Ms B suspected the carers knew what happened and how Mr C sustained the injury, but had not spoken out. She questioned how the carers could have known that the pain was in the left leg as Mr C was unable to communicate.
45. Ms B said she wanted a full investigation as Mr C had suffered a lot of unnecessary pain because of the dishonesty of the care staff. Ms B said she had cancelled Agency L’s service so there was no further risk to Mr C.
46. The Council started a safeguarding investigation.

Initial strategy meeting

47. I asked the Council to send me the minutes of the initial strategy meeting. The Council sent me a document headed ‘adult protection enquiry’ which includes a list of dates and actions identified, but does not include any minutes of the meetings. The document says the investigation should be concluded within 42 calendar days which was 4 August 2016. There is a reference to strategy discussions on 23 June 2016, but it does not say what was discussed.
48. Soon after the incident, the manager of Agency L interviewed the staff involved in the incident and visited Ms B to take records and check the care documentation.
49. On 29 June 2016, the Council decided that the Health Team would carry out the enquiries/investigation. Social worker D was the social worker dealing with the safeguarding investigation from the Council’s perspective.
50. The Health team rang the Council on 7 July 2016 and said it would not investigate the incident as it could not investigate another provider.
51. The Council called the police on 7 July 2016. The note of this conversation says: ‘From information known to date there is no evidence of deliberate assault/wilful neglect or criminal activity.’ It was therefore decided that the police would close the file. The Council would carry out further enquiries and if these raised any concerns, the Council would contact the police.
52. The notes say that on 7 July 2016 the plan was to convene a strategy meeting to ‘bring professionals together to discuss action plan.’
53. The Council spoke to Ms B on 7 July 2016 to appoint an advocate for Mr C.
54. The advocate visited Ms B and Mr C on 12 July 2017 and drafted a list of outcomes that Mr C sought from the investigation.
55. Social worker D rang the Health team on 15 July 2016 to find out which safeguarding officer was dealing with Mr C’s case in the Health Team. The Health Team explained again that it was not investigating the incident. However, it could assist in the understanding of any health/care needs Mr C had. It said it needed to know what information the Council needed and that a strategy discussion would be helpful.
56. Social worker D spoke to Ms B on 16 July 2016. Ms B said she did not think the carers deliberately hurt Mr C but she thought there may be wilful neglect. She suspected Mr C was hurt because of a mistake by the carers. She said it was particularly concerning as, if the carers had been honest, Mr C may not have been misdiagnosed as suffering from gout for a week and his suffering would not have been so long.
57. The Council emailed Ms B with an update on 28 July 2016. It said it was organising an adult protection conference. It was waiting for the Health Team to say who would lead the enquiry into the health issues. It said the police would not investigate at present as there was not enough evidence that a crime had been committed. But the police had been invited to the conference to hear the evidence and then could change its position.
58. An engineer carried out routine maintenance on Mr C’s wheelchair on 29 July 2016. He noted that the left side hanger (my understanding is that this hanger connects the footplate to the chair) was bent inwards by a couple of inches and there were scuff marks on the side of the footplate. He said the footplate was bent and twisted inwards.
59. The chair of the conference visited Ms B on 11 August 2016 to discuss the complaint about the first safeguarding investigation and the progress of the second investigation. Ms B told the chair she had 5 folders of information about the recent incident that nobody had picked up. Ms B says the chair was ‘shocked’ at the lack of progress in the second investigation and the fact that the Council was going to close the investigation. The chair then contacted the police on 19 August 2016 and the police agreed to investigate the incident soon after.

Strategy meeting on 12 September 2016

60. The minutes refer to the meeting as a strategy meeting, but the other documents refer to a multi-agency adult protection conference.
61. Ms B told the meeting that three months had gone by without any progress and this would affect the evidence that could be gathered.
62. The police said it started its investigation two weeks ago and the officers would interview the carers involved.
63. Agency L’s manager said she had interviewed the staff as part of her internal investigation. She said her internal investigation had not substantiated the concerns.
64. She said the Council had advised her on the telephone she did not have to make a safeguarding referral as Ms B had already made one.
65. Ms B said she knew of another vulnerable young man who was cared for by the same carer who cared for Mr C. She said concerns were raised about him.
66. The chair of the conference recommended that the carers involved in Mr C’s care should not work until the investigation was concluded. The chair said she would investigate the timescales in the investigation and why there had been such a delay from the date of the referral to the present.
67. The following actions, among others, were agreed at the meeting:
• The police would continue its investigation.
• The chair would carry out an audit to ascertain why there had been such a significant delay.
• Agency L’s manager would feedback the concerns of the carer who was alleged to be involved in the incident continuing working with vulnerable adults and then feedback Agency L’s decision to the chair and the police.
• Agency L’s manager had to provide the details of the declined safeguarding referral to the chair.
68. There is a note dated 22 November 2016 which says the police has interviewed the suspects, the family, Mr C’s carers and has one more statement to take.
69. The person who chaired the meeting then left the Council so another person was appointed to take over from her.

