Summary: The complaint is about how the Council investigated safeguarding concerns in a nursing home where Mr C lived. There was some fault by the Council, causing some missed opportunity and avoidable frustration. The Council has agreed my recommendations to apologise, pay £200, remind the nursing home of incidents it needs to report and change the Council’s procedures and staff training as necessary. I did not uphold other parts of the complaint.

The complaint

1. The complainant, whom I shall refer to as Mr B, complains the Council failed properly to investigate safeguarding concerns he raised about the care of his relative, Mr C, at a nursing home (‘Home X’).

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What I have investigated

2. I investigated points that Mr B had taken through the Council’s complaints procedure where I considered they were in the Ombudsman’s jurisdiction and were significant enough to merit investigation. The final section of this statement contains my reasons for not investigating the rest of the complaint.

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The Ombudsman’s role and powers

3. 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)
4. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
5. 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)
6. 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

7. I considered the information Mr B provided and discussed the complaint with him. I made written enquiries of the Council and considered its response. I also considered publicly available information about Home X. I shared my draft decision with Mr B and the Council and considered their comments on it.

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What I found

8. The law says that, where the Council has reasonable cause to suspect an adult in its area: has care and support needs; is experiencing, or is at risk of, abuse or neglect; and as a result of those care and support needs cannot protect himself against the abuse or neglect or the risk of it, the Council must make, or cause to be made, whatever enquiries it thinks necessary to enable it to decide whether any action should be taken in the adult’s case. (Care Act 2014, section 42)
9. It is a matter for the Council’s judgement in each case whether it has ‘reasonable cause to suspect’ the relevant points apply and, if so, what enquiries and further action are appropriate.
10. Mr B has power of attorney for his relative, Mr C, who lived in Home X. Mr B made a safeguarding referral to the Council about Home X in July 2017. Mr C went into hospital a few days later and did not return to Home X. The Council upheld one of Mr B’s safeguarding concerns but not the others.
11. Mr B then complained to the Council that he believed its investigation had not covered properly, or at all, incidents when Mr C’s catheter bag overflowed, when Mr C’s toiletries were scattered on the floor, when Mr C’s spectacles and used tissues were left in a wash basin, Mr C’s urinary tract infections (UTIs) and fluid consumption, Mr C being found sitting in his excrement, Mr C suffering injury in a hoist and Mr C fainting. The complaint also said the Council made inadequate minutes of a meeting with Mr B on 28 July 2017 and the safeguarding investigation did not interview enough people. I shall deal first with those points.

Incident when Mr C’s catheter bag overflowed

12. Mr B complained the Council’s safeguarding investigation did not cover an incident when Mr B had found Mr C sitting in urine-soaked trousers because his catheter drainage bag had been allowed to overflow. Mr B had mentioned this in his safeguarding referral and in a meeting with Council officers on 28 July 2017 although he could not identify when this happened.
13. It appears this incident happened at least some months before the safeguarding referral in July 2017. The Council told Mr B: it was difficult to investigate this further because Mr B had not reported it to the Council at the time; Home X’s records show Mr B was washed two to three times daily; and the social worker who saw Mr C at Home X in July 2017 had no concerns with his presentation.
14. I appreciate Mr B had not told the Council at the time or identified a date when he mentioned the incident later. Nevertheless, this allegation could suggest neglect so, on the face of it, it was a safeguarding allegation. Even if Mr C was usually washed regularly and the social worker had no concerns on seeing him on a particular day, that does not rule out that such an incident of neglect might have happened, with potentially significant implications for Mr C’s dignity and health.
15. In the circumstances, I consider the Council was at fault for not trying to find out more about this, at least to try to find out how Home X handled such incidents and whether Home X had not reported such an incident to the Council at the time.
16. Had the Council looked into this, it might not have been able to reach a clear view on the incident itself, given the time lapse. However, the Council might have been able to find out if Home X was not reporting incidents that it should report to the Council. That point was potentially significant as the Council did find such a reporting failure regarding Mr C’s accident in the hoist (see below).
17. Therefore I consider the Council was at fault for simply declining to consider this incident because of the passage of time. We do not know what conclusion the Council would have reached had it sought to consider this. So the Council’s fault here leaves Mr B with a justified sense of missed opportunity.

