Summary: Mr & Mrs C complain about matters relating to a safeguarding investigation that the Council carried out after Mrs C’s mother received an oxygen overdose at a care home. There was fault in how the Council responded the Mr & Mrs C’s complaint, and it has agreed to a suitable remedy.

The complaint

1. The complainants, whom I shall refer to as Mr & Mrs C, complain on behalf of Mrs C’s late mother, whom I shall refer to as Mrs T. They complain that the Council failed to answer questions about a safeguarding investigation it carried out into Mrs T.

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The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’. In this statement, I have used the word fault to refer to these. We must also consider whether any fault has had an adverse impact on the person making the complaint. I refer to this as ‘injustice’. If there has been fault which has caused an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
3. If we are satisfied with a council’s actions or proposed actions, we can complete our investigation and issue a decision statement. (Local Government Act 1974, section 30(1B) and 34H(i), as amended)

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How I considered this complaint

4. As part of the investigation, I have:
• considered the complaint and information received from Mr & Mrs C; and
• reviewed and considered information received from the Council; and
• communicated with Mr & Mrs C about the complaint.
5. I also sent a draft version of this document to both parties and invited their comments.

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What I found

Background

6. Mrs T was 80 years old at the time of these events and was residing in a care home. She was suffering from Chronic Obstructive Pulmonary Disease and therefore was receiving oxygen.
7. The Council started a safeguarding investigation, after Mrs T was admitted to hospital suffering from an overdose of oxygen, and it was suspected that staff at the care home has set the oxygen level too high.

What happened

8. The Council concluded that the safeguarding investigation had been inconclusive. It found Ms T’s oxygen levels had been set too high, but there was no evidence the care home was responsible for this.
9. The Council closed the case on the basis that service improvements at the care home were implemented, and Mrs T was safe because she had moved to another care home.
10. Mr & Mrs C were dissatisfied with the safeguarding investigation and raised several issues with the Council. The Council investigated these under its complaints procedure and provided Mr & Mrs C with its final response.
11. Mr & Mrs C remained dissatisfied with the responses to three questions they raised. These were:
1. The safeguarding report said that a Council Social Worker, whom I shall refer to as SW1, spoke to a member of staff at the hospital which Mrs T was admitted to. Mr & Mrs C asked for the name of this member of staff.
2. The Council told Mr & Mrs C that an Agency Social Worker, whom I shall refer to as SW2, liaised with the Social Team at the hospital Mrs T which was admitted to. Mr & Mrs C asked for the names of the people SW2 spoke to.
3. The Council told Mr & Mrs C that Mrs T’s case on the Council’s computer system had been closed on 12 January. Mr & Mrs C say this is impossible as the safeguarding referral wasn’t made until after this date. They therefore asked what date the case was closed.
12. The Ombudsman made enquiries with the Council about Mr & Mrs C’s complaint and asked them to provide a response to the three questions raised.
13. The Council said that although a thorough investigation into Mr & Mrs C’s complaint had been carried out, there had been significant errors and questions remained unanswered.
14. In response to question 1, the Council said the name of the member of staff was not recorded at the time. The Council said it had since attempted to identify this member of staff but had been unsuccessful.
15. In response to question 2, the Council said the information it provided to Mr & Mrs C was inaccurate, as it referred to another safeguarding referral. The Council accepted that it identified this error but had not communicated it to Mr & Mrs C.
16. In response to question 3, the Council accepted it had given Mr & Mrs C the incorrect date, and the correct date the case was closed was 23 July 2018. The Council said this error was caused by SW2 not understanding the computer system, and the computer system not having a default in place to stop errors such as this.

Analysis

17. In its response to the Ombudsman, the Council has accepted that it did not provide accurate information to Mr & Mrs C and it did not respond accurately when they complained about this.
18. The Council said it had taken the following actions to mitigate the faults it had identified from reoccurring:
• Addressed the recording of accurate case notes with SW1.
• Corrected the system fault which allowed SW2 to make the mistakes she made.
• Terminated the contract of SW2.
19. In addition, the Council also proposed to undertake the following remedies:
• Offer to meet with Mr & Mrs C to apologise for failing to provide an adequate response to their complaint.
• Provide a response at director level, which will include evidence of actions taken to improve the safeguarding process and offer an apology to Mr & Mrs C.
• Offer Mr & Mrs C a payment of £250 in recognition of the distress and anxiety caused.
• Offer Mr & Mrs C a further payment of £250 in recognition of the time and trouble they went to pursuing their complaint.
20. I have considered the proposals the Council have made in relation to improving its service and have concluded that it has taken reasonable steps to mitigate similar faults occurring in the future.
21. I also consider that an apology to Mr & Mrs C in person, and at director level is appropriate in this case.
22. I have also considered the financial remedies proposed by the Council.
23. An injustice such as distress is unlikely to be remedied by a payment, so we often seek a symbolic amount to acknowledge the impact of fault on a complaint. The Ombudsman’s remedy guidance says that any remedy should reflect the circumstances of the case, including the severity of the distress and the length of time involved. It says payments are often between £100 and £300.
24. The Ombudsman’s remedy guidance also explains that when a complainant has been to significant time and trouble pursuing their complaint, we recommend payments of between £100 to £300, which should reflect the level of difficulty experience by the complainant.
25. Having considered the circumstances in this case I consider the distress Mr & Mr C would have suffered to have been high and has continued for a relatively long time due to the Council providing inaccurate responses.
26. Furthermore, I consider that because of the inaccurate responses, Mr & Mrs C went to significant time and trouble bringing their complaint to the Ombudsman.
27. For these reasons I conclude that the Council’s offer of £250 for distress, and £250 for the time and trouble to be acceptable in this case.

Agreed action

28. The Council has agreed to implement the following within 1 month of the date of this decision:
• Offer to meet with Mr & Mrs C to apologise for failing to provide an adequate response to their complaint.
• Offer Mr & Mrs C a payment of £250 in recognition of the distress and anxiety caused.
• Offer Mr & Mrs C a further payment of £250 in recognition of the time and trouble they went to pursuing their complaint.
29. Within three months of the date of my final decision, the Council has also agreed to provide a response at director level, which will include evidence of actions taken to improve the safeguarding process as well as an offer of an apology to Mr & Mrs C.

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Final decision

30. I have concluded my investigation on the basis that there was fault in how the Council responded to Mr & Mrs C’s complaint.

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Investigator's decision on behalf of the Ombudsman