Stockport Metropolitan Borough Council (18 014 455)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 28 Oct 2019

The Ombudsman's final decision:

Summary: Mr X complained the Council failed to provide effective care of his daughter, Miss D, and failed to take responsibility for faults identified by himself and an independent Learning Review. He also complained about the way the Council handled his complaint. The Council was at fault for its failure to carry out an adult social care assessment, take Miss D’s autism into account and in the way it handled safeguarding concerns. The Council also failed to communicate with Mr X both before and after Miss D’s death and to properly conduct the complaints procedure. The Council should apologise to Mr X for these faults, make a financial payment for the unnecessary distress caused to them and provide evidence to the Ombudsman that it has carried out the recommendations of the Learning Review.

The complaint

  1. Mr X complained the Council:
    • did not provide an effective response or care to his daughter, Miss D, between 22 November and 15 December 2016;
    • did not properly investigate his complaint at all stages of the process or respond fully to the issues and questions he raised; and
    • failed to accept any responsibility for the faults identified by himself and the Learning Review or provide a suitable response or remedy.
  2. Mr X says this has caused him and his wife unnecessary distress and frustration. He would like the Council to acknowledge the failings identified by himself and the Learning Review.

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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. I spoke to Mr X and considered the information he provided. This included copies of emails between himself and the Council, complaints correspondence and the Learning Review report.
  2. I made enquiries of the Council and considered the information it provided. This included the minutes of the Safeguarding Adults Board and Miss D’s daily case files.
  3. I considered the following legislation and guidance:
    • Care Act 2014;
    • Care and Support Statutory Guidance and 2014; and
    • Think Autism 2014.
  4. I also referred to the Council’s safeguarding procedures.
  5. I gave the Council and Mr X the opportunity to comment on my draft decision and took those comments into account become making my final decision.

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What I found

Care Act 2014 and the Care and Support Statutory Guidance 2014

  1. Local authorities must undertake an assessment for any adult with an appearance of need for care and support, regardless of whether or not the local authority thinks the individual has eligible needs or of their financial situation. Anyone can request an assessment on behalf of another person.
  2. Section 19 of the Care Act provides local authorities with the powers to meet urgent needs where they have not completed an assessment. Authorities may meet urgent need for care and support regardless of the person’s ordinary residence. Where an individual with urgent needs approaches or is referred to the local authority, the local authority should provide an immediate response and meet the individual’s care and support needs.
  3. Where there is concern about a person’s capacity to make a decision, for example as a result of a mental impairment such as those with dementia, acquired brain injury, learning disabilities or mental health needs, a face-to-face assessment should be arranged.

Autism

  1. The statutory guidance states that local authorities must ensure that all frontline staff have general autism awareness so staff can identify potential signs of autism, understand how to make reasonable adjustments in their behaviour and communication.

Safeguarding

  1. Where a person is at risk of abuse or neglect, local authorities must act swiftly and put in place an effective response. When carrying out an assessment, local authorities must consider the impact of the adult’s needs on their wellbeing. If it appears to local authorities that the person is experiencing, or at risk of, abuse or neglect, they must carry out a safeguarding enquiry and decide with the adult in question what action, if any, is necessary and by whom.
  2. The Council’s safeguarding procedures state the following:
    • managers of ASC must respond to all safeguarding alerts on the same day that they are brought to their attention. A decision must be made on the same day whether immediate action is required;
    • if the alert meets the criteria for an investigation, a strategy discussion must take place as soon as possible and within five days of the alert being received;
    • the investigation must take place within 25 days from receipt of the alert;
    • a case conference meeting to discuss the findings of the investigation must take place within 28 days of the receipt of the alert; and
    • if required, review meetings should be scheduled at the case conference.
  3. The policy says the factors the Council will take into account when deciding if a case warrants further action includes:
    • the level of vulnerability;
    • the views and opinions of other staff in partner organisations; and
    • the impact of the abuse on the individual.

Safeguarding Adult Boards

  1. Every council must set up a safeguarding adult board (SAB) for its area to help and protect adults who have care and support needs, is experiencing or is at risk of abuse or neglect and is unable to protect themselves from that neglect or abuse or risk of neglect or abuse.