Conference on 29 November 2016

70. There was a second safeguarding conference on 29 November 2016. The police said its investigation was ongoing and it may obtain medical evidence on how the injury occurred as this was still unclear.
71. The social worker met Mr C seven months after the enquiry started.
72. Sadly, Mr C passed away on 10 June 2017.

Safeguarding process completed

73. The police investigation ended in June 2017. The file was passed to the CPS who said it would not take any further action. Ms B asked for a review of this decision but the decision not to take further action was upheld.
74. The Council completed its safeguarding enquiry report in October 2017. The conclusion of the report was that the Council could not say how or when Mr C sustained the spiral fracture.
75. The final safeguarding conference took place on 22 November 2017. The safeguarding process was concluded and the outcome was recorded as inconclusive.

Safeguarding enquiry 3

76. There was a third safeguarding investigation relating to the hospital’s actions. Ms B’s complaint relates to the invitations to the safeguarding conferences.
77. These are the relevant dates:
• Ms B spoke to the manager on 31 July 2017. The manager told her the conference had been organised for 8 August 2017. Ms B said nobody had consulted her or invited her. The social worker said she had sent an email to Ms B about the conference. Ms B said she had not received it and asked the social worker to send it again, but she never did.
• The chair of the conference rang Ms B on 27 March 2018 and said she looked forward to seeing Ms B the next day at the conference. Ms B said she had not been made aware there was a conference on the following day. The Council then cancelled the conference.
• On 3 April 2018 Ms B sent the Council a list of dates she was available to attend the conference.
• The Council wrote to Ms B on 17 April 2018 and upheld her complaint that she had not been invited to the previous conference. It apologised for the fault and said that a conference had now been organised in consultation with the advocate.
• Ms B received the Council’s letter on 24 April 2018 and replied to say that neither she nor her advocate had been consulted on the conference so the Council had made the same mistake again.
• The Council sent an email to the hospital on 24 April 2018 to organise an urgent meeting on 2 May 2018 as this was the only date the family could attend.

Complaints

Safeguarding 1 - analysis

78. Ms B says she did not receive the enquiry report until the day of the conference. Therefore, she and the other attendants did not have enough time to properly consider and challenge the report. She feels the Council should have challenged the report as there were inconsistencies in the report.
79. The Council partially upheld both complaints. The Council agreed that it would have been good practice to share the report before the conference. It agreed that, because the report was not available earlier, the attendants did not have enough opportunity to consider and challenge the report.
80. I cannot comment on the enquiry report itself as this was carried out by the Health Team. I can also not comment on the outcome of the safeguarding conference as this was a multi-agency meeting. I can only comment on how the Council conducted the meeting and the safeguarding process.
81. I agree with the Council’s findings and I agree there was fault in the Council’s actions. The enquiry report was lengthy and detailed. Ms B and the other attendants had not seen the report until the conference. This meant that she and the other attendants did not have enough time to properly scrutinise the report.
82. Ms B then went through the report and reported her concerns to the Council in March 2016. As the safeguarding process had presumably been closed, the Council was not certain how to respond to the concerns. It was not sure whether it should deal with this as a complaint or a continuation of the safeguarding process.
83. It proposed a meeting but then did not hold the meeting until September 2016, some six months later. The outcome of this meeting was a further report on the safeguarding process, which was then never carried out. This was further fault and meant Ms B was left without the reassurance that the safeguarding process had been properly completed.

Safeguarding 2 - analysis

84. Ms B says:
• The Council failed to properly respond and investigate the safeguarding referral at the beginning which led to several months of delay and the loss of evidence.
• The Council failed to involve the police from the beginning.
• The Council failed to put Mr C or his advocate at the centre of the investigation.
• The Council failed to invite Mr C or his advocate to the strategy meeting.
• The social worker did not visit the family until 7 months after the referral was made
• The social worker misled the conference on 29 November 2016 about receiving regular updates regarding Mr C from his learning disabilities nurse.
• The Council advised agency L that it did not have to make a safeguarding referral because Ms B had already made a referral.
• There was a conflict of interest as Ms B later found out that the Council directly commissioned care agency L to provide care on behalf of the Council.
• There were three different chairs to the conferences and no continuity.

