Summary: The Ombudsman will not investigate Mr B’s complaint about the Council’s delay in advising him of the outcome to its safeguarding investigation into his late mother’s, Mrs C’s fall. This is because the Ombudsman cannot remedy any injustice to Mrs C caused by administrative fault as sadly she is now deceased. The Council has apologised for the delay in informing Mr B of the outcome of the safeguarding enquiry and advised it has put measures in place to ensure it gives timely and appropriate feedback in the future. The Ombudsman is satisfied this remedies the injustice caused to Mr B from the delay.

The complaint

1. Mr B says the Council failed to adequately explain how his late mother, Mrs C, came to fall in her care home and is concerned she may have lay unobserved for up to two hours when she should have been on a heightened watch. In addition, Mr B says it took the Council six months to advise him of the outcome of its investigation and is concerned its Safeguarding of Vulnerable Adults processes are not fit for purpose given an independent investigation into the Council’s Children’s Services processes found the same.

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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:

• 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)

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How I considered this complaint

3. I discussed the concerns with Mr B and considered the information and documentation he provided. I sent Mr B a copy of my draft decision and considered his comments on it.

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What I found

4. The Council investigated Mr B’s concerns about a fall Mrs C had on 6 January under its responsibility for safeguarding adults. It said Mrs C had felt unwell that morning but decided to visit her husband and the chiropodist as arranged. On her return to the home Mrs C still felt unwell. Staff called the GP and a Paramedic Practitioner attended at 15:09. She advised Mrs C drink plenty of water and her care provider monitor her bowels, temperature and if vomiting or worsening of symptoms become apparent to call back out. Later that evening Mrs C fell on her back, hit her head, became confused and short of breath. The care provider said it called the emergency services. Mrs C was taken to hospital where she remained until sadly she died on 2 February. The Council confirmed Mrs C’s call bell alarm was always in reach and observations were taken both before and after her return from the chiropodist.
5. Mr B says the investigation did not clearly explain how Mrs C had fallen, or how long she had been left unattended. It is not the role of the Ombudsman to provide Mr B with the answers to his unanswered questions and could not say how Mrs C fell. The Council has confirmed Mrs C was always in reach of her call bell. Mrs C has since died, and any injustice caused to her from any fault an investigation might uncover cannot be remedied now.
6. Mr C says it took the Council six months to inform him of the outcome of the safeguarding investigation and says an independent enquiry found its Children’s Services procedures to be inadequate. Mr B wants the Ombudsman to investigate the Council’s Vulnerable Adults Safeguarding procedures.
7. The Council acknowledged Mr B had requested feedback from the outcome of the safeguarding and apologised he did not receive it for six months. It says it has put measures in place to ensure all referrers of safeguarding concerns receive timely and appropriate feedback. The Ombudsman is satisfied this remedies any injustice to Mr B from the delay in receiving an update from the enquiry.

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Final decision

8. The Ombudsman will not investigate this complaint. This is because the Ombudsman cannot remedy any injustice to Mrs C caused by administrative fault as sadly she is now deceased. The Council has apologised for the delay in informing Mr B of the outcome of the safeguarding enquiry and advised it has put measures in place to ensure it gives timely and appropriate feedback in the future. The Ombudsman is satisfied this remedies the injustice caused to Mr B from the delay.

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Investigator's decision on behalf of the Ombudsman