Safeguarding Adult Reviews

  1. The Care Act 2014 states a SAB must carry out a review if an adult has died as a result of abuse or neglect and there is reasonable cause for concern about how the SAB, members of it or other persons worked together to safeguard the adult.

Council’s Multi-Agency Adults at Risk System (MAARS) Panel

  1. The MAARS Panel is an area-wide group formed of different partners within the Council area. The aim of the panel is to provide a single pathway for partner agencies to highlight adults at risk who are coming into contact with the partner’s services but do not necessarily meet the threshold for those services.
  2. The focus is on identifying a lead agency. The Council gives the following examples of need presented to the panel – threat of homelessness, complex needs, risk of harm to themselves or others, substance misuse, low level mental health.

The Council’s corporate complains policy

  1. The Council has a two stage complaints policy. At both stages, this says the Council aims to respond within 20 working days. If this is not possible, it states it will keep the complainant updated of progress and how long the investigation will take.

What happened

  1. The events concerned with this complaint took place between 16 November 2016 and Miss D’s death on 15 December 2016.
  2. Although a number of different agencies were involved, this investigation only considered the actions of the Council.
  3. Miss D was 18 years old and was adopted by Mr and Mrs X when she was of pre-school age.. She had a diagnosis of severe epilepsy and Autism Spectrum Disorder. At the time of her death, she was under the care of an epilepsy consultant and a private psychotherapist because of her challenging behaviour.
  4. Prior to her death, there had been a deterioration in Miss D’s behaviour generally and also in her relationship with her parents. During November 2016, the police and the ambulance service were involved, and Miss D also visited the emergency department of the local hospital. Miss D’s hospital notes recorded she was feeling suicidal, was self-harming and was sleeping rough.

16 to 17 November

  1. On 16 November 2016, the police took Miss D to the emergency department as she had collapsed in the town centre and had suffered a major epileptic fit. Miss D was discharged the following day, 17 November, to a Council run emergency overnight placement at Hostel H. An appointment was arranged with the organisation (Group G) which ran the Council’s social housing stock to discuss her longer-term plans for accommodation.
  2. On the same day as discharge, the hospital sent a safeguarding referral to the Council. This said “A deterioration in relationship with parents over last 2 months resulting in episodes of deliberate self-harm. She has not been sleeping at home… she has been sleeping in the doorway of a supermarket”.
  3. Mr X contacted Group G that day. Group G told him Miss D would be interviewed later that day and it was likely she would be allowed to stay at Hostel H for a few weeks. After that, Group G would decide where she should be placed longer-term.
  4. Also on the 17 November, Mr X visited the Council offices and registered his concerns about Miss D’s vulnerabilities with Adult Social Care (ASC). Later he was passed to a member of staff in ASC who again took some details. Mr X told the staff member that Miss D had autism and epilepsy and was particularly vulnerable in relation to her ability to manage her epilepsy medication, finances, drug use and mental health. He said he also had concerns she was at risk of sexual exploitation. Mr X says he was told someone would telephone him later that day, but no one did.

18 and 19 November

  1. A duty housing officer interviewed Miss D on 18 November. The notes record that Miss D said she was frightened to return home. The notes also recorded “She has epilepsy which at the moment appears unstable… [Dr Z] … has expressed concerns… regarding epilepsy and self-harm, risk of overdose and suicidal ideation… [Miss D] also claims to be pregnant… I feel [Miss D] is very vulnerable at the moment… however due to lack of agency involvement to date it is difficult to confirm the details above… it is difficult to establish whether there is a genuine risk to her welfare if she were to return home”. The duty housing officer did not pass this information onto anyone else until 24 November.
  2. A statement by an ASC manager, Officer C, to the coroner after Miss D’s death, recorded the duty housing officer contacted Miss D’s epilepsy consultant. The statement recorded the consultant said Miss D was generally vulnerable and had a tendency to misrepresent events.
  3. The duty housing officer spoke to Hostel H who said once Miss D became a resident at Hostel H she would receive a key worker who would provide support about rehousing, benefits and education or employment. Currently, because there was a lack of beds, Miss D was sleeping on one of the settees at Hostel H.
  4. The Council’s out of hours service contacted Miss D on the nights of 18, 19 and 20 November to check she had returned to Hostel H and was taking her epilepsy medication.
  5. 22 to 28 November
  6. On 22 November, Mr X emailed a social worker, Officer F, in ASC and highlighted Miss D’s vulnerability, including her long-standing and serious psychological issues and the fact she was vulnerable to physical and sexual exploitation. He asked the Council to provide Miss D with a care plan and to address issues of safeguarding via an immediate multi-agency referral. Mr X provided details about Miss D, including the fact she was receiving therapy from a psychotherapist. Mr X said Miss D could be suffering from disassociative disorder, as well as autism and epilepsy. Officer F forwarded the email to Officer C the same day.
  7. On 24 November, the duty housing officer emailed the notes of the telephone call with Miss D from 18 November to the ASC contact centre. The contact centre forwarded the email to Officer C the same day.
  8. Officer C asked her manager, Officer Z, on the same day, for advice about whether ASC should take on Miss D’s case or whether they should refer her to mental health services.
  9. On 28 November, Officer Z replied to Officer C and said she should refer Miss D to the multi-agency adults at risk system (MAARS) panel. Officer Z said Miss D might need an adult social care assessment at a later date. Officer C made the referral and closed Miss D’s case.
  10. On the same date, the After Adoption Team contacted Officer F and offered to provide information about Miss D. Officer F said she was not the designated social worker and told the Team to contact the general ASC telephone number.

29 November to 6 December

  1. On 29 November, Officer C contacted Mr X. She said the Council would follow up with housing, mental health and children’s services to determine who was best placed to deal with Miss D’s issues. This was the first time the Council contacted Mr X after he raised concerns with it on 17 November.
  2. On 4 December, Miss D was taken to hospital after suffering a second major epileptic fit. Miss D suffered a third major fit in the town centre on 6 December.

7 to 14 December

  1. On 7 December, Mr X sent a detailed email to Officer C which provided more information about Miss D’s immediate vulnerabilities and state of mind. Mr X said Miss D had shown a marked deterioration in her physical health and had suffered two major fits in the last three days. He reiterated Miss D’s troubled history and the fact she had autism. He said there were significant safeguarding issues and she was at risk from sexual exploitation. He wrote “Leaving her to her own devices and allowing her complete self-determination as an adult would thus seem to us to be a highly likely recipe for at least one or more kinds of disaster”.
  2. On 7 December, Officer Z chaired a meeting of the MAARS panel. The minutes noted “Currently stable at [Hostel H]. May not need MAARS input. Does not appear to have eligible needs under the Care Act”. The panel did not identify a lead agency to take Miss D’s case forward.
  3. Officer C emailed Mr X on 8 December and said further discussions about Miss D were needed about who would be the lead agency and she would respond to his concerns by the end of the week.
  4. Mr X said he and Mrs X managed to keep some contact with Miss D whilst she was in Hostel H. Mrs X visited her on 10 December and was concerned that she seemed to have lost a significant amount of weight. Mr and Mrs X also spoke to Miss D by phone on 14 December.
  5. Miss D was found dead on the morning of 15 December in Hostel H. The coroner determined that her death was due to natural causes linked to her epilepsy.

Events following Miss D’s death

  1. In October 2017, Mr X complained to the Council and two NHS Trusts about their actions in relation to Miss D from 16 November 2016 to her death. Mr X’s complaints about the Council included:
    • it failed to take any timely or suitable actions, or follow its own policies or statutory guidance, when he raised safeguarding concerns about Miss D on several occasions:
    • it failed to carry out a face to face meeting with Miss D; and
    • the MAARS panel failed to consider relevant information or take appropriate action at its meeting on 7 December 2016.
  2. The Council responded in November and said it would make a referral to its SAB to consider whether it should consider Mr X’s complaints under its safeguarding adults review process. The Council told Mr X the SAB would be chaired by an independent person and would have the power to call for evidence from all parties involved.
  3. The Council wrote again to Mr X at the beginning of December 2017. It told him it had decided to carry out a safeguarding adults review into the events leading up to Miss D’s death.
  4. Mr X heard nothing further from the Council. Therefore, he phoned at the end of January 2018. The Council told him that it had now decided not to carry out a safeguarding adult review but would instead look at his complaints through a multi-agency Learning Review process. Mr X says the Council did not give him an explanation for the change in plans. Mr X says the Council also told him the multi-agency Learning Review would not look to apportion blame, but would focus on identifying possible improvements for future practice.
  5. In February, the independent person (IP) who the Council had appointed to carry out the Learning Review met with Mr and Mrs X.
  6. On 3 March, the IP emailed Mr X and said that following his meeting with Mr and Mrs X, the Council had decided the review would not go ahead at this stage and instead the Council and NHS trusts would provide a joint response to his complaints. The IP said a decision about whether to restart the Learning Review would be made following the completion of the complaints process.
  7. Mr X heard nothing further from the Council. Therefore, he emailed it for an update on 1 April 2018. The Council responded on 27 April and apologised for not responding sooner. It said it was holding a meeting with the NHS trusts involved in the events on 27 April and would send a joint response following that.
  8. The Council responded to Mr X about his complaint on 12 September 2018, on behalf of itself and the two NHS trusts. The letter apologised for the “extensive length of time it has taken to respond to your complaint”.
  9. In relation to the complaints about the Council, the response said:
    • the Council arranged for Miss D to be placed in Hostel H because there was no medical need for her to be admitted to hospital, it was felt a placement by Adult Social Care would produce better outcomes and Miss D had expressed to staff at the hospital a wish for long-term housing and to have a social support structure;
    • Miss D did not meet the thresholds for an assessment under the Care Act 2014;
    • the decision to refer Miss D to the MAARS panel was the correct one and “if the planned discussion had taken place at the January panel, it was likely that [Miss D] would have been offered support through the Prevention Alliance. The Prevention Alliance is commissioned by Stockport Council to provide support to adults who have needs for support but who do not meet the threshold for adult social care support”; and
    • it believed that its actions in relation to Miss D met their service standards and its general responsibility to safeguard Miss D.
  10. The Council apologised for “any lack of clarity in describing how support would be provided for [Miss D]”. It said it had now introduced a ‘team around the adult’ process to ensure all agencies were aware of what actions were being taken with the individual and who the lead agency was.
  11. Mr X contacted the Council again on 1 October 2018 and said he was dissatisfied with its response. He disagreed the Council had met its service standards to safeguard Miss D. Mr X also asked for further clarity over what the Council meant when it said Miss D did not meet the threshold for adult social care support.
  12. The Council responded on 12 November and suggested a meeting with Mr X to discuss his outstanding issues. This took place on 13 December 2018.
  13. Mr X took notes at the meeting and he recorded the Head of Safeguarding who was also the chair of the MAARS panel said “We didn’t do a very good job in caring for your daughter”.
  14. Mr X’s notes of the meeting record the principal social worker said ASC’s lack of any face-to-face meeting with Miss D was a failing, as was the lack of further investigation into her vulnerabilities and needs. As a result, ASC failed to carry out an assessment of Miss D’s needs and the risks to her.
  15. Mr X’s notes record the principal social worker told him some new arrangements had been introduced and a daily ‘at risk’ meeting would be held with a social worker in addition to ASC’s existing call centre arrangements.
  16. Mr X’s notes said he told the attendees that if they responded to his complaint letter in line with what had been agreed at the meeting and also answered the additional questions he had already put to the Council, this would address all his issues. The chair of the MAARS panel asked him if he would like a further meeting with the IP of the Learning Review. Mr X said he would.
  17. The additional questions put to the Council by Mr X were about:
    • the specific actions of particular staff;
    • how the Council dealt with individuals who did not seem to meet the threshold for an adult social care assessment and/or have capacity;
    • safeguarding actions;
    • how particular staff investigated his complaint;
    • whether the Council could provide details of the learning points it had taken from Miss D’s case; and
    • an indication of when the Council would provide a response to these matters.
  18. On 29 February 2019 the IP completed his review and issued a report to Mr X and the SAB. This did not comment on whether the Council had acted with fault but identified where “there was any learning” from Miss D’s case.
  19. The report identified seven learning points. These included:
    • Miss D had autism. However, the professionals involved did not fully understand her needs and her autism and, therefore, the best way to communicate with her;
    • The decision not to carry out an adult social care needs assessment “fell below expected standards”. Relevant professionals needed better understanding of the Care Act requirements, the Care and Support Statutory Guidance and the Autism Act 2010;
    • When Miss D went into Hostel H there was no clarity as to her long-term needs, the support she required and how it should be co-ordinated;
    • It “would have been expected” that once Miss D was resident at Hostel H, she should have received a timely face-to-face meeting;
    • Agencies had not addressed the issues raised by Miss D when she was in hospital in relation to her self-harming, and her claim her mother had hit her;
    • Miss D’s parents made a number of telephone calls and visits to the Council expressing their concern. However, no face-to-face meeting took place and the Council offered them no support; and
    • When the IP held a meeting of professionals for his review, they spoke of there being no strategic vision for how to deal with cases such as Miss D’s and of feeling overwhelmed by the number of cases similar to hers.
  20. The Council provided some information on the work it had carried out already to address issues which had arisen in Miss D’s case. The IP also made a number of recommendations around the learning points in paragraph 65.
  21. Mr X remained unhappy and complained to the Ombudsman.

My findings

Outcome of the independent Learning Review

  1. The investigation carried out by the independent reviewer was thorough and proportionate. The reviewer interviewed the relevant officers, spoke to Mr and Mrs X, considered Miss D’s case notes and came to robust, evidence-based findings. The reviewer made relevant recommendations and learning points. There was no fault in how the Council conducted Learning Review.
  2. However, because the role of the review was to learn lessons, and not identify which agency was at fault, the reviewer was unable to come to a conclusion on whether the Council acted with fault. Therefore, my investigation has considered this matter based on the learning points identified by the review.

Council failure to take Miss D’s autism into account

  1. The Learning Review found some officers did not fully understand Miss D’s needs resulting from her autism and, therefore, the best way to communicate with her.
  2. The Autism Strategy 2010 says councils should provide autism awareness training to all staff. The Council’s response to my enquiries said it had no record of the duty housing officer who interviewed Miss D receiving any autism training. This is not in line with the law and it is fault.
  3. As a result, the Council missed an opportunity to communicate in the most effective way with Miss D.

Council’s decision not to carry out an adult care assessment and lack of long-term planning when Miss D was in Hostel H

  1. The Learning Review found that “The decision not to undertake a Care Act assessment with [Miss D] was practice that fell below expected standards… [there was] no clarity as to what her longer term needs were, what support she needed and how it should be coordinated”.
  2. The law says local authorities must undertake an assessment for any adult with an appearance of need for care and support, regardless of their financial situation or whether or not the local authority thinks the individual has eligible needs. If the Council had carried out an assessment, it would have enabled it to make long-term plans to meet any identified eligible needs Miss D had.
  3. Notwithstanding this duty to assess any adult with an appearance of need for care and support, Miss D had strong indications of eligible needs. She had been admitted to hospital after a serious epileptic fit, Mr X had informed officers she was not taking the medication needed to control her epilepsy, she was sleeping rough, was self-neglecting and Mr X had said she was at risk of financial and sexual abuse. In addition, Miss D had autism and learning difficulties. The Council should have made arrangements to carry out a face-to-face Adult Care assessment when the hospital and Mr X first made it aware of the situation on 17 November. The Council failed to act in line with the Care Act and Statutory Guidance when it did not do so. This is fault.
  4. Instead, the Council referred the matter to the SAB which decided on 7 December, despite having had two further serious epileptic fits, that Miss D did not meet the threshold for an assessment under the Care Act. The MAARS panel did not have the authority to make this decision and even it did, I am not persuaded this decision was either robust or evidence-based. This is fault.