Analysis

85. The Council received the safeguarding referral on 21 June 2016. The referral should have raised serious concerns from the outset for two reasons:
• Mr C was a very vulnerable man who was not able to mobilise and who was meant to be supervised all the time. He suffered a spiral fracture which indicated either deliberate harm or an accident/lack of correct supervision.
• The carers who were meant to supervise him said they could not say how Mr C sustained the injury. This was concerning if one considered the level of strength that was needed to cause the breakage and the level of pain Mr C would have been in when it happened.

Overall delay and lack of planning at the beginning

86. There was a long delay at the beginning of the process where the Council failed to progress the investigation and this is fault.
87. The Council should have organised an immediate strategy meeting. It should have identified who would carry out the enquiry, what enquiries they would make, who they would interview, what the deadlines were and so on.
88. I accept that a strategy meeting does not have to be in person and can be over the phone. However, it is very difficult to see from the documents that the Council has given me what the Council’s strategy was and how it was conducting the investigation in the first three months. There was reference to a strategy discussion on 23 June 2016, but there are no minutes of the discussion and there is no clear plan of enquiries.
89. From the documents, it appears the outcome of the strategy discussion on 29 June 2016 was that the Health Team would carry out the enquiry. The Health Team then told the Council on 7 July 2016 that it would not lead the enquiry. The Council then contacted the police but they said they would not investigate either.
90. There are no notes on what the Council’s plan was at that stage. The notes say that on 7 July 2016 the plan was to convene a strategy meeting to ‘bring professionals together to discuss action plan.’ But there is no explanation why this did not happen.
91. If nobody else was carrying out the enquiry, the Council should have started its own enquiry and drawn up a plan. I would have expected the Council to interview Ms B, Mr C, possibly the carers and so on. However, nothing much was progressed until the strategy meeting of 12 September 2016.
92. The chair of the strategy meeting on 12 September 2016 said there should be an audit into the significant delay in responding to the safeguarding concerns and this should be completed within 28 days. However, there was then further fault as this audit never took place.
93. I am also concerned about the poor record keeping in the safeguarding process. It has been difficult to ascertain what the Council’s actions were and better record keeping including minutes of meetings, conversations and clear plans would have kept the process on track and were required in line with its own policies.

Failure to contact police

94. The Council should have had an immediate strategy meeting with the police when it received the referral but failed to do so until two weeks after it received the referral. This is fault.
95. Unfortunately, there are only very brief notes of the conversation on 7 July 2016 where it was decided that the police would close the case. I cannot say therefore, who made the decision and what information they had before they made the decision. Clearly this was an investigation that should have been carried out by the police from the outset.

Failure to assess risk

96. The Council also did not follow its own policy in the assessment of the risk and this was also fault. I appreciate that Mr C was no longer at risk because Agency L was no longer providing care to him. However, there was no indication the Council carried out any other risk assessment and assessed whether other vulnerable adults, like Mr C, could be at risk from the same carers.
97. It was not until the meeting on 12 September 2016, some three months later, that the chair of the conference realised the error and recommended that the carers who were being investigated should not be working with others until the investigation was concluded.

Conflict of interest

98. I understand that the Council commissions Agency L to provide care for other care users. Ms B was concerned that meant there was a conflict of interest as the Council was also carrying out the enquiry into agency L.
99. I find no fault in that respect. The Council commissions a lot of companies and agencies to provide care on its behalf. It does this to meet its duties under the Care Act. The Council has the overall responsibility for any safeguarding enquiry in its area. That is a separate duty carried out by a different department and it is quite common for councils to investigate organisations which they also commission.

Failure to put Mr C at the centre

100. I agree with Ms B that the Council did not put Mr C at the centre of the investigation and this is fault.
101. I accept the Council appointed an advocate for Mr C and the advocate went to see Mr C on 12 July 2016. However, that is not the same as a visit by the social worker.
102. The social worker should have visited Mr C while he was supported by his advocate and Ms B.
103. This visit should have happened for two reasons. Firstly, the Council’s own policy says Mr C should be kept at the centre of the investigation and should be seen within 9 days of the receipt of the concern. Secondly, Mr C was the alleged victim and social worker D should have spoken to Ms B and obtained all the information that she could about the incident, from an evidence point of view. Ms B had a lot of information which would have been vital for their enquiries.
104. Ms B says she was not involved in the initial strategy meeting in June 2016. The notes show there were a couple of telephone calls to Ms B in June and July 2016 to set up the advocate and to determine how Mr C’s care needs would be met. But I agree that this was not a full involvement in a strategy meeting and that there was a lack of communication with Ms B and Mr C during the safeguarding process.

