London Borough of Haringey (18 004 554)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 18 Dec 2018

The Ombudsman's final decision:

Summary: Ms X complains the Council failed to properly investigate her safeguarding concerns in relation to her father. Based on the information currently available, there was fault in the way the Council responded to Ms X and her family’s safeguard concerns. This fault has caused Ms X an injustice in the form of distress and anxiety, and has put her to unnecessary time and trouble.

The complaint

  1. The complainant, whom I shall refer to as Ms X complains the Council failed to properly investigate her safeguarding concerns in relation to her father.

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The Ombudsman’s role and powers

  1. 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
  2. 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

  1. As part of the investigation, I have:
    • considered the complaint and the documents provided by Ms X;
    • made enquiries of the Council and considered the comments and documents the Council provided;
    • discussed the issues with Ms X;
    • sent a statement setting out my draft decision to Ms X and the Council and invited their comments. I have considered Ms X’s response.

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What I found

  1. Safeguarding means protecting an adult’s right to live in safety, free from abuse and neglect. Councils must make sure they promote the wellbeing of people at risk. They should also consider the person’s views, wishes, feelings and beliefs when deciding on any action. If the person cannot make a decision (lacks mental capacity) about safeguarding, the actions a council takes should be in their best interests. (Care and Support Statutory guidance, Sections 14.7 and 14.79)
  2. The Care Act requires councils to make enquiries if they believe an adult is experiencing, or is at risk of, abuse or neglect. An enquiry should determine whether the council needs to take any action to prevent or stop abuse or neglect. Councils must act proportionately when undertaking safeguarding work. (Care Act 2014, Section 42, Care and Support Statutory guidance, Sections 14.10 and 14.13)

