Summary: We have found in the Council’s actions as the Council failed to provide Ms B with the review report it had promised to deliver. There were also delays in the process and there was poor communication during and after the review. The Council has agreed to apologise to Ms B, have a meeting with Ms B and pay a financial remedy.

The complaint

1. Ms B complains about the Council’s review report following her son’s death. She says the Council did not deliver the review it had promised. Ms B also complains about the delays in the process, the communication and the Council’s response to her complaint.

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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’. 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)
3. 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

4. I have discussed the complaint with Ms B. I have considered the documents that she and the Council have sent, the relevant law, guidance and policies and the comments on the draft decision.

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What I found

5. The Care Act 2014 and the Care and Support Statutory Guidance 2014 (updated 2017) set out the Council’s safeguarding duties. The Council also has its own policies.
6. The Care Act 2014 section 42 says a safeguarding duty applies where a council has reasonable cause to suspect that an adult:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.
7. Neglect includes (among other things):
• Emotional or physical care needs.
• Failure to provide access to appropriate health, care and support or education services.
• Self-neglect. This covers a wide range of behaviour neglecting to care for one’s personal hygiene, health or surroundings. Not all self-neglect will trigger a section 42 enquiry and an assessment should be made on a case- by-case basis. It depends on how far a person can protect themselves by controlling their own behaviour or whether they need external support to do so.

Safeguarding Adults Review

8. Each local authority must set up a Safeguarding Adults Board (SAB).
9. Section 44 of the Care Act 2014 says SABs must arrange a Safeguarding Adult Review (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.
• If the same circumstances apply where an adult is still alive but has experienced serious neglect or abuse.
• SABs are free to arrange an SAR in other situations where it believes there will be value in doing so.
10. SARs should seek to determine what the agencies 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.
11. The SAB should aim for completion of an SAR within a reasonable time, within 6 months of initiating it, unless there are good reasons for a longer period for example, because of potential prejudice to related court proceedings. 

What happened

12. Mr D was a young man who had a diagnosis of Asperger’s, substance and alcohol misuse and mental health problems.

Agencies providing support

13. Mr D was subject to a multi-agency risk management protocol since the beginning of 2018 due to the risks he posed to himself and others.
14. Mr D lived in a supported housing unit (SHU) for adult with mental health needs and learning disabilities.
15. He also received support from two agencies which provide support to people with drug and alcohol services. Their main aim was to support Mr D in reducing his alcohol misuse and to mitigate the risks posed by the alcohol misuse.
16. This support was provided by Agency 1 until October 2018 when agency 2 started to provide the support. Agency 1 remained involved as Mr D had a positive relationship with one of the case workers.
17. On 4 January 2019, Mr D was found at home, confused and disorientated. He had injuries on his body. The Council and the agencies had great concerns about Mr D and discussed whether an in-patient detoxification was possible. Mr D agreed to attend hospital with a view to being admitted if appropriate. Staff from the SHU and agency 1 accompanied Mr D to the hospital.
18. Mr D’s father, Mr E, joined them at the hospital.
19. The hospital’s alcohol liaison nurse said there was a bed for Mr D at detoxification unit K. Mr D was initially reluctant to agree to this plan as he had had a previous negative experience at unit K. But he was then persuaded to cooperate and was positive about accessing detox at unit K.
20. Unit K has two admission pathways:
• Planned admissions for people with complex substance misuse problems and co-existing physical and mental health concerns.
• A 5-7 day rapid alcohol detoxification programme.
21. The support workers left as Mr E would stay with Mr D until he was admitted to unit K.
22. The plan then changed and the emergency admission to unit K was cancelled. The agencies said they did not know of the change in plan until were informed of the change by Ms B.
23. Mr D’s social worker rang unit K and unit K told him that they had spoken to agency 2’s support worker and it was decided that a planned admission was more appropriate as this would allow a two-week admission.
24. The Council agreed to provide additional emergency support for Mr D while he waited to be admitted to the detox unit.
25. The Council held a multi-agency meeting about Mr D on 7 January 2021. They agreed that Mr D was now at ‘high risk’. Agency 2 said the nurse had declined the referral for Mr D because it ‘was her clinical judgment that an unplanned one-week admission would be less successful due to [Mr D’s] identified needs, previous and recent refusals for referral to inpatient units and the hospital stating that he was medically fit for discharge.’
26. Tragically, the CSU staff found Mr D at home in his shower later that day. They called an ambulance but Mr D had passed away.
27. Mr D’s death certificate said the cause of his death was a ‘sudden and unexpected death in alcohol dependency’ with an underlying condition of alcoholic fatty liver disease which may have contributed to his death.

SAR decision – January 2019

28. The Council made a referral for a Safeguarding Adult Review (SAR) to the SAB. The Council said the issue for discussion was:
• On 4 January 19, all professionals involved with Mr D felt that he required detox and the risk was too high for Mr D to remain at home alone. Nobody knew Mr D had not gone into detox until they received an email from Ms B. They felt that this was a missed opportunity and that, if Mr D had gone into detox, the outcome may have been different.
29. The SAB panel asked the Council for further clarity on how the case met the criteria for SAR as it was not clear on the form.
30. The Council then added:
• ‘… the death is suspected to be caused by self-neglect (misuse of alcohol). Self-neglect is considered to be a safeguarding issue in the Statutory Care Act 2014 guidance.’
31. The SAB told the Council on 21 January 2019 that it would not carry out an SAR:
• ‘… this does not meet criteria for screening as there is not at present any evidence that his death was linked to abuse or neglect. Drinking to excess would normally be considered to be self-neglect.’
• ‘Should the coroner conclude that the death was caused by self-neglect or that this was a contributory factor, we would review the case.’

Ms B’s requests for a review

32. Ms B wrote an email to the council on 13 May 2019 and said:
• ‘I assumed when [Mr D] died that as a matter of course there would be an investigation into the sudden death of a young vulnerable adult, supported by a range of CQC regulated organisations. In [Mr D’s] case this was further exacerbated by him dying four days after being turned away from hospital.’

Safeguarding Adult Board’s letter – 7 June 2019

33. The SAB’s Chair wrote to Ms B on 7 June 2019 and said:
• ‘Although the criteria are not met for a statutory review, I am of the view that it is important to see what lessons might be learned by further examination of the circumstances and have therefore decided to ask agencies to participate in a multi-agency learning review which the Board will facilitate.’
• ‘While this is not a formal Safeguarding Adult Review, we will appoint an independent reviewer who will undertake the exercise, collate the findings and we will share the recommendations when they are made.’

Council’s letter – 14 June 2019

34. The Council wrote to Ms B on 14 June 2019 and said:
• ‘A decision has been made that the Rochdale Safeguarding Adults Board will undertake a professional review.’
35. Ms B said she spoke to the SAB’s Chair who assured her that the review would be done to the same high standard than an SAR and that Ms B would be involved in the consultation on the report.
36. Internal emails show that the Council closed Ms B’s complaint for the time being as the matter was being dealt with under the safeguarding procedures.
37. The Coroner started an inquest into Mr D’s death.
38. The officer who was carrying out the review had a meeting with Ms B in July 2019 and with Mr E in August 2019 to discuss the review. Ms B says the officer assured her that the report would not be finalised without sharing a draft with her to discuss it.
39. Ms B contacted the Council on 17 October 2019 as it had been nine months since Mr D died and five months since the start of the safeguarding review. She said there had been a pre-hearing at the Coroner’s office that day and four of the attendants from the Council did not appear to know about the review. She felt that there had been little progress.
40. The SAB replied on 21 October 2019 and said:
• The Business Unit of the SAB was ‘supporting [the independent reviewing officer] in an administrative capacity.’
• ‘We have previously called this a professional review or multi-agency review and we appreciate this might’ve caused confusion.’
41. The Council wrote to the Coroner on 25 November 2019 and said it could not complete the report by 28 November 2019 but would complete it by 31 December 2019.

