Summary: Mrs B and Mr D complain about the Council’s failure to provide support to Mr C or to properly respond to safeguarding referrals relating to Mr C. A decision has been made that this case meets the threshold for a Safeguarding Adults Review. The Ombudsman has discontinued its investigation because a Safeguarding Adults Review is a more appropriate investigation into this complaint.

The complaint

1. Mrs B complains on behalf her ex-husband, Mr C, who has sadly passed away. Mr D is Mr C’s son. The complainants say the Council failed to provide support to Mr C and failed to properly respond to safeguarding referrals relating to Mr C which were made in the days before his death. They say that, when Mr C was discharged from hospital, there were concerns about Mr C’s mental capacity and the Council did not contact the complainants.

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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’. 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:

• there is another body better placed to consider this complaint.

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

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How I considered this complaint

3. I have discussed the complaint with Mrs B. I have considered the Council’s response and both sides’ comments on the draft decision.

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What I found

Law and guidance

Safeguarding Adults Board

4. Each local authority must set up a Safeguarding Adults Board (SAB). The main objective of a SAB is to assure itself that local safeguarding arrangements and partners act to help and protect adults in its area who meet the criteria.
5. The SAB oversees and leads adult safeguarding across the locality and will be interested in a range of matters that contribute to the prevention of abuse and neglect.
6. One of the duties of the SAB is to decide when a safeguarding adults review is necessary, arrange for its conduct and implement any findings.

Safeguarding Adults Review

7. Safeguarding Adults Reviews (SAR) replace serious case reviews. SABs must arrange an SAR when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.
8. SARs should seek to determine what the relevant agencies and individuals involved in the case might have done differently that could have prevented harm or death. This is so that lessons can be learned from the case and those lessons applied to future cases to prevent similar harm occurring again.

What happened

9. Mr C was an elderly gentleman who had limited mobility and suffered poor physical health. Mrs B says that, in the year before his death, Mr C had become increasingly unable to care for himself and the Council had become involved.
10. Mr C spent a lot of time in hospital in the year before his death. He was discharged from hospital in early December 2018. Mrs B says the ambulance service made three safeguarding referrals relating to Mr C in the days following his discharge. The concerns related to a lack of food in the house and the fact that Mr C was unable to care for himself.
11. Sadly, Mr C died sometime in early December and then lay undiscovered in his home until the end of December 2018.
12. There was a Coroner’s inquest into Mr C’s death. The Coroner said the exact cause of Mr C’s death could not be determined but said: ‘There was no food in the house and this may have been a factor in his death.’
13. Mrs B complained to the Council about what happened to Mr C and the Council’s failure to take any action. The Council initially said it could not disclose information about Mr C to Mrs B as she was no longer married to him. In March 2020 the Council then said it would carry out a Safeguarding Adult Review into Mr C’s case. Mrs B then heard nothing further from the Council so she took her complaint to the Ombudsman.
14. On 30 October 2020, the Council confirmed that a Safeguarding Adults Teview would be carried out.
15. The Safeguarding Adults Board is better placed than the Ombudsman to carry out this review as it has powers to involve all the agencies, not just the Council. Therefore, the SAB can provide a broader investigation than the Ombudsman could. There is also no point in having two investigations into the same matter running at the same time. Therefore, the Ombudsman will discontinue its investigation.

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Final decision

16. There will be a Safeguarding Adult Review into Mr C’s death so I have discontinued the Ombudsman’s investigation.

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Investigator's decision on behalf of the Ombudsman