Summary: Mrs B complains about a safeguarding alert raised by the Trust’s district nurses. She also says the Council’s safeguarding investigation was flawed. The Council and Trust have remedied any injustice to Mrs B. The Ombudsmen therefore will not investigate.

The complaint

1. Mrs B complains the Trust’s nurses raised safeguarding concerns about the way she cared for her friend, Mrs C. Mrs B says some of the concerns were based on false information and taken out of context. Mrs B also says there were flaws in the Council’s safeguarding investigation. Mrs B says that, as a result, she feels humiliated and the events have impacted on her family life.

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The Ombudsmen’s role and powers

2. The Ombudsmen provide a free service, but must use public money carefully. They may decide not to start or continue with an investigation if they believe:

• it is unlikely they could add to any previous investigation by the bodies, or
• they cannot achieve the outcome someone wants.

(Health Service Commissioners Act 1993, section 3(2) and Local Government Act 1974, section 24A(6), as amended)

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How I considered this complaint

3. I have considered Mrs B’s complaint form and the original complaint responses to her from the Council and Trust. I have shared a draft of this decision with Mrs B and considered her comments.

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What I found

4. In August 2018 one of the Trust’s nurses contacted the Council with concerns about the way Mrs B cared for Mrs C. The nurse was concerned about an unknown male being in the property and Mrs B was encouraging Mrs C to eat and transferring her against medical advice. The Council investigated the concerns under its safeguarding process and concluded the concerns were ‘inconclusive’ the following month.
5. On 18 December 2018 Mrs B wrote to the Council to complain about the safeguarding investigation. The Council replied on 28 February 2019. It acknowledged several failings in the investigation. It agreed with and apologised to Mrs B for the social worker’s failure to discuss the concerns with her in private. The Council also accepted it did not challenge the wording the nurse used in the safeguarding referral. It also agreed that the final report was not written clearly. It confirmed it had updated the report and addressed the issue in supervision with the social worker.
6. Mrs B wanted the outcome of the Council’s report changed from ‘inconclusive’ to ‘innocent’. The Council explained that it followed local protocol in investigations and was therefore bound to use certain wording. It explained that it had, however, updated the outcome of the report to reflect the social worker’s view that Mrs B was always acting in Mrs C’s best interests. The Council said that it had taken learning points from the complaint and shared it with the local Safeguarding Adults Board to help service planning. Finally, the Council confirmed it had no doubt about Mrs B’s integrity and was sorry for the upset caused to her and her family.
7. In May 2019 Mrs B wrote to the Trust. She complained about the nurse who had contacted the Council with safeguarding concerns. Mrs B felt the concerns were not based on evidence.
8. Mrs B had a telephone conversation with the Trust the same month. She explained she wanted to know whether the Trust had spoken to the nurse about reporting concerns without proof. She also wanted a letter of apology from the nurse and wanted the Trust to tell the nurse that Mrs B had formally complained.
9. On 11 July, the Trust wrote in response to Mrs B’s complaint. It explained that it had seen evidence in the nursing records to support the safeguarding referral. The Trust also explained nurses’ duty to report any concerns. It also clarified that several nurses reported the concerns, so it was difficult to identify any one person responsible. However, it apologised for the distress and impact the situation had on Mrs B and her family.
10. Mrs B met with Trust representatives on 28 August and the Trust followed up in writing on 30 September. It acknowledged the information about the unknown man should not have been included in the safeguarding referral. The Trust confirmed it had contacted the Council on 2 September 2018 to clarify this. The Trust again apologised for the impact on Mrs B and her family.
11. On 14 October, the Trust wrote again to Mrs B. It explained again that it had contacted the Council within a matter of days from the referral and asked it to remove the reference to the ‘unknown male’ from the alert. It also explained it owed its nurses an obligation of confidentiality so it could not reveal the nurse’s identity. The Trust explained the information about the unknown male had come from the agency caring for Mrs C in her home. The Trust confirmed it had spoken to the nurse involved and stressed the importance of only reporting concerns she had witnessed, rather than accounts from third parties.
12. In relation to encouraging Mrs C to eat, the Trust said its nurses raised the concern to explore whether Mrs B needed additional support in caring for Mrs C. The Trust’s records documented various conversations where nurses had discussed the risks of encouraging Mrs C to eat. Mrs C had an increased risk of choking as she was at the end of her life. However, Mrs B had explained she continued to encourage Mrs C to eat as she did not want her to die. The Trust confirmed that once Mrs B explained she did not realise Mrs C was at the end of her life, the Council stopped the safeguarding process. Likewise, in relation to transferring Mrs C. Mrs B said she had received mixed advice about this, which the Council accepted.
13. On 5 November Mrs B complained to the Ombudsmen. She confirmed the Council and Trust responses had addressed all aspects of her complaint. However, Mrs B was not satisfied with the responses. In particular, she sought:
• A personal apology from the person or persons who made the safeguarding referral;
• Compensation for the distress resulting from the safeguarding process; and
• To ensure the same situation did not happen to anyone else.

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Final decision

14. I will not investigate this complaint. The Trust and Council have given Mrs B detailed responses to her concerns. The Trust also met with her at her request and both it and the Council have apologised to Mrs B. The Ombudsmen, even if they found fault, would not recommend an apology from an individual staff member. I consider the Trust and Council have taken sufficient steps to ensure the situation does not happen again.
15. Mrs B also says she wants compensation for her distress. However, the Ombudsmen would not generally recommend a financial remedy because there has been a safeguarding investigation. The nature of these investigations means they will almost always be stressful. In this case, the Council has acknowledged the flaws in the investigation, amended its report, taken learning points and apologised. I do not consider an additional financial remedy is appropriate.

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Investigator's decision on behalf of the Ombudsman