Misleading the conference

105. Ms B says social worker D misled the conference as she said she had received regular updates regarding Mr C from the learning disabilities nurse.
106. One of the recommendations of the September 2016 strategy meeting was that the Council and social worker D should continue to support and advise Ms B. At the conference in November 2016, Ms B said that she had still not received regular updates. Social worker D said she had received regular feedback from Mr C’s disabilities nurse but had not passed this on to Ms B. She also said that, if there was nothing to report, then she had not thought to ring Ms B.
107. Later, the disabilities nurse then said social worker D had only contacted her twice, in July and November.
108. I agree with the Council it is difficult to say whether the social worker was misleading the conference. Probably it would have been better if she had not used the word ‘regularly’, but I accept she may have tried to convey that she had sufficiently regular updates about Mr C’s condition as far as the investigation went. However, the underlying problem was that there was a lack of communication between social worker D and Ms B and Mr C.

Advice to Agency L

109. The Council advised Agency L that it did not have to make a safeguarding referral as Ms B had already made one. The Council has already upheld the complaint and I agree that this was fault. The procedures are clear that all agencies have a duty to report safeguarding concerns.

Different chairs to the conference

110. I agree with Ms B that the situation was not helped by the fact that there were 3 chairs over the time of the investigation which led to a lack of continuity. However, I cannot say this is fault as the Council cannot control staff’s movements or sickness.

Injustice

111. I have considered the injustice that Ms B and Mr C suffered because of the fault.
112. There is no indication that Mr C suffered any additional physical harm because of the delay in the safeguarding investigation. Ms B took the correct action to minimise any risk by stopping Agency L from providing any care as soon as it was discovered that Mr C had suffered a spiral fracture.
113. Ms B was very disappointed by the outcome of the safeguarding investigation as it did not give her any of the answers that she was seeking. It is impossible to say whether the outcome of the investigation would have been different if the police had been involved from the outset and if there had not been the long delay and lack of strategy at the beginning of the investigation.
114. Therefore, the injustice is that Ms B will always have the uncertainty of not knowing what the outcome would have been if things had been done differently.

Safeguarding 3 - analysis

115. Ms B’s complaint relates to the Council’s continued failure to invite her to meetings which led to several conferences being cancelled and more delay.
116. I agree there was fault in the Council’s actions. The Council failed to properly notify or invite Ms B to the conference in July 2017 and in March 2018. It then upheld her complaint about this failure in April 2018 but in the same letter it then made the same mistake again by saying it had organised the conference in April in consultation with the advocate when this was not the case. It then had to organise an urgent conference and said this was because Ms B only could attend one date. That was not true as Ms B had given the Council a list of dates she could attend a few weeks earlier.
117. Ms B has suffered an injustice as a result of this fault as she felt the Council continued to fail to properly involve her in the process.

Consideration of remedy

118. Sadly, Mr C has passed away so any injustice he has suffered cannot be remedied.
119. This whole process has been very difficult for Ms B. The second safeguarding investigation, particularly, was a long process which did not give her any of the outcomes she sought. Ms B feels the Council has let Mr C down.
120. It is difficult to provide a remedy for Ms B’s injustice which reflects her distress. The Ombudsman normally recommends an apology and sometimes a small amount of money (£100 to £300) which is purely a symbolic sum. In this case, considering the seriousness of the failings, I recommend £600.
121. The Ombudsman also sometimes makes a small symbolic payment to reflect that the complainant has had extra difficulty in pursuing the complaint and I am of the view that such a payment is appropriate in this case.
122. I have also considered service improvements to ensure that the same failings do not occur again.
123. The Council has made the following service improvements after Ms B’s complaint about the third safeguarding enquiry. It has:
• Issued a reminder to staff of the importance to ensure that family members and/or their advocates are consulted when arrangements are made for adult safeguarding conferences.
• Shared its findings of the complaint with staff in the team and discussed it during a staff meeting so that all staff members are aware of the importance of keeping others informed.
124. Those service improvements address the importance of involving the person and their family in the process. I have made a further service improvement recommendation relating to the safeguarding process as a whole.

Agreed action

125. The Council has agreed to take the following actions within one month of the final decision. It will:
• Write to Ms B to acknowledge the fault and to apologise.
• Pay Ms B £600 to acknowledge the distress she has suffered because of the fault and £150 for the additional time and trouble she went through to pursue the complaint.
• Ensure that all staff involved in safeguarding investigations are reminded of the Council’s own safeguarding policies. The Council has said that all its staff involved are required to attend level 4 training in safeguarding. So far, 200 staff have attended the training and this is ongoing.

Final decision

126. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman