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North Lincolnshire Council (20 003 328)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 14 Oct 2020

The Ombudsman's final decision:

Summary: The Ombudsman will not investigate Mrs X’s complaint about failures in the Council’s safeguarding investigation into her father’s care. This is because the Council has taken appropriate and proportionate action to address the faults identified by the Safeguarding Adults Review and we cannot achieve the outcome Mrs X wants.

The complaint

  1. Mrs X complains about failures in the Council’s safeguarding investigation into her father’s care. She says the Council did not investigate properly and did not involve other agencies it should have done. She says those responsible for the Council’s previous procedures should be held responsible.

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The Ombudsman’s role and powers

  1. 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:
    • we are satisfied with the action a council has taken, 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

  1. I considered the information Mrs X provided in her complaint, the Council’s responses to her and additional information the Council provided in response to my request. I also discussed Mrs X’s complaint with her.
  2. I sent a copy of my draft decision to Mrs X. I considered her comments before making a final decision.

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What I found

Background

  1. Mrs X’s father, Mr Y, moved into a care home in the Council’s area in June 2018. Mr Y has since died.
  2. In July 2018, Mr Y was admitted to hospital with extensive bruising. The hospital made a safeguarding referral to the Council, which started an investigation.
  3. Mrs X says the investigation was done poorly. She says:
    • the conclusions were not consistent with the evidence;
    • the social worker gave wrong information to the police which caused the police to decide not to investigate;
    • the Council did not invite the police to the right meetings; and
    • the Council did not involve Mrs X, or her sister, who were her father’s attorneys, in the investigation.
  4. Following complaints from Mrs X, the local Safeguarding Adults Board arranged an independent Safeguarding Adults Review (SAR) into the failings in Mr Y’s case. The review, published in mid-2020, identified failings in the safeguarding process and recommended service improvements.
  5. The Council accepts all the findings and recommendations of the SAR. As part of the SAR, the Council conducted a review of its safeguarding procedures and developed an action plan to address the recommendations.
  6. The Council commissioned an audit of its progress against the action plan in mid-2020. This audit showed the Council had fully completed all the actions or had plans in place to complete outstanding actions.
  7. A senior member of the Council has met with Mrs X to assure her how seriously the Council takes its responsibilities and to apologise for the failings.

Analysis

  1. The Council accepts its failings in Mr Y’s case and has identified significant service improvements in line with the SAR findings.
  2. The evidence provided by the Council shows it has implemented these improvements or is making good progress towards completing the changes. The Council has had its progress audited which shows its commitment to improving its services and reducing risk.
  3. The information I have seen shows the Council has identified and made significant improvements to its safeguarding process following the SAR. In my view the Council’s response to the SAR and Mrs X’s complaint has been appropriate and proportionate, so I am satisfied with the action the Council has taken.
  4. The Council acknowledges it cannot go back and make up for the failures to Mr Y. Since Mr Y has died, the Ombudsman would also be unable to remedy the injustice caused to Mr Y.
  5. Mrs X says that she wants those responsible for the Council’s previous procedures to be held responsible. However, our role is to investigate the actions of the Council as a corporate body, not to hold individual officers accountable, so we cannot achieve the outcome Mrs X wants.

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Final decision

  1. The Ombudsman will not investigate this complaint. This is because the Council has taken appropriate and proportionate action to address the faults identified by the Safeguarding Adults Review and we cannot achieve the outcome Mrs X wants.

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Investigator's decision on behalf of the Ombudsman

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