Summary: The Council’s service to the family during an adult safeguarding investigation failed with delays and communication errors. The Council failed to meet expectations when it arranged a meeting and then cancelled it and refused any further meeting. The Council will apologise and make a payment to acknowledge the upset, time, and trouble its actions caused.

The complaint

1. The complainant, who I will call Mr B, acts for himself, his brother, and their mother. Mr B says during a safeguarding investigation of an incident involving his father and Bluebird Care the Council had a meeting with Bluebird Care and a representative (who the Council will not disclose) after which the Council’s draft report was changed. Two meetings were arranged with the family but cancelled at short notice, for which Mr B and other family members had already taken time off work to attend. The Council then said it could see no purpose in a meeting and refused to arrange to meet the family. This has left the family feeling there is some collusion between the Council and the Care Provider, and a feeling of total disregard for the family.
2. Mr B says although they had the final report there has never been any explanation of the findings or information about an action plan, or what will happen to prevent future failings. Mr B says the Council’s communication has been poor since there was a change in staff completing the safeguarding investigation. The Council refused requests for information, so the family put in a formal Freedom of Information request. The family say the Council’s actions following what was a traumatic incident, have compounded their stress levels, caused them unnecessary time and trouble, and confusion. The family feel disregarded and feel they have not found peace or a full understanding of what happened to their father, and what processes are now in place to ensure it does not happen to anyone else.

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The Ombudsman’s role and powers

3. We may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by:

• their personal representative (if they have one), or
• someone we consider to be suitable.

(Local Government Act 1974, section 26A(2), as amended)

4. 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)
5. 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

6. I considered:
• Information provided by Mr B, including during a video meeting.
• Information from the Council in response to my enquiries.
• The Care Act 2014 and associated statutory guidance.
• The Leicestershire, Leicester, and Rutland Safeguarding Adults Process.
7. Mr B and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

8. The family employed a live-in carer, provided by Bluebird Care, to care for their father (Mr C) at home while their mother was in hospital. After the carer went to bed, Mr C left the house. A neighbour found Mr C outside several hours later and called an ambulance. It was a freezing cold night; Mr C went to hospital.
9. The incident triggered a safeguarding investigation by the Council. A council must make necessary enquiries if it has reason to think a person may be at risk of abuse or neglect and has needs for care and support which mean he or she cannot protect himself or herself. It must also decide whether it or another person or agency should take any action to protect the person from abuse or risk. (section 42, Care Act 2014)

What should happen?

10. The Council follows the procedures laid out in the Leicestershire, Leicester, and Rutland Safeguarding Adults Process. The Council should:
• Complete a strategy discussion/meeting within five working days of deciding the incident meets the criteria for a Safeguarding Adults Enquiry.
• Conduct a Section 42 Enquiry with appropriate professionals and compile a report/record. This should include:
1. face to face contact with the adult of harm wherever possible;
2. ascertaining the views and wishes of the adult and providing appropriate support to them;
3. undertaking an assessment of risk of harm;
4. collating all evidence and information gathered and completing an investigator’s report.
• Feedback to the alerter/referrer as appropriate. No timescale is given for how long the Enquiry should take.
• Conduct a Case Conference/Safeguarding meeting as appropriate.
• Create a protection plan/safety plan.
• Review the protection plan/safety plan.
• Review whether a further case conference is required.
• Feedback to the alerter as appropriate.
• Conclude and monitor as required.
11. It is important the Council gives feedback to the alerter at each stage of the safeguarding adults’ process, the extent of the feedback will depend on various things and must not risk compromising the Enquiry.
12. The Council must coordinate the enquiry process to avoid any duplication of work. Different types of enquiry can be undertaken simultaneously, everyone leading those enquiries must keep in regular contact to ensure that one enquiry does not impact or interfere with another.

What did happen?

13. The Council held a strategy discussion within five working days of its decision the incident met the criteria for a Safeguarding Adults Enquiry. The Council agreed an action plan, and to proceed to a Section 42 enquiry.
14. The Council should have had face to face contact with Mr C where possible. The Council recorded it was not appropriate to consult Mr C at first, that it would do so later, and that family were acting on his behalf. The safeguarding documents record the Council could not complete a capacity assessment of Mr C or get his views but sought and recorded the views of the family.
15. The Council should undertake an assessment of risk of harm. Given Mr C was being cared for in hospital and no longer by the Care Provider, there was no continuing risk to Mr C.
16. The Council should gather evidence and information and complete an investigator’s report. It did this by gathering information from the Care Provider, the family, the ambulance service, the hospital, the Police, and the care home where Mr C was staying. The Council can appoint roles to other agencies, and in this case, it let the Care Provider take the lead in gathering the information as it had already conducted its own internal investigation.
17. The Council shared its report with the Care Provider to check for factual accuracy but did not share it with the family at the same time. The Council amended its report to reflect comments from the Care Provider and sent the final report to the family. The family sent comments in response to the final report but there is no evidence the Council considered these.
18. The report confirmed neglect by three care workers. The report confirmed the actions taken so far and further recommendations and next actions, these were:
• To tell the Council’s Contracting department of the outcome of the safeguarding enquiry.
• To tell the Care Quality Commission.
• To make referrals to the Disclosure and Barring Service.
• The Care Provider to produce and provide a ‘Service User Guide for Live in care’ in response to relevant enquiries.
• The Care Provider to consider additional actions regarding one of its employee’s responsibilities and training needs.
• The Care Provider to consider contingency planning with customers dependent on informal carers to limit dependence on emergency care planning at the point of crisis.
19. A safeguarding conference was booked with the Care Provider and family to provide the findings of the investigation. The Care Provider said it did not wish to attend. It provided a written statement to be read in its absence. The Care Provider accepted some of the findings and disputed some others and detailed the actions it had taken, it also apologised to the family. The Council did not share this document with the family.
20. The Care Provider did not wish to attend due to concerns with the Council’s process. The Council acknowledged it had indicated an outcome to the family before it had completed the safeguarding enquiry, which brings into question its impartiality in the process. The Council also acknowledged delays in communication and process.
21. The Council cancelled the conference at short notice telling the family it would be unproductive and inappropriate to proceed. The family challenged this and asked for a meeting to discuss the findings, but the Council refused this request saying it had answered their queries in writing. The family were disappointed not to have the meeting, to get answers and to feel there was some closure to the process.
22. The family made a formal complaint to which the Council responded. The Council confirmed that neglect has been substantiated in respect of Mr C by the live-in carer and two employees of the Care Provider.
23. The Council wrote to the family confirming the closure of the safeguarding enquiry and said it would not engage in any further correspondence on this matter.
24. The Council told the family it had informed the Care Quality Commission of the outcome and had referred the three carers to the Disclosure and Barring Service. The Care Provider had carried out learning from the case.
25. The Council has apologised to Mr B for some of its delay and has apologised for language used in correspondence regarding the cancellation of the meeting.

