Summary: Mrs D says the Council failed to adequately investigate safeguarding alerts about her late mother, Mrs C, regarding financial abuse and neglect. She says the Council’s failures caused injustice to her in the form of distress and to her mother’s estate in the form of financial loss. The Council accepted it was at fault for a failure to arrange family mediation in 2018. But it was also at fault for failures in its safeguarding procedures. These failures caused Mrs D injustice. The Council has already paid for Mrs C’s outstanding care. It has agreed to pay Mrs D a sum in consideration of her time, trouble, distress and expenditure.

The complaint

1. Mrs D says the Council failed to adequately safeguard her mother, the late Mrs C, from financial abuse and/or neglect despite Mrs D raising her concerns with the Council on multiple concerns between January 2017 and June 2019.
2. Mrs D says this caused injustice to Mrs C and herself because:
1. Mrs C’s estate lost money, (Mrs D is Mrs C’s executor) and
2. Mrs D was caused distress by the Council’s failure to intervene. She suffered a breakdown and received anti-depressant medication and counselling.

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What I have investigated

3. Mrs D says she first raised her concerns with the Council in 2017. Section 26B of the Local Government Act 1974 says we cannot investigate complaints brought to us more than 12 months after the events complained of without good reason.
4. In this case, I have decided that there is good reason for us to investigate the complaint from 2017 onwards. It is clear from the facts that this is a matter which has gone on since 2017. Mrs D has continuously raised concerns with the Council since then. Further, Mrs D has said she only became aware of the true extent of the injustice suffered by Mrs C’s estate after Mrs C went into hospital and then residential care in 2019. Before then, throughout 2017 and 2018, she says she had been barred from visiting her mother by her brother Mr B.

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The Ombudsman’s role and powers

5. We cannot investigate late complaints unless we decide there are good reasons. A late complaint is one where the complainant comes to the Ombudsman more than 12 months after something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
6. 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)
7. 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)
8. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means that we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
9. Under the information sharing agreement between the Local Government and Social Care Ombudsman and the Office for Standards in Education, Children’s Services and Skills (Ofsted), we will share this decision with Ofsted.

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How I considered this complaint

10. I spoke to Mrs D. I wrote an enquiry letter to the Council requesting further information. I considered the Council’s response, the evidence and any relevant law and guidance.
11. Mrs D and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What should happen

Safeguarding

12. Councils’ duties and powers for adult safeguarding investigations are set out in the Care Act 2014. Guidance on how to apply these powers are set out in the government’s Care and Support Statutory Guidance. The Care Act requires councils to investigate when it has reason to suspect that anyone in its area is in need of care and support and is experiencing or is at risk of abuse or neglect and is unable to protect themselves. (Care Act 2014, s.42)
13. Abuse can take many forms including physical abuse and financial abuse. The Care and support statutory guidance says, ‘Defining abuse can be complex but it can involve an intentional, reckless, deliberate or dishonest act by the perpetrator.’ (Care and Support statutory guidance 14.41)
14. Anyone can raise an alert if they have concerns that someone is being abused. Councils must act promptly. They should hold a strategy meeting and, if necessary, consult with a range of professionals, such as the police and medical professionals.
15. The purpose of an investigation is to:
• Establish the facts.
• Ascertain the individual’s views and wishes and seek consent.
• Assess the needs of the adult for protection, support and redress.
• Decide what, if any, follow-up action should be taken.
16. Six principles should underlie all safeguarding work:
• Empowerment. People should be supported to make their own decisions.
• Prevention. It is better to take action before harm occurs.
• Proportionality. Councils should opt for the least intrusive response appropriate to the risk.
• Protection. Support and representation should be provided to those in the greatest need.
• Partnership. Solutions should be local.
• Accountability.
17. When deciding whether to intervene, councils should consider:
• The individual’s need for care and support.
• The individual’s risk of abuse or neglect.
• The individual’s ability to protect themselves.
• The impact on the individual, their wishes.
• The possible impact upon important relationships.
• Potential of action increasing risk to the individual.
• Risk of repeated or increasingly serious acts involving children, or another adult at risk of abuse or neglect.
18. Information must be shared widely and early to allow effective intervention. Organisations should have policies in place setting out how this should happen. No professional should assume that someone else will pass information on.
19. After an initial investigation, councils should hold a case conference at which further action should be discussed. The investigation can be closed at any point if it is agreed that further investigation is not necessary. Typically, the process is ended at the case conference or following a review of a protection plan.

Financial abuse

20. The Care and support statutory guidance sets out various indicators of financial abuse. The list is not exhaustive but includes:
• a change in living conditions;
• lack of heating, clothing or food;
• inability to pay bills/unexplained shortage of money;
• unexplained withdrawals from an account;
• unexplained loss/misplacement of financial documents;
• the recent addition of authorised signers on a client or donor’s signature card;
• sudden or unexpected changes in a will or other financial documents.
  (Care and support statutory guidance 14.25)
21. The Care Act requires that each local authority must arrange for an independent advocate to represent and support an adult who is the subject of a safeguarding enquiry or Safeguarding Adult Review where the adult has ‘substantial difficulty’ in being involved in the process and where there is no other suitable person to represent and support them.

Mental Capacity Act 2015

22. The Mental Capacity Act 2015 sets out the steps a council must take in order to establish whether a service user has the capacity to make decisions in their own best interest. There are five principles underlying the Act:

• Presumption of capacity - every adult has the right to make his or her own decisions and must be assumed to have capacity to do so unless it is established that he or she lacks capacity. This means you must not assume that someone is unable to make a decision for themselves just because they have a particular medical condition or disability.
• Individuals supported to make their own decisions - a person is not to be treated as lacking capacity unless all practicable steps taken to help that person make a decision have been unsuccessful. This means you should make every effort to encourage and support people to make the decision for themselves. If lack of capacity is established, it is still important that you involve the person as far as possible in making decisions.
• Unwise decisions - people have the right to make decisions that others might regard as unwise or eccentric. You cannot treat someone as lacking capacity for this reason. Everyone has their own values, beliefs and preferences which may not be the same as those of other people.
• Best interests - anything done for, or on behalf of a person who lacks mental capacity must be done in their best interests.
• Least restrictive option - someone making a decision for or acting on behalf of a person who lacks capacity must consider whether it is possible to decide or act in a way that would interfere less with the person’s rights and freedoms of action, or whether there is a need to decide or act at all. Any intervention should be weighed up in the circumstances of the case.

23. There is a requirement to apply the MCA in adult safeguarding enquiries. The MCA also created criminal offences of ill-treatment and wilful neglect in respect of people who lack the ability to make decisions. These offences are punishable by fines and imprisonment.

