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Sandwell Metropolitan Borough Council (20 004 873)

Category : Adult care services > Safeguarding

Decision : Upheld

Decision date : 27 May 2021

The Ombudsman's final decision:

Summary: Ms B complained on her own behalf and on behalf of her late father about the standard of her father’s care while he lived in extra care housing, issues that arose about her father’s funeral plan and burial plot and the Council’s failure to deal with her complaints about these matters. She said her father was not cared for properly and his wishes for burial could not be met. She said she was caused stress and upset. There was fault by the Council that caused injustice to Ms B. The Council will apologise and make a payment to her.

The complaint

  1. I call the complainant Ms B. She complained on her own behalf and on behalf of her late father about the standard of her father’s care while he lived in extra care housing, issues that arose about her father’s funeral plan and burial plot and the Council’s failure to deal with her complaints about these matters. She said her father was not cared for properly and his wishes for burial could not be met. She said she was caused stress and upset.

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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’. 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)
  2. 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)

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How I considered this complaint

  1. I considered the complaint and documents provided by Ms B and spoke to her I asked the Council to comment on the complaint and provide information. I sent a draft of this statement to Ms B and the Council and considered their comments.
  2. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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What I found

  1. I call Ms B’s father Mr Y. He lived in extra care housing, Walker Grange, and some of his care and support needs were met by staff there. Mr Y died in February 2019.
  2. Ms B was unhappy about some incidents which happened while Mr Y was in Walker Grange. In September 2018 she complained about incidents where the necessary thickener had not been added to his drinks. This was needed as Mr Y was at risk of choking. She raised some other matters but I do not consider they are relevant to this complaint.
  3. The Council wrote to Ms B in December with the outcome of the safeguarding investigation into the failure to add thickener. It was found to be fully substantiated and there had been a failure.
  4. In January 2019 Ms B complained about a further failure to put thickener in her father’s drinks. The Council carried out a safeguarding investigation and again found fault. But it did not tell Ms B of the outcome.
  5. Ms B complained to the Council in early March and chased that up later that month. In that correspondence she said she hadn’t had a response to her complaints and also complained about arrangements for her father’s burial. She said she had been told that her sister’s grave could accommodate another burial so had purchased a funeral plan on that basis. But the day before her father’s funeral she was told that couldn’t happen.
  6. Ms B chased the Council again in June and July. She then approached us but we referred the matter back to the Council. This prompted the Council to write to Ms B in January 2020 setting out how it was going to investigate her complaints. It also invited her to agree to her complaint about the burial arrangements being referred to the relevant department. Ms B agreed.
  7. The Council responded to her complaints at the end of October 2020. It said it had agreed to investigate the complaint in November 2019. It accepted the investigation had been delayed. It said this was partly because of the Council needing to redirect its resources between April and July 2020 while handling the COVID-19 pandemic. It apologised for not updating her about its investigation after it restarted services in July 2020.
  8. The Council’s response was that it:
    • partially upheld her complaint about delayed responses to her complaints;
    • explained how it had investigated the incident in January where Mr Y’s drink had not been thickened and how it had taken action to prevent recurrence of such an incident. It partially upheld her complaint because it had failed to inform Ms B of the action it took at the time;
    • explained the housing facility’s procedures where Mr Y lived for collecting and giving prescribed medication. It explained why on one occasion it had not been possible to collect and give prescribed medication to Mr Y as soon as it would normally have expected. It did not uphold this complaint.


  1. The Council accepted it failed to tell Ms B of the outcome of the safeguarding investigation in January 2019. This was fault. The Council apologised for this failure.
  2. The Council twice found fault in the failure to administer thickener. The Council has commented that the manager of Walker Grange arranged for the speech and language team to provide updated training and guidance to all the care staff based at the unit on the process and importance of the use of thickeners. All staff were asked to review Mr Y’s care plan and notes and were asked to sign to acknowledge they had done so.
  3. This was an appropriate response and we cannot now achieve anything more on this point.
  4. The Council says it investigated the complaint and a response was prepared in February 2020 but was not sent. This is fault.
  5. Mr Y had purchased the grave in the 1960’s. The deed showed it was for two bodies. Ms B’s baby sister was buried in the grave. She purchased a funeral plan in 2017 with the intention that her father should be buried in the same plot. It was only on the day before the funeral that the Council realised the plot could not accommodate a second burial.
  6. The deed was wrong but that error happened many years ago. The Council has accepted it should have realised sooner that the grave could not accommodate a second burial.
  7. There were faults in the handling of Ms B’s complaints. It was clear there were unresolved matters in Ms B’s correspondence of March 2019. The Council only started to deal with them in November 2020 following a referral from us. A response was sent in October 2020. The Council’s response to the COVID-19 pandemic will have caused some delay but, even taking that into account, the delay here was unacceptable and fault.
  8. The Council accepts there were delays and has now introduced a central point for tracking complaints. It intends to do further work over 2021-22 to move customer feedback functions into a single directorate.
  9. In responding to me the council accepted the faults and the time, trouble and distress this will have caused to Ms B. It offered to make a payment of £250 to her in recognition of this. That is a reasonable and fair response.

Agreed action

  1. The Council will apologise to Ms B for the faults found and pay her £250. It should do so within a month of the final decision.

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Final decision

  1. There was fault that caused injustice to Ms B.

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Investigator's decision on behalf of the Ombudsman

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