Was there fault causing injustice?

26. The Ombudsman must now consider whether there was any fault in the actions of the Council, which caused injustice to the complainants. If we find fault causing injustice, then I may recommend action the Council can take to acknowledge the impact. I cannot recommend any redress for Mr C as he has since died.
27. The duty of the safeguarding enquiry is to protect the adult at risk, and to consider if other adults are affected. The Council followed its procedure in this regard.
28. The Council can ask the Care Provider to complete the investigation, as happened in this case. The policy says the Council must be satisfied the Care Provider’s response has been sufficient to deal with the safeguarding issue, and if not, it will undertake its own enquiry and take any appropriate follow up. The Council completed its report and shared it with the Care Provider for accuracy, the Care Provider responded, and the Council amended its report. This is not fault. The family are concerned that the draft report was not shared with them for accuracy, they say the officer told them it would be. This was not a requirement of the process so I cannot say it is fault that the Council did not share a draft with them. However, upon sharing the final report and the family making comments, I would expect the Council to consider those comments and decide whether any action was needed. There is no evidence the Council did this, and that is a failure in its service to Mr B.
29. The policy requires the Council to review whether a further case conference is required. The Council obviously thought that it was required because it arranged one, but then cancelled it saying it would be unproductive and inappropriate. It is unclear how the Council reached this view, and what changed its mind on the necessity of a case conference.
30. The policy requires the Council to give feedback to the person who made the alert but does not say this feedback must be given in a meeting. It is therefore not fault for the Council to give the feedback in writing to confirm the findings.
31. However, although the Council does not have to have a case conference meeting to conclude the investigation. in this case the Council said it would meet with the family and then withdrew this offer without giving a good reason. The offer of a meeting raised the expectations of the family that it would happen, and they are left disappointed that it has never gone ahead. It has also made the family feel there was collusion between the Council and the Care Provider, and they were being shut out of the process. I find this is fault in the Council’s service. I also find it is fault that the Council did not share the statement which the Care Provider had given it, which gave an apology to the family and explained the actions it had taken. Had the Council provided the family with this statement, it might have given them a better understanding of the actions that had been taken to improve service. I have now shared this statement with the family.
32. I find no evidence of collusion between the Council and the Care Provider. The Care Provider was not happy with the Council because it was not responding to their correspondence, had not shared information it had gathered from the family, and prejudged the outcome before the enquiry was concluded.
33. Although there is no timescale given for the completion of safeguarding investigations, the Council acknowledged delays in communication and process. This is fault. In this case the enquiry took one year. I note on the Council’s chronology nothing is recorded between March and July, a period of four months. Though I recognise Covid-19 had an impact as staff were redeployed and urgent work prioritised, the Council should have ensured to tell the family of reasons for any delay. The Ombudsman published a guide called ‘Good Administrative Practice during the response to Covid 19’. We still expect councils to keep people informed, give realistic timescales, and update of any further delay.
34. Although there was no ongoing risk to Mr C, the longer the enquiry took the harder it was for the family who felt they needed answers and wanted to grieve the death of their husband and father. The purpose of the safeguarding enquiry is not to provide answers to the family, but to protect vulnerable adults so this process might never have achieved what they were seeking. But chasing the Council for information caused unnecessary time and trouble to Mr B, who even went to the trouble of formal Freedom of Information requests. And the Council’s failure to share the Care Provider’s statement was a missed opportunity to provide relevant information to the family.

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Agreed action

35. To acknowledge the impact on Mr B, and to prevent future problems, the Council will:
1. Apologise to Mr B for raised expectations, failing to consider the family’s comments on the report, and failures in communication including not sharing the Care Provider’s statement.
2. Pay Mr B £150 for his unnecessary upset, time, and trouble.
36. The Council should complete the agreed actions within the next month and provide evidence of compliance to the Ombudsman.

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Final decision

37. I have completed my investigation on the basis the agreed actions are sufficient to acknowledge the impact on Mr B and to prevent future failings.

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Investigator's decision on behalf of the Ombudsman