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What happened

Background

24. In 2016, Mrs C lived alone in the Council’s area. Her adult daughter, Mrs D lived nearby. Mrs C had a chronic complaint which affected her cognitive abilities but the Council assessed that she had capacity to make decisions. She was able to look after herself in her own home.
25. As time progressed, her confusion worsened and she needed more assistance. Her home was adapted for her needs with a stairlift. Mrs D did her accounts and looked after her money. She says Mrs C had an income from pensions and benefits of around £1600 per month. Mrs D allowed her mother a budget of £1250 per month for bills and general living expenses allowing a contingency fund for emergencies to grow. By the end of 2016, this had reached about £12,000.
26. As Mrs C’s condition worsened, her son, Mr B, who lived outside the area, began to spend more time staying at her house and looking after her.
27. Mrs D says that, in early 2017, Mr B asked her for money from Mrs C’s bank account. She says she refused and, shortly afterwards, Mrs C’s bank received an anonymous tip-off that Mrs D had been stealing from Mrs C’s account. Mrs D denies this and says she offered to show the bank evidence. The bank returned the bank books and cards to Mrs C at Mrs C’s request.
28. Mrs D says she told the bank that she was concerned that Mr B would begin to spend Mrs C’s money. The bank said it would place an alert on her account which would suspend the account if there was any irregular spending.
29. Mrs D then told the Council she was concerned that Mrs C was losing her capacity and Mr B would financially abuse her by removing money from her bank account. The Council noted her concerns but said no abuse had occurred so it would not investigate. However, it said it would monitor the situation.
30. Mrs C says, from then on, Mr B refused to allow her to go and see Mrs C at home. She says he placed padlocks around the house to secure it and was abusive and threatening if she ever tried to enter. She says Mr B also threatened and assaulted her children.
31. In April 2017, Mr B became an appointee for Mrs C and therefore had access to her bank accounts. The Council says it carried out an MCA assessment of Mrs C’s capacity to make her own financial decisions and found she had capacity.
32. Mrs D says that, not long after that, the bank’s alert for irregular spending was activated and Mrs C’s main bank account was suspended. Only Mrs C could remove money from it. However, Mr B still had access to Mrs C’s DWP bank account. She says that she and other family members would often see Mr B taking Mrs C to the bank to withdraw money from her main bank account too.
33. In June 2017, Mrs C’s neighbours phoned another of her daughters who lived far away and said there was shouting and screaming coming from Mrs C’s house and that they feared that Mrs C was being abused. The Council was contacted. A social worker replied saying that there was no risk.
34. In July 2017, Mrs C’s gas was cut off. Mr B told the Council that Mrs C had fallen into a hole dug by gas contractors in her garden after Mr B removed the boards around the hole. The Council’s records show that Mr B told officers that he would not allow the gas company into the house to reconnect the gas. Nor would he replace the boards.
35. This meant that the gas cooker was no longer operational in the house. The Council investigated. It found that the property had a microwave and a fire and therefore decided that there was no unacceptable risk to Mrs C. However, Mrs D says that, in fact, the fire was broken by this stage so there was no heating.
36. The care record shows that Mr B frequently contacted the Council and left rambling messages in which he threatened to contact the police and the prime minister to expose the Council and his relatives.
37. At around this time, Mr B was housed by the Council in a one-bedroom property not far from his mother’s house. It took him eight weeks to move his belongings there. Mrs D says Mr B took Mrs C from her home and moved her in with him.
38. In October 2017, Mr B was taken into hospital briefly. The ambulance service made a safeguarding alert to the Council saying Mrs C was left alone in a property which was dirty, cluttered and full of tripping hazards.
39. The Council assessed Mrs C’s care and support needs and arranged for Mrs C to have four 15-minute visits a day to help with her personal care. Mr B returned from hospital later that day and the visits ceased.
40. In December 2017, Mrs C went into hospital. Mrs D was able to visit Mrs C in hospital and says she became concerned because Mrs C was clearly, by now, doubly incontinent. She says Mrs C was filthy on arrival and had uncut nails and smelt of urine. She and her son made a safeguarding alert and said Mr B could not look after Mrs C, particularly in his one-bedroom property.