The report – 24 December 2019

42. The reviewing officer completed her report on 24 December 2019. The officer said:
• She was appointed to ‘undertake a professional review of the family concerns.’ The contributions from Mr D’s parents were the ‘key issues highlighted to me to consider.’
• She summarised the parents’ concerns in 13 questions which she attempted to answer in her report. The questions centred around the roles the different agencies played in the decision-making process regarding the detox admission and whether agency 2 had properly supported Mr D.
• She found no major failings by the agencies involved with Mr D. She said there had been a miscommunication at the hospital. The hospital’s alcohol liaison nurse had found a bed for Mr D at unit K, but it was not made clear that this bed was subject to unit K’s approval. Unit K then decided Mr D did not meet its admission criteria.
• She found no fault in agency 2’s actions in supporting Mr D or in tailoring the support to his Asperger’s. She acknowledged agency 2 missed two meetings but said that this happened once because of staff sickness and the other time because of a ‘catalogue of issues’ which included the agency saying it had not received an invite, despite the reviewing officer seeing the email inviting agency 2.
43. The Council provided the final report to the Coroner in January 2020 without sharing the document with Ms B first.
44. The report was disclosed to Ms B on 15 January 2020 after several requests. Ms B had a meeting with the reviewing officer on the following day and said she was very unhappy with the report. The reviewing officer sent an email to the SAB and the Council to find out whether there was an alternative resolution as Ms B had threatened to complain.

Ms B’s complaint – January 2020

45. Ms B complained to the Council on 21 January 2020. She said:
• The report was unacceptable.
• She felt ‘badly let down’ as she had expected an inquiry into the events prior to Mr D’s death. This had not happened.
• She had been assured that the review would be of the same standard as an SAR. Instead, the review had been dealt with as a response to her complaint.
• The report was delayed several times.
• She had been promised that she would see the report and be consulted about it before the final version was published. That did not happen.
46. The Council replied on 23 January 2020 and said:
• There was a ‘mismatch in perceptions and assumptions on both our parts’ of what type of report would be produced and apologised for the distress this caused.
• There was nothing in the report to suggest Mr D’s death was as a result of neglect or abuse so the original decision not to carry out an SAR was correct.
• Some learning had come out of the report and the Council was formulating a multi-agency action plan.
• If Ms B was not satisfied with the response, she could go to the Ombudsman.
47. The Council further replied on 5 February 2020 and said:
• It was sorry if the review ‘did not tally with your expectations’.
• It treated ‘her concerns as a complaint and, following completion of the investigation, we feel we have exhausted the council’s complaints policy and procedure’ so Ms B could contact the Ombudsman.
48. Ms B continued to pursue her original complaint and raised further questions and concerns about the report in February 2020. She said:
• She questioned the SAB’s decision not to carry out a review. Mr D was an autistic vulnerable young man who was being supported by different agencies. There had possibly been neglect that the agencies had not acted quickly enough and should have done more. An SAR could have investigated this.
• There was a lack of communication which was witnessed at the Coroner’s pre-inquest hearing where the agencies did not know what was happening.
• She had been promised that the independent reviewer would contact her before finalising the report but this did not happen and the report was given to the Coroner without her having seen it.
• There were issues with the content of the report. The reviewing officer had accepted the agencies’ responses as fact without sufficient questioning or analysis, for example about agency 2’s failure to attend meetings.
49. The Council said in February 2020:
• The investigation was undertaken in a way akin to a complaint with issues of concern discussed with her and addressed.
50. The Safeguarding Adults Board’s Chair said:
• The criteria for an SAR were not met but she had encouraged the Council to undertake an independent management review and ‘offered some business support from the Board in completing this.’ Unfortunately, this had ‘muddied the waters’ somewhat.
51. Ms B instructed a solicitor in March 2020 to pursue her complaint. The Council replied and said her complaint had been fully and properly investigated and not upheld.
52. The Council later agreed to review the report. The review investigated the same 14 questions as the original report and said the original response addressed the concerns identified by the parents.
53. It is our understanding that Ms B did not see the Council’s action plan until the Coroner’s inquest took place.