Safeguarding issues

  1. The hospital and Mr X made a safeguarding referral about Miss D to the Council on 17 November. The Council failed to take immediate action to contact Miss D to ascertain the risk she was under. Instead, the housing section contacted her on 18 November for a telephone interview. As a result of this interview, it decided Miss D should remain at the hostel for the immediate future. Although these were appropriate steps to take in relation to Miss D’s housing situation, they failed to address the issues relating to her other care needs. These actions also failed to explore Miss D’s claims that she was afraid to return home.
  2. The is no evidence a safeguarding manager carried out a formal assessment of the referrals made by the hospital and Mr X. The Council’s safeguarding policy states when making a decision about whether to carry out a formal safeguarding investigation, issues such as the person’s vulnerability, the impact of the abuse and the views of other professional should be taken into account. Miss D had autism, learning difficulties and previous ongoing mental health issues. She was self-neglecting by not taking her medication which was likely to, and did, have catastrophic results, and her father had said she was at risk of sexual and financial risk. It is likely, that if the Council had assessed these details against its policy, it would have deemed a formal investigation was required. It failed to do so and this is fault.
  3. Instead, despite noting that she was “very vulnerable”, the housing section failed to refer the matter to ASC until 24 November, six days later. This is delay and is fault.
  4. When ASC received the information from the housing service, it should have again considered this against its safeguarding procedures. There is no evidence it did and this is fault.
  5. The Council failed to contact Mr X for 12 days after he made the referral. The Council also failed to hold a face-to-face meeting to discuss Mr X’s concerns at any stage before Miss D’s death. Given the level of safeguarding issues raised by Mr X, together with the referral from the hospital and the fact Miss D had autism and learning difficulties, this is fault.

Injustice resulting from the Council’s fault

  1. The Council failed to act with any sense of urgency when it became of Miss D’s situation on 17 November. Despite having strong indications of multiple eligible needs. The Council failed to carry out a social care assessment, instead determining some weeks later that Miss D failed to meet the threshold for an assessment.
  2. The Council failed to follow its own safeguarding procedures, which meant the referral made by Mr X and the hospital were not assessed immediately. Instead, Miss D was interviewed by a duty housing officer who, despite recording she was “very vulnerable”, failed to pass the interview records to ASC for six days.
  3. The Council failed at all stages in the process to hold a face-to-face meeting with Miss D or with Mr X at any stage before Miss D’s death.
  4. Mr X does not complain that there is a direct causal link between the Council’s actions and Miss D’s death. However, he is left with an enduring uncertainty over whether the outcome could have been different if the Council had acted sooner and without fault. The Council should apologise for this and the other faults identified in this investigation and make Mr and Mrs X a symbolic financial payment to acknowledge this.

Council delayed in dealing with Mr X’s initial complaint

  1. Mr X made his initial complaint in October 2017. He did not receive a response until September 2018, nearly one year later.
  2. Although some of the delay can be explained by the Council’s decision to hold a safeguarding adult review, its subsequent decision to change this to a Learning Review and then the need for the Learning Review IP to meet with Mr X, there were still significant and unnecessary delays. For example:
    • the Council told Mr X at the beginning of December 2017 it would hold a safeguarding adult review. Mr X heard nothing further for around eight weeks and had to phone for an update;
    • the IP told Mr X at the beginning of March 2018 the Council would respond to his complaint via the complaints procedure. Mr X heard nothing further and had to telephone at the beginning of April to request an update. The Council failed to respond to his request for a further four weeks when it said it would send a response after meeting with the NHS trusts. In reality, the Council did not provide its response until 12 September 2018, about 26 weeks later, and nearly one year after Mr X made his complaint.
  3. These delays are significant and are fault. The Council has already apologised to Mr X for the delays in responding to his complaint in a timely manner. However, this is not sufficient. The Council should also make a payment to remedy the prolonged distress and frustration these unnecessary delays caused Mr X.
  4. In addition, the Council’s communication with Mr X was poor when it failed either to inform him of its decision not to hold a safeguarding adult review or the reasons why. This is fault.
  5. This added to Mr X’s distress in an already difficult situation as he had to chase the Council for a response and for an explanation of why it had decided not to hold a SAR.

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Agreed actions

  1. Within one month of the date of the final decision, the Council has agreed to:
    • apologise to Mr and Mrs X for the faults identified in this investigation; and
    • make a symbolic payment of £1,000 to them to acknowledge these faults.
  2. Within three months of the date of the final decision, the Council has agreed to provide the Ombudsman with evidence it carried out the recommendations from the Learning Review.

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Final decision

  1. There was fault leading to injustice. The Council has agreed to my recommendations. Therefore, I have completed my investigation.

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Investigator's decision on behalf of the Ombudsman

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