41. The Council began a safeguarding investigation. Mr B was frequently evasive and threatening on the phone to social workers and refused to grant them access to Mrs C.
42. In early January 2018, a note on the Council’s system stated, ‘there is no suggestion that [Mr B] has not been caring for [Mrs C]’.
43. In mid-January 2018, social workers visited Mr B at his property. When questioning Mrs C about her wishes, the social worker identified Mrs D and her son as those who had raised the alert about Mr B. Mrs D says that she believes Mr B found out about this and, thereafter, made multiple unfounded allegations about her and her family to the police and Council. She says he also sent her obscene letters and threatened her and her family.
44. A week later, a social worker told Mrs D and her son that there was ‘no evidence’ to support their claims of abuse.
45. However, social services told Mr B that Mrs C could not continue to live with him in his property as it was not suitable. He said he understood and intended to move back into Mrs C’s house but her stairlift was broken. Mr B also said he needed help caring for Mrs C. The Council arranged a care package with daily visits to help her with hygiene and dressing.
46. Mrs D continued to be concerned that Mr B was not paying his mother’s bills. She passed on concerns that their mother’s house insurance had not been paid to the Council. She and her son asked social services to remind Mr B that his mother had to pay. He told them that he would.
47. In March 2018, the Council carried out an MCA assessment of Mrs C at Mr B’s house. She did not know where she was. The Council officer found that she did not have capacity to make decisions in her own best interest. He began a best interests investigation to try to discover what would be in Mrs C’s best interest. He spoke to various members of the family over the next few months.
48. At around the same time, Mr B said he was interested in family mediation to deal with the animosity affecting the family.
49. Social workers continued to try to persuade Mr B to return Mrs C to her own house. He said the stairlift was broken so it would not be safe. The Council contacted the stairlift company on his behalf but Mr B did not return their calls. In April 2018, after protracted attempts to persuade Mr B to allow them access, a social worker went into Mrs C’s house and found that it would require a deep clean before Mrs C could move back in.
50. Mr B cancelled the care package for his mother. The Council’s notes show that he was concerned about the cost until a financial assessment was completed.
51. In April 2018, a Council officer visited to assess Mrs C’s ability to pay for the care she was receiving. Mr B showed them the records he had. Mrs C received approximately £250 a week into her DWP account. This was all being spent. Mr B said it was being spent on ‘living’.
52. An officer noticed that £700 had recently been withdrawn from Mrs C’s account. The officer asked him to explain what had happened to it. Mr B said he could not do so. The officer also asked to see Mrs C’s private bank book. Mr B refused to show it to him saying that it was ‘private’.
53. The officer made a safeguarding referral citing the missing £700. He said an investigation should follow.
54. Mrs D spoke to the Council in June 2018. She told him the police had received several anonymous calls claiming that she was running a drug den. She said she knew the calls came from Mr B. She said she and her family had seen Mr B alone in the pub and were concerned that Mrs C was being left alone.
55. In June 2018, a social worker spoke to Mrs D about Mrs C’s best interests. Mrs D again said she worried that Mr B was financially abusing Mrs C. Shortly thereafter, Mr B made a complaint about this social worker. He spoke to a senior officer who apologised and had the social worker removed from the case.
56. A financial assessment meeting was arranged for July 2018. The Council was intending to gain evidence about the missing £700. However, the finance department said it was satisfied that Mrs C was a self-funder because she owned a house, so the meeting was cancelled. In late July, the Council closed the safeguarding investigation.
57. In November 2018, the Council assisted Mr B to become a deputy for Mrs C. This gave him greater power over her finances.
58. In December 2018, Mrs D says a neighbour of Mrs C contacted her to tell her that bailiffs were entering Mrs C’s house to cut off energy supplies. The social worker contacted Mr B who said he had been unaware of the issue and would sort it out. He later told the social worker that his mother had known about the issue but did not mind.