Key facts

  1. Ms X’s father, Mr Y had dementia. In July 2017 Ms X contacted the Council to raise concerns about Mr Y’s welfare. Ms X told the Council her brother, Mr Z who had not been in contact with Mr Y for 15 years, had recently moved in with him. Ms X was concerned Mr Z was financially abusing Mr Y.
  2. At around the same time, Mr Y’s GP asked the Council to carry out a care assessment. The GP was concerned Mr Y was experiencing memory impairment which was impacting on his ability to cope at home. According to the Council’s records this assessment did not go ahead as Ms X told the Council Mr Y was managing his care needs and his family were supporting him.
  3. In December 2017 members of Mr Y’s family contacted the Council to request a care assessment. They were concerned Mr Y’s health and ability to cope had declined. The family were also concerned Mr Z was preventing other family members visiting or assisting Mr Y. Mr Y’s church elder also raised concerns about his welfare.
  4. The safeguarding team contacted Mr Y and spoke to Ms X and other family members. The triage notes confusingly state both that Mr X has been assessed as lacking mental capacity, and that he has mental capacity. It also notes that Mr Y did not give consent to carry out the enquiry “due to his dementia”.
  5. The safeguarding team considered the level of safeguarding risk to be medium and recommended a care assessment. The Council allocated Mr Y’s case to a social worker on 16 January 2018. The social worker arranged a meeting for 1 February 2018 but this did not go ahead as Mr Y was unwilling to leave the house for the meeting.
  6. The social worker visited Mr Y at home on 8 February 2018 to carry out a welfare check. The records of this meeting state Mr Y was able to communicate, but his memory impairment was evident. Mr Z told the social worker Mr Y could wash and dress himself and prepare his own meals. Mr Y also enjoyed going to church.
  7. The social worker visited Mr Y at home again on 16 February 2018 and arranged for Mr Y and Mr Z to attend the Council offices on 20 February 2018 to carry out the care assessment. The assessment did not take place as Mr Z attended the meeting without Mr Y.
  8. It is unclear whether the assessment was rescheduled. According to the Council’s records the social worker next contacted Mr Z on 27 March 2018 and left a message asking him to contact them.
  9. In early April 2018 a family member contacted the Council to raise concerns about Mr Y. They told the Council Mr Z was preventing family members from seeing Mr Y. They were concerned that Mr Z had taken over Mr Y’s finances, but there was no food in the house.
  10. Officers visited Mr Y’s home with the police on 5 April 2018 to carry out a welfare check. Mr Z would not allow access to the property.
  11. Mr Y’s social worker met with Mr Y and Mr Z at the Council’s offices on 18 April 2018 to carry out the care assessment. They were unable to complete the assessment so agreed to continue at Mr Y’s home on another day. A couple of days later Mr Z contacted the social worker to say Mr Y did not want any care and did not need the assessment. Mr Y also confirmed this, although the social worker noted they could hear Mr Z telling Mr Y what to say.
  12. In early May 2018 Ms X made a formal complaint about the way the Council had dealt with her safeguarding concerns. The Council set out the action it had taken to investigate Ms X’s concerns and to establish whether Mr Y wanted a care assessment, and had capacity to make decisions about his care. The Council was liaising with other professionals and was awaiting feedback so it could decide whether to take matters further.
  13. The social worker contacted Mr Y’s GP to request a referral for a psychogeriatric assessment and mental health screening for Mr Y. The GP agreed to make a home visit, but this did not take place. Mr Z had agreed to bring Mr Y to the surgery for a check up, but did not keep the appointment.
  14. On 4 June 2018 social workers visited Mr Y’s home with Ms X and other family members. They carried out a care assessment and mental capacity assessment. These assessments concluded Mr Y did not have capacity to manage his health and welfare, and needed support to ensure his well-being at home and in the community. The care assessment recommended Mr Y receive support with personal grooming and an escort to and from the church each week.
  15. Following the assessment the Council commissioned a package of care for Mr Y, which began on 15 June 2018. The care agency advised the Council they had been unable to provide care as Mr Z had said Mr Y did not need their services. Mr Y had also declined their support. The Council advised the care agency to continue to attend and offer services in line with the support plan.
  16. Ms X continued to raise concerns about Mr Y and asked for them to be logged as a safeguarding alert
  17. On 25 June 2018 Mr Y’s psychiatrist raised a safeguarding alert. They had attempted to visit Mr Y at home, but he refused to see her. The psychiatrist noted Mr Y looked significantly under-weight and was confused. They were concerned Mr Y was vulnerable and at risk of neglect, financial abuse and control.
  18. The social worker and police carried out a welfare check on 26 June 2018. They spoke to Mr Y and Mr Z through a window, but Mr Y would not let them enter the property.
  19. The Council arranged a best interest meeting on 12 July 2018 and made a referral to an advocacy service. On 5 July 2018 the advocate told the Council he had discussed the matter with Ms X and her family, but Mr Z had refused to allow him access to Mr Y. The advocate asserted the Council or other agencies should use their powers to take Mr Y in to hospital as a matter of urgency, rather than wait for the best interests meeting on 12 July 2018.
  20. On 8 July 2018 Ms X visited Mr Y and took him to hospital. Mr X was admitted for observation and assessment. The records of the best interests meeting on 12 July 2018 note that Mr Y did not have any medical problems which required him to stay in hospital. The family, hospital staff, advocate and Council all agreed Mr Y’s needs could be best met in a nursing home. Ms X and her family found a suitable home, and Mr Y moved there when he was discharged from hospital on 8 August 2018.
  21. Since raising this complaint with the Ombudsman, Mr Y has passed away.
  22. In response to my enquiries, the Council states it received a number of concerns which were initially identified as a safeguarding concern. Some were triaged by the safeguarding team and referred to Mr Y’s social worker to include in Mr Y’s care management.
  23. The Council did not hold any formal safeguarding meetings. It considered this but the Safeguarding manager recommended that due to the difficulties in engaging with Mr Y further attempts were made to engage with him. They also recommended contacting other professionals involved in Mr Y’s care.
  24. The Council has gathered information regarding all concerns raised and is drawing this together under a section 42 enquiry to ensure the actions taken have been proportionate.
  25. Ms X has responded to the draft decision and reiterated her concerns that he Council did not respond appropriately to her concerns about Mr Ys welfare. She does not feel the Council took her concerns seriously. It did not respond to her correspondence or keep her informed. She was unaware until she complained that social workers had visited Mr Y. Ms X states the Council’s response to my enquiries is incomplete as it does not refer to all of her did calls and emails to the Council.