Incident when Mr C’s toiletries were scattered on the floor

18. Mr B is dissatisfied the safeguarding investigation did not cover in detail an incident when he discovered Mr C’s toiletries scattered on the floor. Mr B says he raised this as evidence of an underlying pattern of neglect in Home X.
19. This incident seems to have been at least some months before the safeguarding referral in July 2017. Mr B told the Council Home X had ‘eventually’ apologised to him for this, in the presence of a social worker. The Council said it did not investigate this in detail because the incident had been dealt with already and the Council did not believe it amounted to neglect.
20. As explained above, the Council is entitled to judge whether something might be abuse or neglect. While toiletries should not be left scattered on the floor, I do not fault the judgement that this did not amount to neglect warranting further action.
21. I note Mr B disagrees with the Council’s understanding of why the toiletries were on the floor. However, I consider it would be disproportionate for me to consider the explanation further as I do not fault the Council’s decision that this was not neglect.

Incident when Mr C’s spectacles were in a wash basin with used tissues

22. On 22 March 2017, Mr B discovered Mr C’s spectacles and used tissues lying in Mr C’s wash basin. Mr B told Home X a few days later although that was not the same as raising a safeguarding referral with the Council. The Council says Mr B raised this with it in May 2017 and declined the Council’s offer of a review of Mr C’s care then. Mr C raised the matter again in his safeguarding referral in July.
23. The Council’s safeguarding investigation included speaking to friends who had visited Mr C in Home X. The Council recognised the friends said Mr C’s bedroom was often messy. The Council’s safeguarding report said this incident appeared to have happened when carers had to leave Mr C’s room to deal with an emergency involving another resident. Mr B disputes this is accurate. The Council said it did not believe the incident amounted to neglect.
24. The Council seems not to have investigated this in depth. However, I note:
• The incident happened several months before Mr B raised safeguarding concerns,
• Mr B did not raise it with the Council at the time (although the Council had apparently advised him to raise concerns promptly with it) and he declined a review of Mr C’s care in May and
• This was a single incident of untidiness or carelessness (less serious than, for example, the catheter overflow incident).
25. So I can understand the Council’s view that this did not reach the threshold of neglect warranting safeguarding action. The evidence suggests the Council considered information from Mr B and others before reaching its decision. I consider the Council reached that decision properly. So, while Mr B can disagree with the decision, I cannot criticise it, as paragraph 4 explained.
26. In that context, the questions of why this happened and whether Home X accurately explained the incident are not significant to my investigation.

The Council’s investigation of concerns about Mr C’s UTIs and about Mr C not receiving enough fluids