59. Mr B then cancelled Mrs C’s care package again. In March 2019, the social worker in the case said she would end Council involvement as there was no role for the Council to play.
60. In May 2019, Mrs C was taken into hospital again. Mrs C stayed in hospital for over a month. Mrs D says she was able to see her mother for the first time in over a year. She said she visited every morning to avoid Mr B who came in the afternoon.
61. The Council carried out an MCA assessment and found Mrs C lacked capacity to decide where she should live. The Council took a best interests decision to discharge her to residential care. Mrs D was then able to see more of her mother. She says it was only at this time that she began to understand quite how poorly Mr B had cared for her mother and her finances.
62. The Council records say a social worker asked Mrs D to help with the selling of Mrs C’s house and that she agreed to do so. Mrs D says she did not and, instead, says she wanted full guardianship. Which version is correct is not relevant to this decision. However, it is relevant that Mrs D met a Council officer and explained that Mr B had had control of Mrs C’s finances for 18 months. She asked the officer to help her get all the bank books and financial records she would require.
63. Later, an officer looking into a separate safeguarding matter began a further safeguarding investigation into possible financial abuse. The officer visited Mrs C’s bank to ask it to suspend her account. The officer wrote on the care record that there were concerns that Mr B was still in receipt of Mrs C’s benefits. She said she suspected Mr B would not have paid any of Mrs C’s bills.
64. A further assessment in August 2019 found Mrs C lacked capacity to manage her finances. The Council said it should apply for a court-appointed deputy to manage them for her while a further safeguarding investigation into the residential care placement took place. It looked into appointing Mr B and another of Mrs C’s children as deputies.
65. Mrs D complained to the Council in August 2019. She received a stage one response in which the Council admitted to a failure to organise family mediation in early 2018 and a failure to adequately support Mrs C to return to live in her own home on her discharge from hospital at around the same time. The Council agreed to pay her outstanding care fees of around £10,000, to fund a deep clean of Mrs C’s house and to pay Mrs D £2,000 for her distress and time and trouble.
66. Feeling she had not received an adequate response, Mrs D escalated her complaint to stage two. Below I have set out the salient parts of Mrs D’s stage two complaint with the Council’s response to each point.
1. Mrs C’s household bills were not being paid by Mr B. The arrears were building up. Everyone knew it was happening and nobody was doing anything about it. Council’s response: The Council had responded to alerts from family members in June 2018 and December 2018. After the June alert, a social worker had visited and found that Mrs C was being well looked after and wanted to live with Mr B. The unpaid insurance was subsequently paid. After the December alert, the Council contacted Mr B who had not been aware that the gas had been cut off or that the bills had not been paid. Once he became aware of the arrears, he agreed to pay them. The Council believed, at this time that Mrs D would not have been willing to take joint deputyship with Mr B though the Council accepted it had not asked her about this.
2. Mrs D had raised concerns that an outstanding £1200 care bill had not been paid by Mr B. The Council did nothing about this either.
   Council response: Because Mrs C was away from home for longer than two months, there was an overpayment of benefits. The agencies have now been informed. Mrs C needs a deputy to help with her finances. The Council would visit Mr B and ask him about the arrears and about relinquishing deputyship.
3. Mrs C had had no dementia assessment although Mrs D had frequently requested one. Mrs C had dementia and the panel had not been aware of this when making the best interests decision.
   Council response: The Council had recently requested an assessment for dementia but the social worker had kept Mrs C under observation. She had been discharged to a care home for further assessment.
4. As a result of the Council’s failure to properly assess Mrs C’s capacity, Mr B had been able to financially abuse her for years.
   Council response: The Council had fully investigated alerts from the family. Mrs C was always asked whether she was happy living with Mr B and with him managing her money. The Council kept family members fully advised of Mrs C’s care.
67. Mrs C died in November 2019 after an accident at the care home. The Council paid her outstanding care bill of approximately £10,500. It says it did so because it:

‘…could have been more proactive in terms of both addressing the deep clean of Mrs C’s property and in terms of progressing the deputyship’.

68. Mrs D was the executor of Mrs C’s estate. She says that, when going through Mrs C’s affairs, she discovered that Mrs C’s estate had lost in the region of £40,000. This was mainly due to a depreciation in the value of Mrs C’s house due to neglect. Mrs C has sent me videos of the house which shows it is in such a state of disrepair that it appears to be uninhabitable.
69. Mrs D also says that, over the period that Mr B controlled Mrs C’s finances, the balance had reduced by approximately £9,000. She asked the Council not to pursue Mr B because she said he was unwell and might be driven to suicide if steps were taken against him. She said the Council should have stopped him earlier rather than allow things to progress as they had.

Was there fault causing injustice?

70. The Council has accepted that it was at fault for:

• its failure to provide family mediation in 2018, having offered to do so.
• its failure to support Mrs C in returning to live in her own home,
• its failure to progress a deep clean of Mrs C’s home, and
• its failure to arrange the deputyship it said it would issue in 2018.

71. The Council has offered to pay:

• for a deep clean of Mrs C’s house which it says will cost around £2,000, and
• Mrs D £2000 for her distress, time and trouble.

72. However, on the evidence I have seen so far, the care record shows that the Council was also at fault for a series of errors in the safeguarding process that put Mrs C at risk of abuse.
73. The main fault identified is that, while officers recorded facts on the care record as is required, there was evidently insufficient oversight and management of the case to allow anyone to form an informed overview of the facts. This in turn allowed Mrs C to remain at risk of neglect and abuse for over two years.
74. The first reference to potential abuse to be found in the Council’s records was made in late 2016 when Mr B took the phone off Mrs C when she was talking to the Council and hung up.
75. Mrs D warned the Council that Mr B had alienated the rest of the family and would isolate their mother and financially abuse her in early 2017. A social worker said that there was no abuse at that point so could not investigate but said the Council would be vigilant for abuse. On the evidence I have seen, it does not seem to have been so.
76. In June 2017, neighbours reported shouting at Mrs C’s house. They were concerned for her safety. The Council dismissed these concerns. Thereafter, Mr B moved his mother out of her house into his own property which was not suitable as it was not adapted to her needs. Such a move, according to the Care and Support statutory guidance referenced above, is an indicator of abuse. It was not addressed by the Council.
77. It seems more likely than not from the facts on the care record, that, by this point, Mrs C’s house was already unfit for human habitation. The record shows Mr B was evasive and refused to allow access to the house for over a year. When officers finally gained access, the Council said it would require a deep clean before Mrs C could return. Again, this does not seem to have been addressed as a risk factor.
78. The records show that, in July 2017, Mr B told the Council that Mrs C had fallen into a hole in her garden made by a gas company. Mr B had taken the boards from around the hole, the gas company said, and refused to return them or to allow them to relight the boiler. The Council was aware of this but took no action.
79. The notes show that Mr B was continually abusive and angry to Council officers in a way that suggests he was not fully in control of himself. He made threats to expose the Council, to write to the papers and the prime minister, to leave the property and live on the streets.
80. When Mrs C went into hospital in late 2017, the Council received an alert that, on admission, she was dirty, had missing dentures, filthy nails and matted hair and a request to investigate. A few days later, a social worker wrote on the record that there was ‘no suggestion that [Mr B] is not looking after her’. That record does not make sense given the report that had been made.
81. The Council was on notice, then, from late 2016 onwards that Mr B required, at least, increased scrutiny. Later, he failed to pay Mrs C’s utility bills resulting in her gas and electricity being cut off which, Mrs D says, was a risk factor because of Mrs C’s poor lungs. Mr B twice cancelled Mrs C’s care package and told the Council it was because they were too expensive, while he was in control of her money. It is odd that this did not raise concern for Mrs C’s care. Care packages are provided to meet need. Since Mr B cancelled them, the Council should have reviewed Mrs C’s care and support needs to determine how they were being met. This is especially so in a context where various reports had been made to the Council from people who had concerns about Mrs C’s care.
82. The Council also received a safeguarding referral from the local ambulance service because it considered Mrs C was at risk.
83. The Council did, on several occasions, carry out initial safeguarding investigations and found that Mrs C said she was happy where she was. But there must have been doubt about Mrs C’s capacity, particularly by early 2018. The records show that, Mrs C did not know where she was when officers visited her, believing she was in her own home when she was at Mr B’s. She was unclear about other fundamental details of her life.
84. The Council determined Mrs C did not have capacity in March 2018. It did consider that she needed an advocate, as is required, but then, when Mr B was resistant to the idea did not follow up on it. This too was fault.
85. The Council visited Mr B after Mrs C was discharged from hospital in early 2018 and told him that his accommodation was unsuitable. The notes show that Mr B gave various different accounts of where Mrs C lived to different officers. If there had been an overview of the case, concerns might have been identified sooner.
86. The situation was complicated by the fact that Mr B made numerous safeguarding allegations himself claiming that he was being abused by Mrs D and members of her family including one occasion when he alleged that Mrs D’s daughter had visited his house and abused him and Mrs C while drunk.
87. The Council carried out a safeguarding investigation. They found that Mrs C could not recall the allegations made against Mrs D’s daughter. If the Council believed that Mrs C did not recall a shocking incident that had allegedly happened the day before, it should have had concerns about her capacity to make decisions in her best interests. No such concern is noted.
88. Mrs D had said in 2017 that Mr B had prevented other family members from seeing Mrs C. The Council did begin to take some action to attempt to rectify the situation in 2019 but, by then, the situation had continued for a year and a half. The actions were, in any event, unsuccessful as Mr B refused to cooperate.

Financial abuse

89. Turning to financial abuse, the notes show that Mrs D warned the Council in early 2017 that she believed Mr B would spend Mrs C’s money.
90. The Council said it would be alert to this possibility. But there is no evidence on the record that it was. It was not long before Mrs C’s bank suspended her account following unusual spending patterns as Mrs D had predicted. Throughout the following period, many of the indicators of financial abuse set out in the Care and Support Statutory Guidance were present:

• Mrs C’s living conditions changed. Firstly, her previously tidy home became so cluttered as to be dangerous, according to the ambulance service. Later, Mr B took her to live in his property.
• Over the next two years, the record shows reports that bills were not paid and the Council identified unexplained withdrawals from Mrs C’s account. Mr B told officers that he would not show them Mrs C’s bank records as they were ‘private’. The council did, twice, say it intended to carry out a financial safeguarding investigation but it never actually did so.
• Again, in April 2018, the Council discovered that £700 had gone missing from Mrs C’s bank account. It arranged to inspect Mrs C’s bank records though Mr B initially refused to allow them to do so. It then cancelled the inspection.