  1. The documentation provided shows there was fault in the way the Council responded to Ms X and her family’s safeguard concerns. There were delays in appointing a social worker, in carrying out the care assessment and mental capacity assessment, and in providing an advocate. The Council also failed to hold formal safeguarding meetings or review whether safeguarding would be appropriate.
  2. When the case was allocated to a social worker in January 2018, the supervision/ manager’s decision notes record that Mr Y’s capcity is unknown. The note states the social worker should:
    • Contact the GP to ascertain if they have any concerns;
    • Carry out a mental health assessment to ascertain whether Mr X is able to make decisions regarding his welfare, particularly, where he lives and who looks after him;
    • Carry out an assessment of needs and offer a supportive package.
  3. Although the social worker met with Mr Y in February 2018, they did not carry out a mental capacity assessment, nor did they contact Mr Y’s GP.
  4. A management note of 6 February 2018 also suggests that, given the family’s ongoing concerns the social worker should discuss with their manager whether to commence a safeguarding investigation. There is no record of any discussion between the social worker and their manager about safeguarding.
  5. The social worker began a care assessment in February 2018, but this was not completed and the process was allowed to drift for over a month.
  6. A safeguarding manager’s update on 6 April 2018 also sets out several actions that need to be taken. These include that the social worker:
    • carry out a care assessment at Mr Y’s home, with an advocate within a week of the social worker returning from leave;
    • carry out a mental health capacity assessment;
    • make a referral to Mr Y’s GP to request an up to date mental health assessment; and
    • arrange a formal safeguarding meeting within five working days of the social worker returning from leave.
  7. There is no record of a formal safeguarding meeting within this timeframe, and the care assessment and mental capacity assessments were not completed until June 2018. The Council did not appoint an advocate until late June 2018.
  8. I recognise some of the delay was due to Mr Y and Mr Z’s unwillingness to engage, but would have expected the Council to be more proactive in its approach given the concerns raised.
  9. Having identified fault, I must then consider whether this has caused an injustice. The principle injustice in this case would have been to Mr Y. There were concerns about Mr Y’s mental capacity from the outset. Had the Council acted in a timely manner and carried out assessments at the earliest opportunity, it is possible best interest decisions could have been made to assist and support Mr Y much earlier. Unfortunately, Mr Y has passed away, so we are unable to remedy any injustice to him.
  10. I consider Ms X has also suffered an injustice because of the Council delays and failure to properly investigate her concerns. Ms X has suffered distress and anxiety and been put to unnecessary time and trouble in trying to resolve this matter. Ms X states that when Mr Y was admitted to hospital he was diagnosed with malnutrition and lung cancer. He had been socially isolated and living in unacceptable conditions. She is left with the uncertainty of whether this could have been avoided if the Council had responded promptly and appropriately.
  11. I note the Council is reviewing how it dealt with this matter as part of a s42 enquiry, and would expect it take appropriate action to address any issues this identifies.

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Agreed action

  1. The Council has agreed to apologise to Ms X and pays her £250 in recognition of the distress and anxiety she has experienced because of the failings in the way the Council dealt with her safeguarding concerns. The Council should do this within one month of the final decision.

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Final decision

  1. There was fault in the way the Council responded to Ms X and her family’s safeguard concerns. This fault has caused Ms X an injustice in the form of distress and anxiety.

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Investigator's decision on behalf of the Ombudsman

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