Summary: Mrs X complains the Council failed to deal properly with safeguarding concerns raised in May 2018, involving her now late grandmother, and failed to tell her the outcome. The Council accepts responsibility for a lack of communication with Mrs X about the safeguarding concerns. It has now improved the procedures for dealing with safeguarding concerns, to ensure this does not happen again. It needs to apologise to Mrs X and pay her £350 for the distress caused and trouble she has been put to.

The complaint

1. The complainant, whom I shall refer to as Mrs X, complains the Council failed to deal properly with safeguarding concerns raised in May 2018, involving her now late grandmother, and failed to tell her the outcome.

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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, sections 30(1B) and 34H(i), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended)

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How I considered this complaint

5. I have:
• considered the complaint and the documents provided by Mrs X;
• discussed the complaint with Mrs X;
• considered the comments and documents the Council has provided in response to my enquiries; and
• shared a draft of this statement with Mrs X and the Council, and invited comments for me to consider before making my final decision.

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What I found

What happened

6. Mrs X raised safeguarding concerns with the Council on 20 May 2018 about her grandmother’s (Mrs Y) treatment on a ward in Calderdale Royal Infirmary (the Hospital) on 19 and 20 May.
7. On 21 May the Hospital held a safeguarding adults strategy meeting. A Matron for Acute Medicine chaired the meeting. It included medical staff involved in Mrs Y’s care, Mrs X and her mother. They explained their concerns about the lack of care and treatment for Mrs Y, including:
• the failure to carry out tests identified on 19 May, including a urine dip, until the day after;
• the lack of handover between staff working on 19 and 20 May;
• leaving food and tablets for Mrs Y without checking she took them;
• inappropriate treatment for low blood sugars.
8. The record of the meeting says Mrs Y was not responding to treatment, there were no alternatives, so the Hospital had placed Mrs Y on the “care of dying pathway”. Doctors agreed to continue with Mrs Y’s treatment until her son arrived from abroad.
9. Mrs Y died during the night of 23/24 May.
10. The Council told Mrs X the Hospital safeguarding team would investigate her concerns and the Council would contact her when it had completed the investigation.
11. The Council’s safeguarding records dated 29 May say Calderdale and Huddersfield NHS Foundation Trust would provide a report with their findings, conclusions and recommendations.
12. Mrs Y’s death was referred to the Coroner who decided it was due to natural causes (hypertension and heart failure).
13. On 2 July Mrs X complained to the Hospital about the way it had treated Mrs Y.
14. The Hospital acknowledged the complaint on 4 July.
15. On 29 July the Hospital contacted Mrs X to clarify her outstanding concerns.
16. On 14 August the Hospital sent Mrs X the minutes of the meeting held on 21 May.
17. The Trust responded to a complaint from Mrs X in September 2018. It sent her a copy if its complaint investigation report. It said it understood the Council’s safeguarding team was investigating allegations the Ward at the Hospital had failed to work within policy, procedure and legal requirements. It said the Trust would review and respond to any recommendations made by the Council.
18. On 5 November the Council responded to a complaint from Mrs X. It said:
• it apologised for the time taken to complete the safeguarding investigation;
• the Trust had gathered statements from staff at the Hospital involved in her mother’s care from 1 to 19 June;
• on 21 June the Trust told the Council it could not give a timescale for completing the investigation;
• it asked the Trust for a timescale on 25 June;
• on 4 July the Trust told the Council it had nearly completed the investigation and was awaiting “internal signoff”;
• it chased progress on 16, 19 and 25 July and 3 August;
• it received the completed report on 12 October;
• it accepted that after 3 August there was little contact with Mrs X; and
• it apologised for the distress this caused, which left the impression the family’s concerns did not matter and would not be resolved.
19. Mrs X complained to the Council in April 2019.
20. On 25 April the Trust told the Council:
• it received Mrs X’s complaint on 2 July 2018;
• it sent a letter on 4 July 2018 saying “this will proceed under the complaint process”;
• its legal adviser said it should continue to deal with the matter as a complaint.
21. When the Council replied to Mrs X’s complaint in June it said:
• based on the completed investigation and Coroner’s report, “it was felt the safeguarding concerns raised were of a medical nature” which the Trust had robustly investigated;
• at this stage the safeguarding process was “exited”, so it did not hold a safeguarding case conference;
• both the Council and the Trust accepted responsibility for poor communication and the Council apologised;
• the Council was developing improved procedures with the Trust to provide clear communication in the future
22. The Council used to pass safeguarding cases on to Calderdale and Huddersfield NHS Foundation Trust and rely on the Trust to report its findings. It accepts Mrs X’s experience shows this failed. The Council has introduced new protocols which will ensure it works with the Trust on safeguarding concerns. They will also ensure the Council can fulfil its responsibilities for involving the people affected in safeguarding.

Is there evidence of fault by the Council which caused injustice?

23. Under the Care Act, local authorities have overall responsibility for dealing with safeguarding concerns, although they have the power to delegate safeguarding enquiries to other bodies. The Care & Support Statutory Guidance stresses the need to put the adult, or anyone speaking on their behalf, at the centre of safeguarding. There is no dispute over the fact this did not happen in Mrs Y’s case. No one told Mrs X the safeguarding had ended or involved her in that decision. It appears the Trust decided to end safeguarding in July 2018 but failed to communicate it to Mrs X or the Council. Although it responded to her complaint, it did not explain there would be no further response to the safeguarding concerns. That was fault for which the Council is accountable. The Council accepts it failed to communicate with Mrs X after August 2018.
24. This has left Mrs X feeling the family’s concerns have not been properly addressed. However, I cannot say the Trust was wrong to end safeguarding or that it would not have done so if Mrs X had had the opportunity to comment on this proposed course of action.
25. The Council has now agreed new protocols which should ensure the problems Mrs X experienced are not experienced by others.

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Agreed action

26. When a council commissions another organisation to provide services on its behalf (e.g. investigate safeguarding concerns) it remains responsible for those services and for the actions of the organisation providing them. So, although I found fault with the actions of the Trust, I have made recommendations to the Council
27. I recommended the Council:
• writes within four weeks to Mrs X apologising for the failings and pays her £350 for the distress caused and the time and trouble she has been put to through complaining.

The Council has agreed to do this.

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Final decision

28. I have completed my investigation as the Council has agreed to take the action I recommended.

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Investigator's decision on behalf of the Ombudsman