91. Later, in June 2018, when Mrs C’s social worker was investigating Mrs C’s best interests and wanted to carry out a dementia test, Mr B complained that the officer had been rude. A manager apologised and removed the officer from the case. There is no evidence of any effective handover and, from the record, the officer’s work seems to have ceased or, at least, been substantially delayed.
92. The Council suggests, in its complaint response, that it responded to Mrs D’s alerts. However, while it did respond to individual alerts in isolation, it did not maintain an overview of the case as it had said it would do. Thus, when this officer left, no one seemingly had a full picture.
93. Mrs D said she had lost contact with her mother, because Mr B would not allow her to see him. The Council accepted, in 2019, that this had happened. Therefore, Mrs D could not know what was happening in Mr B’s house. And she could not be expected, having been rebuffed in early 2017, to make continuous alerts with no new information. It was for the Council, through assessment of Mrs C’s care and support needs, scrutiny of the notes and case management to keep tabs on the case and to be alive to the various indicators of abuse that were present. I have seen no evidence that this happened.
94. In late 2018, even after receiving various alerts about the fact that Mr B was likely to be spending Mrs C’s money, the Council supported him in applying for deputyship for her finances.

Injustice

95. Mrs D says Mrs C’s estate has lost approximately £40,000. She says this is because of depreciation of her mother’s house, the decrease in her savings and the outstanding bills which went unpaid.
96. However, Mrs C has now cleaned the house and restored the garden and paid the utility bills. The Council has paid the £10,500 care bill. The house has been sold. Mrs D says it sold for £20,000 less than market value. However, the Ombudsman is not expert in such matters and I cannot link any depreciation in value to Council fault. I have therefore linked my remedy to Mrs D’s expenditure, distress, time and trouble.
97. The Council offered to pay for a deep clean of the house and to pay Mrs D £2000 for her time and trouble and distress. However, as Mrs D has already cleaned the house and restored the garden this can no longer be an appropriate remedy. However, I support the Council’s view that there should be a remedy related to the damage to Mrs C’s property and a remedy for Mrs D’s distress.
98. Mrs D says prior to her illness, Mrs C had kept her house impeccably clean and her garden well-cared for. Mrs D says this made it very distressing to see the state the house had reached when she first entered it in 2019. She says it took her three months and cost her £3000 to set it straight. Having seen the videos she sent me, I accept that this is a credible figure.
99. I have therefore recommended that the Council should pay Mrs C the £3,000 she spent on the property providing Mrs D can provide evidence of her expenditure. I am also recommending the Council should pay her £1000 for the time and trouble she took in carrying out the work.
100. I have also recommended the Council pay Mrs D £2500 for her distress, rather than the £2,000 it offered. This is high by the Ombudsman’s standards but this was an episode which ran from late 2016 until summer 2019 during which time Mrs D’s warnings went unheeded and she suffered the injustice of believing her mother was in danger of neglect and abuse, financial or otherwise. Further, the Council offered £2000 on the basis of far lesser fault than I have found. The extra amount is to represent my finding of further fault.
101. I have considered whether to recommend a payment to Mrs C’s estate but have decided against this. This is because the Council has already paid Mrs C’s outstanding care bills of £10,500 which would otherwise have been paid by the estate. Further, the money taken from Mrs C’s bank account between early 2017 and Mrs C’s death was spent by Mr B, who would be a beneficiary of the estate. The evidence also shows some of the money at least was spent on or with Mrs C, on food and care and on joint shopping trips with Mr B. I therefore consider that Mrs C’s estate has already been substantially reimbursed and I do not intend to recommend any further remedy.
102. I have though made recommendations for service improvement.

Failure to refer Mrs D to the Ombudsman

103. The Council has also pointed out that it failed to direct Mrs D to the Ombudsman in its final complaint response. The Council has accepted that this was fault.

Agreed action

104. Within two weeks of the date of this decision, the Council has agreed to:
1. Write to Mrs D and apologise for the fault found and the injustice suffered by Mrs C, Mrs D and the wider family.
2. Pay Mrs D £3,500.
105. Within two months of the date of this decision, on the provision of evidence which shows, on the balance of probability, Mrs D spent a sum of up to £3,000 on Mrs C’s house and garden, the Council will pay her that amount.
106. Within three months of the date of this decision, the Council will:
1. Review its adult safeguarding policies and processes focusing on increasing supervision and case review;
2. Ensure that all final complaint responses point complainants to the Ombudsman if they remain dissatisfied with the response; and
3. Write to the Ombudsman setting out the improvements in oversight and management in safeguarding cases that it has made or intends to make and confirming that it has provided Mrs D with the required remedy and that it has taken steps to ensure that future complainants are referred to the Ombudsman.

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Final decision

107. I have made my decision. The Council has accepted my recommendations. I have closed my investigation.

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Investigator's decision on behalf of the Ombudsman