27. I shall deal with these points together as they are closely related. Mr B is dissatisfied the Council’s safeguarding investigation did not establish how many UTIs Mr C had at Home X or the cause of the most recent one, when a hospital reportedly found Mr C was dehydrated. The Council responded that UTIs were common and having a catheter, even with good care, increased the risk of UTIs so someone having UTIs did not necessarily mean there was neglect. The Council stated that, on investigation, it found Mr C’s GP was not concerned with Home X’s management of Mr B’s health and the Council was not concerned about Mr C’s fluid intake. So the Council says it did not conclude Mr B’s suffering UTIs was a sign of neglect therefore did not investigate the UTIs further.
28. Mr B’s safeguarding referral did not mention concern about Mr C not receiving enough fluids as a possible cause of UTIs. It is likely Mr B raised this with the Council at or around a meeting on 28 July. The Council evidently regarded this as a concern by 4 August 2017, when it discussed this with Home X.
29. A social worker who visited Home X on 14 July 2017 noted that, as Mr C became ill during her visit, she could not access his care notes as planned but spoke briefly to the nurse in charge. The notes show the conversation covered several subjects but do not show the conversation included Mr C’s fluid intake or UTIs.
30. At this visit, the social worker noted there were drinks on Mr B’s table. Mr B says Mr C was unable to pour out a drink or lift a cup to drink at that time. This was simply a snapshot of what the social worker saw at a particular moment. It did not in itself show Mr B was able to get a drink himself, whether staff were prompting him to drink, or whether he was actually drinking enough. Nor did this, in itself, show adequate consideration by the Council of what was happening overall with Mr B’s fluid intake though I realise the care records could not be seen that day.
31. On 19 July 2017, the social worker visited again. Her notes refer to Home X’s care records of the hoist incident and of Home X’s contact with the GP and the ambulance service but do not mention records covering fluid intake or UTIs.
32. Those two visits were before Mr B apparently raised the question of fluid intake at the 28 July meeting. Overall, the evidence does not suggest the Council considered evidence about Mr C’s fluid intake or UTIs at these two visits.
33. On 4 August 2017, the social worker visited Home X again. The visit record shows a discussion of safeguarding concerns with the home’s manager, who stated there were no major concerns about Mr C’s weight and dietary intake but he had ‘food and fluids chart for regular monitoring’ and staff encouraged him to drink regularly rather than accepting him refusing. There is no indication this visit involved the social worker looking at and assessing the fluid charts herself or comparing them with daily care logs.
34. Also, during the safeguarding investigation the Council had access to information from another source that Home X’s fluid monitoring charts were poor quality and did not show people were always offered, or always had, enough drinks. There is no indication the Council considered this if it inspected the fluid charts.
35. During its investigation, the Council spoke to a nurse who had visited Mr C. She stated there were occasions when Mr C did not have a drink in front of him and he had once seemed thirsty.
36. We would expect records of a safeguarding investigation to include, at least, details of the evidence the Council considered on each substantive point of investigation. Here, there is inadequate evidence the Council directly looked at and assessed evidence about Mr C’s fluid intake rather than just noting the GP was not concerned and Home X stated Mr C was on fluid charts. The evidence suggests either inadequate investigation of this point or inadequate record-keeping of any investigation. Either way, there was fault.
37. I cannot say, on balance, what the Council might have concluded if it had investigated more thoroughly and/or kept better records. Nor is it the Ombudsman’s role in this case to assess whether a care provider took adequate steps regarding fluid intake and UTI risk. So the Council’s fault leaves Mr B with a sense of missed opportunity and uncertainty about whether the Council’s investigation might have reached a different decision on these matters.
38. I do not consider the fault here disadvantaged Mr C. This is because the Council was investigating after the event and because Mr C only remained in Home X for a few days after the safeguarding alert.

Incident when Mr C was found sitting in his excrement

39. Mr B’s safeguarding referral mentioned him finding Mr C sitting in his excrement after experiencing incontinence. The Council’s investigation noted: Mr C had incontinence several times daily; his medication could cause sudden bowel movements; Home X’s records showed Mr C received regular personal care; the Council had spoken to friends who visited Mr C, who described two occasions when Mr C was incontinent during visits and staff took a while to respond (it was unclear when those incidents happened), so the Council recognised there was some contradictory evidence.
40. The Council concluded that, given Mr C’s needs, the incontinence Mr B referred to might have happened shortly before Mr B arrived rather than necessarily showing Mr C had been left for an unreasonable period. The Council did not judge this incident amounted to neglect.
41. I consider the key point here is the specific incident Mr B referred to. If someone experiences sudden incontinence, staff might not always know of and react to the situation immediately. The Council had to reach a judgement on the information it had. In all the circumstances, I consider the Council properly reached its decision that this incident did not amount to abuse or neglect.
42. Mr B suggests Mr C might have sat in soiled clothing because he was afraid of asking staff for help. Mr B cites complaints the Council had upheld from other people about Home X staff’s conduct. I consider that point too speculative for me to be able to reach a meaningful view.

