Summary: The Ombudsman will not investigate Mr A’s complaint about the Council’s actions regarding the safeguarding of Mr B. This is because there is not enough evidence of fault with the actions taken by the Council to warrant an Ombudsman investigation.

The complaint

1. Mr A complains the Council did not do enough to safeguard his stepson, Mr B, a vulnerable adult prior to his death. Mr A says the Council failed to assess and investigate information provided to it about Mr B and says the Council’s failure to take immediate action was influenced by the conditions of Mr B’s flat. Mr A says the Council knew Mr B was living in horrific conditions for six days and its failure to protect him led to his death.

Back to top

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’. We provide a free service, but must use public money carefully. We may decide not to start or continue with an investigation if we believe:

• it is unlikely we would find fault, or
• the fault has not caused injustice to the person who complained, or
• the injustice is not significant enough to justify our involvement, or
• it is unlikely we could add to any previous investigation by the Council, or
• it is unlikely further investigation will lead to a different outcome, or
• we cannot achieve the outcome someone wants.

(Local Government Act 1974, section 24A(6), as amended)

Back to top

How I considered this complaint

3. I considered the information and documentation Mr A provided. I sent Mr A a copy of my draft decision for comment.

Back to top

What I found

4. The Council received a referral from Mr B’s housing provider on 11 September. The case was assigned to a Social Care Assessor (SCA) on 12 September who agreed with the housing provider to undertake a joint visit the same day. The SCA contacted NHS referrals and checked records. The last record showed Mr B had been referred to an Occupational Therapist (OT) in 2017 but there was no record of Mr B being admitted to hospital. A joint visit was carried out with housing provider, but they were unable to gain access. They were concerned about state of property given what they could see through the letterbox.
5. The SCA contacted Mr B’s GP on return to the office and was advised he had not been seen since 2013. The GP confirmed the Out of Hours service contacted Mr B the previous night, but he declined a visit.
6. The housing officer said it had contacted Mr B’s mother who advised Mr B was an alcoholic and recluse who refused to engage with services and declined offers of help from family members.
7. The housing officer advised the Council it had emailed police’s non-emergency 101 service to request a welfare visit and advised it would only receive the outcome of the visit when office reopened on Monday 16 September.
8. The SCA contacted the police for an update on 13 September. The police said Mr B had opened the door but looked unwell and had refused medical attention.
9. On 16 September the housing provider contacted the Council advising they had spoken to Mr B who was refusing all medical intervention and support offered. The SCA sent all information to the safeguarding team. The safeguarding team screened the referral as a high priority and discussed concerns with the SCA who was waiting for the outcome of GP visit later that day.
10. The SCA contacted the GP who advised they had visited Mr B who was in very poor health. Mr B agreed to have a referral to the complex medical team arranged further visit for 23 September.
11. On 17 September Mr A contacted the Council. He was concerned it had not visited Mr B and complained no action had been taken on a referral he had made the previous day.
12. The Council contacted Mr B’s GP. It advised the crisis team were going out that afternoon but said it is unlikely he would be detained under the Mental Health Act. The Council received a further call from Mr A and signposted him to the crisis team. The Council spoke to Mr B’s mother, who said the crisis team had not been out and was concerned everyone was passing the buck.
13. The Council contacted the crisis team who advised mental health nurses had attended and discussed whether Mr B needed a mental health assessment. The Council contacted the crisis team on 18 September and was advised Mr B was in hospital. Mr B verbally agreed to allow his mother and Mr A to be involved.
14. Mr A says the Council did not act upon the information he provided. The Council says it could have acknowledged Mr A’s referral sooner, but was following up the concerns raised in its role as safeguarding lead agency, by coordinating several professional agencies with a view to addressing Mr B’s situation as a matter of urgency. The Council had to wait until Mr B, who was deemed to have capacity, agreed to share information with Mr A before explaining what it had done. The Council were dealing with someone reported to have capacity but who was declining access to services and support. The Ombudsman could not say this is fault nor could he make the causal link between the Council’s actions and Mr B’s death even if he investigated.

Back to top

Final decision

15. The Ombudsman will not investigate this complaint. This is because there is not enough evidence of fault to warrant an Ombudsman investigation.

Back to top

Investigator's decision on behalf of the Ombudsman