Coroner’s report – January 2021

54. The Coroner completed her report in January 2021. The record and the reporting of the inquest said:
• Mr D did not have a post detoxification care plan during 2018 after he had been an in-patient for drug detoxification in February 2018.
• Agency 2 failed to attend key multi-agency meetings to discuss Mr D’s alcohol management and treatment on 25 October, 9 November and 4 December 2018. Agency 2 did not attend a meeting until the multi-agency risk management meeting on 13 December 2018. Agency 2 had sent apologies to the meetings so it had been aware of the meetings.
• Agencies could have acted earlier. It was known from 5 November 2018 that Mr D was not suitable for home detoxification, but this was not communicated and no plan was put in place to facilitate an in-patient detoxification until 13 December 2018.
• There was no consideration for extra support for Mr D over the Christmas period during which time his drinking increased.
• There was no adequate training programme for agency 2 staff for caring for people with autism or a learning disability diagnosis.
• There was inadequate communication and engagement with Mr D’s family by agency 2.
• Agency 2 did not admit any failures at the beginning of the Coroner’s inquest hearing, but made significant admissions of failure after the hearing started.
• The Coroner questioned whether an adequate assessment had been done to decide that Mr D was medically fit for discharge from hospital on 4 January 2019.
• The Coroner said unit K decided Mr D was not eligible for the fast detox programme on 4 January 2019 because he was medically fit for discharge. Unit K’s staff member rang agency 2 to see if agency 2 could make a referral for a planned admission as beds were available for a planned admission. It was a Friday afternoon and unit K did not take patients at the weekend. Agency 2 had a different recollection of the call. Its understanding of the call was that Mr D would be admitted to unit K. The Coroner said it was impossible to reconcile the different recollections of the conversation.
• The Coroner concluded: ‘Due to poor communication between staff and a lack of understanding by the alcohol liaison nurse as to the requirements for an emergency inpatient admission to [Unit K] [Mr D] was not admitted for an inpatient alcohol detoxification.’

Ombudsman’s investigation

55. The Council made the following comments in response to the Ombudsman’s investigation. It said:
• The question whether to proceed with an SAR was properly considered at the time. However, the Council acknowledged that, with hindsight and following the Coroner’s inquest, it may have been appropriate to undertake a discretionary SAR.
• Although the review undertaken was not an SAR, it was a similar investigation. The report achieved what Ms B asked the Council to do, but the Council did not properly explain this in its letter of 23 January 2020 and it apologised for this.
• It accepted there had been delays in the review and apologised for this.
• It provided the Ombudsman with the action plan and statements it had written for the Coroner’s inquest which set out what changes it had made as a result of the review.
• It had taken on board the Coroner’s inquest’s report and it had made further changes as a result of the inquest. It engaged in an improvement plan with agency 2. Agency 2 now submitted quarterly safeguarding lessons log as part of its contract monitoring process.
56. I asked the SAB to further clarify how it made the decision as I did not understand its letter of January 2019, in particular its comment relating to neglect and self-neglect. The SAB said its decision making was in line with the Care Act 2014, but did not really explain this further.

Analysis

57. I have investigated Ms B’s complaints about the Council’s review and its communications relating to this. I have not investigated the Council’s or the agencies’ actions relating to Mr D.

Decision not to carry out an SAR

58. I accept that the SAB’s decision making is subject to judgment. I have focussed my investigation on whether the SAB has properly communicated how it reached the decision that the matter did not meet the criteria for an SAR.
59. The SAB provided its reasons in its letter to the Council dated 21 January 2019. The SAB said there was no evidence Mr D’s death was linked to abuse or neglect. It then said that drinking to excess would be considered self-neglect, but it did not explain what the implication of that was in terms of an SAR. Self-neglect can be considered under the neglect category (depending on the circumstances) so it was not clear what the SAB meant by that second sentence.
60. The SAB then contradicted itself by saying that if the Coroner concluded that the death was caused by self-neglect, then it would review the case, which made no sense.
61. Therefore, I find fault in the way the SAB has communicated its decision not to pursue an SAR as it has not provided a clear explanation for its reasons to do so.