Incident when Mr C suffered injury while using a hoist

43. Home X staff were hoisting Mr C when the hoist tipped and Mr C cut his toe on the skirting board. The Council upheld that this was a safeguarding incident and that Home X should have reported it to the Council at the time. Home X accepted the Council’s recommendations about: avoiding transferring residents to other rooms where possible; risk assessments; the staff involved to have refresher training, a supervision discussion and random observations of their work with hoists; and Home X to report such incidents to the Council.
44. Mr B complained the Council had not dealt with this thoroughly enough. He believes the Council wrongly accepted Home X’s account that the accident happened because Mr B was temporarily using a different, smaller, room. Mr B believes, from discussion with an occupational therapist (OT), it might have been due to poor procedure or a failure to use brakes or straps properly.
45. During the safeguarding investigation, the Council twice asked Home X for more information about this incident. At the time, the Council said it wanted that information because the investigating officer was not an expert in moving and handling people and wanted to understand the incident better to decide whether to consult an OT. I see no evidence Home X provided the requested information or the Council decided it did not need that information after all.
46. It was poor that the Council proceeded to make a decision with some enquiries outstanding. At the least, it was fault not to record the reasons it no longer believed it needed the requested information, if that was the case.
47. However, the Council seems to have erred on the side of finding fault. It did not establish definitely the cause of the accident, only a probable cause, for which it accepted Home X’s explanation. Mr B argues the Council should have done a reconstruction of the event and taken advice from an OT to establish a definite cause. The evidence I have seen suggests the Council only said it would consider this; it did not commit definitely to do so.
48. Whatever caused the accident, the Council’s recommendations about: risk-assessment of moving and handling whenever someone changes rooms and training and observing staff should guard adequately against further incidents. So, although there was some fault in the Council’s investigation here, I do not consider I need to recommend any further action.

The Council’s consideration of how Home X dealt with Mr C fainting and vomiting

49. Mr C suffered bouts of vomiting and fainting. Mr B argues Home X wrongly failed to tell Mr C’s GP that Mr C was fainting as well as vomiting. Mr B suggests this delayed the discovery that a colon lesion was the possible cause.
50. Home X told the Council it might not have told the GP of every time Mr C vomited but staff sought medical attention (either from the GP or by calling an ambulance) for every serious instance of vomiting or fainting. The Council noted Home X’s records showed in recent months Mr C had seen the GP several times about vomiting and there were several 999 calls about Mr C fainting or vomiting.
51. The Council noted Home X is a nursing home so would not necessarily have to call the GP every time Mr C was unwell. The GP believed Home X staff contact the GP appropriately.
52. I am considering how the Council conducted the safeguarding investigation. I am not investigating Home X’s relationship with the GP. The records the Council cites do not show Home X told the GP that Mr C’s vomiting was accompanied by fainting. However, such records are necessarily brief and this could also be because Home X called an ambulance rather than the GP on more serious occasions.
53. Home X was a nursing home and could legitimately make its own judgements about whether external medical attention was needed and, if so, whether from the GP or an ambulance. In all the circumstances, I do not consider the Council was at fault for not finding a safeguarding failure in terms of how Home X handled these incidents overall.

The minutes of the Council’s meeting with Mr B on 28 July 2017

54. On 28 July 2017 Council officers met with Mr B and a charity worker supporting him, Ms C. The Council took minutes. Mr B chased the Council several times asking for a copy of the minutes ‘for review’ and for ‘the draft minutes’. This implies Mr B might have believed he could ask for changes to the minutes.
55. The Council sent its minutes (four pages) on 30 August, apologising for the delay. I note the minutes got the meeting date and Ms C’s name wrong. Those faults did not in themselves cause significant injustice.
56. On 5 September, Mr B emailed the Council saying he and Ms C had ‘reviewed the minutes…and attached our own comments/observations/actions.’ He attached seven pages of ‘Actions & Observations’. The Council says Mr B did not actually ask for changes to its minutes. I understand how the Council thought that though I also understand why Mr B might have thought his comments would lead to the Council changing its minutes. The Council now says it would have been helpful if it had explained at the time that it did not think Mr B was seeking changes to the minutes and that it considered its minutes sufficiently detailed.
57. Mr B says he asked the Council to change the minutes. However, the evidence suggests that was in November 2017, after the safeguarding investigation ended. So this is not material to my consideration of the Council’s actions during the investigation. Mr B also showed me 15 pages of notes he reports Ms C made during the meeting.
58. Mr B says the Council’s minutes did not record all the agreed actions properly. I have compared the minutes and Mr B’s ‘actions and observations’ list. Many of Mr B’s points are not specific actions, or do not show the Council committed to a specific action rather than just discussing something, or the points were broadly covered by the action points in the Council’s minutes and/or the Council’s later recommendations to Home X. So I see nothing more to pursue there.
59. However, one action Mr B cites, which the Council’s minutes do not cite, was that the Council would ask Home X if Mr C’s care plan included UTI management. I consider that is likely to have been raised because, after this meeting, the Council asked Home X about Mr C’s fluid intake. I have explained above my concerns about how the Council dealt with that subject. So I need not repeat those findings here.
60. I agree it would have been helpful if the Council had clarified with Mr B in September 2017 that it did not believe he was seeking to change its minutes and that it believed its minutes were adequate. The Council is willing to apologise for this, which I welcome.
61. Minutes need not be verbatim or exhaustive. There remains disagreement about whether the Council’s minutes adequately recorded the important points of the meeting. I shall not be able to resolve this now. Mr B wants the Council to review the minutes and action points now. I do not consider further communications between Mr B and the Council about the minutes would be likely to achieve anything significant. Further action on this point would be disproportionate.