The Council’s review

62. Ms B’s main complaint is that the Council promised her a review which would be similar to an SAR and then failed to deliver it. Instead the Council carried out an investigation into the concerns/complaint she had raised.
63. I uphold this complaint and agree there was maladministration/fault.
64. The SAB said on 7 June 2019 that it had asked the agencies to participate in a multi-agency review which the SAB would facilitate.
65. The Council said on 14 June 2019 that a decision had been made for the SAB to undertake a professional review.
66. Yet, in October 2019 the SAB started to renege on that promise. It said it was only supporting the reviewing officer in an ‘administrative capacity’. It had previously called this a professional review or a multi-agency review which may have ‘caused confusion’.
67. In January 2020 the Council said there had been a ‘mismatch in perceptions and assumptions’ on both sides.
68. In February 2020 the SAB said it offered some business support and this had ‘muddied the waters’.
69. I do not agree with the Council and the SAB that there had been confusion or a ‘mismatch in perceptions’ by Ms B. There was no confusion on her part. Ms B had been promised a professional multi-agency review which the SAB was going to carry out. The Council and the SAB both confirmed this in letters in June 2019. At some point, the scope of the review was changed, but nobody told Ms B.
70. It is not surprising, therefore, that Ms B was not satisfied with the review report as it was not the review she had been promised.
71. There was a big difference between carrying out a review similar to an SAR and carrying out an investigation into complaints about the service raised by Ms B and Mr D.
72. An SAR would have taken an open approach investigating all the agencies’ actions to see whether there was anything they could have done differently and to learn lessons.
73. However, by limiting the review to concerns/complaints raised by Ms B and Mr D, the Council was expecting Ms B and Mr D to already know what the agencies had done wrong and to raise a complaint. But that was a flawed approach. Ms B’s main aim in asking for an SAR was to find out what happened so it was unfair to expect her to know what the concerns were. It meant the Council’s review was far more limited than what was promised and did not identify the failings of the different agencies.
74. There was then further fault in the Council’s refusal to reply properly to Ms B’s complaint. The Council never fully acknowledged or admitted that it had not provided the review it had promised her. It refused to engage with her about the complaint and instead it said that, as the review had found no fault, her complaint had been considered and that was the end of the matter.
75. Even after Ms B went to see a solicitor and the Council agreed to carry out a further review, the review made the same mistake by only considering the 13 questions which the original reviewing officer had identified. But this never addressed Ms B’s complaint which was that she wanted a full review, not just an answer to the 13 questions.
76. I also agree with Ms B that the review did not fully question the claims the agencies made. For example, some of the failings identified by the Coroner’s report, particularly in relation to agency 2’s failure to attend meetings and its communications on the 4 January 2019 should have been more properly considered and analysed in the Council’s review report.
77. I also uphold the complaint that there was delay in delivering the report. The Council has already upheld this complaint and has apologised for this. This delay then meant that the Council submitted the final report before sharing it with Ms B. Ms B says the reviewing officer had told her she would share the report with Ms B before finalising it and this did not happen.

Injustice

78. Ms B says the Council’s actions caused her a lot of distress at a difficult time. She was distressed at the content of the report but also the Council’s refusal to have any further discussion with her about the report. She said the Council’s actions made the Coroner’s inquest longer and more difficult.
79. I asked Ms B what remedy she wanted to achieve by coming to the Ombudsman. Ms B agreed that she was not seeking another review into what happened. Fortunately, the Coroner’s inquest had provided her with some of the information she was seeking in relation to what the agencies did in the months and days before Mr D’s tragic death.
80. Ms B said she was not convinced the Council had learned any lessons from the review or from the Coroner’s inquest. The Council did not involve her in any way in the action plan that came out of the review. She said the action plan was insufficient and the actions had not been completed. She felt the action plan should have been updated in light of the Coroner’s inquest. She wanted a chance to give her view on what should change.
81. Ms B also said the Council told the local media it regretted what happened but did not approach the family. She would like the Council to acknowledge its failings and to apologise to her.
82. The Council has agreed to apologise to Ms B in writing and provide her with a symbolic payment of £500. The Council has also agreed to have a meeting with Ms B where Ms B can provide the Council with her views on the action plan and the changes the Council has made and what other improvements she thinks the Council could make. The Council has agreed that a senior person in the Council’s Adult Social Care department and the Chair of the SAB will attend the meeting.
83. The Council has agreed to write to Ms B after this meeting, to confirm what the outcome of the meeting was. If the Council makes any changes to the action plan or its practice as a result of the meeting, then the Council will set out those changes in the letter.

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Agreed action

84. The Council has agreed to take the following actions within two months of the final decision. It should:
• Write to Ms B and acknowledge the fault and apologise.
• Pay Ms B £500.
• Hold a meeting with Ms B to discuss the action plan and the changes it has made to its practice following the review and the Coroner’s inquest. The Council will write to Ms B, following this meeting, to confirm the outcome of the meeting.

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Final decision

85. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

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Investigator's decision on behalf of the Ombudsman