Complaint that safeguarding investigation did not interview enough people

62. At the meeting on 28 July 2017, the Council asked Mr B for contact details of people he suggested the Council should speak to during its investigation. I see no evidence the Council said it would not necessarily speak to everyone Mr B suggested. Mr B sent some contact details. On 4 September, he sent another person’s contact details. The Council’s email response said, ‘ok thanks’. Again, the Council did not say it might not contact that person. In total, Mr B gave the Council contact details of seven people who had visited Mr C at Home X in various capacities. The Council contacted four of them.
63. During the investigation, Mr B asked if the Council would speak to former Home X staff, given the home’s turnover of staff. The Council replied it did not consider interviewing staff necessary. As well as speaking to Mr B and four people he suggested, the Council looked at some of Home X’s records and interviewed the manager.
64. The Council was entitled to decide how much investigation it considered proportionate. I have not seen evidence the Council failed to speak to a particular person it had reason to believe had important relevant information that no-one else could provide. So I do not fault the Council for not interviewing more people.
65. However, I consider the Council avoidably raised Mr B’s expectations by requesting and accepting various people’s contact details without clarifying that it was not committing to contacting all of them. That fault caused Mr B some avoidable frustration.
66. One of the people the Council contacted at Mr B’s suggestion was a nurse whom Mr B had asked to visit Mr C. Mr B suggested the Council did not interview the nurse sufficiently about the safeguarding concerns. However, it is reasonable to expect a nurse would understand what the Council’s investigation would be interested in and would mention anything she considered relevant. I do not fault the Council on this point.
67. I shall now deal with points Mr B raised with the Council or with the Ombudsman, or that I discovered during my investigation, and which I consider closely enough related to Mr B’s complaint to the Council for me to include in my investigation.

Comments Mr C made about Home X’s staff

68. A social worker visited Mr C in hospital with Mr B present. Mr C said he would like to move to another home and described staff at Home X as ‘rough’ and ‘riff-raff.’ Mr B says the Council did not ask Mr C to expand on this. The social worker noted at the time that Mr C ‘is a man of few words and would not say more.’
69. A Council manager visited Mr C in hospital a week later. I see no evidence the Council told Mr B it was arranging this visit. Mr C spoke positively of Home X’ staff and said his memory was not good when asked about his previous comments about the staff. He confirmed he had no concerns about Home X and would tell someone if he did. The manager intended to visit again when Mr C had settled into his new home.
70. Six weeks later, the same Council manager visited Mr C in his new home. Mr B was present. Mr C could not remember his previous comments about Home X’s staff or anything about Home X.
71. Mr C was vulnerable, his memory evidently fluctuated and the Council had to avoid risking pressurising or leading him in his comments. The Council did not ignore Mr C’s comments about staff and sought to discuss this twice more. Officers were entitled to use their judgement about what to ask Mr C and when. So I do not consider the Council was at fault in its reaction to Mr C’s comments.
72. However, Mr B, as Mr C’s attorney who had made the safeguarding referral, should have known about the second hospital visit in advance. The Council was at fault for not telling him. While it might be unlikely that Mr B’s presence would have resulted in a substantively different result of that visit, the fault causes Mr B some justified frustration and a sense of missed opportunity.

The relevance of complaints from other people

73. Mr B suggests the Council was at fault for not telling him and families of other residents about some other upheld safeguarding complaints. However, the Council’s role was to satisfy itself Home X was taking appropriate action about any such points. The Council is not obliged to tell all residents or their relatives about any upheld safeguarding matters.

The Council not holding a further meeting with Mr B

74. The Council’s minutes of the meeting with Mr B and his associate on 28 July 2017 said, ‘A further meeting to be arranged as required.’ The detailed notes Mr B gave me of this meeting said the Council would await more information then decide if another meeting was needed to discuss the information. Meanwhile, the Council was looking into the safeguarding allegations.
75. The Council says it did not consider another meeting necessary as it believed its written response to the safeguarding referral would deal with Mr B’s concerns. Mr B says the Council has not adequately justified not having a follow-up meeting.
76. The evidence does not suggest the Council committed to another meeting, just that it would consider this. The Council’s role is to conduct a safeguarding investigation and reach its own conclusions. That does not require ongoing discussion with, and input from, the person who raised the concern. So there was no need to discuss this further with Mr B unless the Council thought something had arisen that was best dealt with in a meeting. That was for the Council to judge. I do not see fault here albeit Mr B would have preferred another meeting.

The timescale of the safeguarding investigation

77. The local practice guidance the Council follows states the Council should decide within two working days whether a referral meets the threshold for safeguarding enquiries. The evidence I have seen suggests the Council did not formally decide this until 28 July 2017, over two weeks after the referral. That was fault. The effects were mitigated as the Council had already visited Home X during that time and for most of that time Mr C was not in Home X.
78. The local practice guidance also says most safeguarding enquiries should take place within one month with the reason recorded if that is not possible. This investigation took three months (10 July to 12 October 2017). I have not seen a clear note of reasons for exceeding the normal timescale although it appears some of that time was due to Council staff or others not being available.
79. I do not consider the length of time in itself significantly disadvantaged Mr B or Mr C. Nevertheless, it seems somewhat lengthy for an investigation of this nature.

The effect of the faults I have identified

80. I have not upheld every part of the complaint. I have described above where I consider there was some fault. Those faults caused Mr B avoidable frustration and a sense of missed opportunity. He also went to some time and trouble pursuing matters. Those are injustices.
81. The faults I have found concern how the Council considered safeguarding matters after 10 July 2017. For most of that period, Mr C no longer lived at Home X. So the Council’s faults that I have identified did not directly disadvantage Mr C.

Agreed action

82. At my recommendation, the Council has agreed to:
1. Apologise to Mr B for the injustice caused by the faults I identified.
2. Pay Mr B £200 to recognise that injustice. This comprises £100 for the avoidable frustration and missed opportunity and £100 for the time and trouble.
3. Remind Home X of the kinds of incidents it should report to the Council (for example, if a catheter bag overflows).
4. Review the Council’s handling of this matter and make any necessary changes to procedures or staff training to minimise the chances of the identified faults recurring.
83. The Council should complete points a) to c) within one month of today. It should complete point d) within three months of today.

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Final decision

84. I have completed my investigation because the Council’s agreement to my recommendations will put right the injustice its fault caused, as far as possible.

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Parts of the complaint that I did not investigate

85. I did not investigate matters that had not already been through the Council’s complaints procedure, including concerns Mr B had about some of Home X’s provision of personal care to Mr C.
86. Nor did I investigate any complaints about Home X itself, including the standard of its care and its communications with Mr B. Mr B’s complaint to us was about the Council’s handling of the safeguarding referral, not directly about Home X. Also, such points had not been through the home’s complaints procedure.
87. Mr B also raised incidents dating back to 2013 and 2014, including the response to Mr C falling out of bed. The Council declined to investigate those events because they were so long ago. I consider the restriction described in paragraph 5 applies to this point. If Mr B was concerned about the handling of incidents, he could reasonably have raised it with the home and the Council at the time. If he remained dissatisfied, could reasonably have complained to us much sooner. Also, I do not consider I could reasonably expect to reach a clear enough view about matters so long ago. Therefore I have not investigated those points.

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Investigator's decision on behalf of the Ombudsman