Summary: Ms X complained on the late Mrs Y’s behalf, that the Council did not deal properly with a safeguarding concern. It did not provide an advocate to support her and did not inform family what was happening. Ms X says it was traumatic to see the unfinished safeguarding enquiry referred to on Mrs Y’s death certificate. We found the Council was at fault in the way it dealt with the safeguarding concern. The Council has already apologised and made a £250 charitable donation in Mrs Y’s name, to remedy the injustice to the family. The Council has also agreed to complete the actions we recommended to avoid similar problems in future.

The complaint

1. The complainant, whom I shall refer to as Ms X, complained on behalf of her late mother, Mrs Y, that the Council:
• Did not properly deal with a safeguarding matter involving her late mother;
• Did not provide an advocate or social worker to help her make decisions about her care and medication in the last weeks of her life; and
• Did not inform family what was happening.
2. Ms X says an advocate did not contact family until six days after Mrs Y’s death. The safeguarding enquiry also remained open for two weeks after her death and was referred to on her death certificate. Ms X says she found that “traumatic”.

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The Ombudsman’s role and powers

3. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word ‘fault’ to refer to these. We cannot question whether a council’s decision is right or wrong simply because the complainant disagrees with it. We must consider whether there was fault in the way the decision was reached. (Local Government Act 1974, section 34(3), as amended)
4. 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)
5. 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.

6. (Local Government Act 1974, section 26A(2), as amended) We are satisfied that Ms X is a suitable person to complain on Mrs Y’s behalf.

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How I considered this complaint

7. I considered information from the Complainant and from the Council.
8. I will send both parties a copy of my draft decision for comment and will take account of the comments I receive in response.

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What I found

Background

Safeguarding

9. 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)
10. The safeguarding duties apply to an adult who:
• have needs for care and support (whether or not the local authority is meeting any of those needs)
• are experiencing, or at risk of, abuse or neglect
• as a result of those care and support needs are unable to protect themselves from either the risk of, or the experience of abuse or neglect

(section 42, Care Act 2014)

Safeguarding Adults Boards

11. The Care and Support Guidance to the Care Act 2014, says a Safeguarding Adults Board (SAB):
• “oversees and leads adult safeguarding across the locality”
• “can be an important source of advice and assistance, for example in helping others improve their safeguarding mechanisms”.

West Berkshire Council Safeguarding Adults Policy and Procedure

12. The Council’s policy and procedure document says:
• “Local Authorities should aim to provide swift and personalised safeguarding responses, involving the adult at risk in the decision making process as far as possible.”.
• “There also needs to be a focus on multi-agency communication and consideration should be given on setting up a multi-agency planning group.”.
• “The Local Authority should decide very early on in the process who is the best person/organisation to lead on the enquiry. Where there are multiple agencies involved, the LA should take the lead and delegate specific parts of the enquiry as appropriate, co-ordinate the response and ensure the enquiry is completed to a satisfactory standard…The Local Authority retains the responsibility for ensuring that the enquiry is referred to the right place and is acted upon.”.
• “The degree of involvement of the Local Authority will vary from case to case, but at a minimum must involve decision making about how the enquiry will be carried out, oversight of the enquiry, decision making at the conclusion of the enquiry about what actions are required, ensuring data collection is carried out, and quality assurance of the enquiry has been undertaken.”.

What happened

13. Mrs Y lived at home with Ms X who cared for her. She had a life limiting illness and had decided in July 2020, to end her life and stopped eating and drinking. The health professionals involved in her case were aware of this.
14. One day in August 2020, Ms X says she mentioned to one of the health professionals that Mrs Y was considering taking some old pills to help her sleep. They referred her to her GP who then referred her to the mental health team (MHT) who telephoned Ms X. They told her suicide was illegal and asked her to remove all medication from Ms X’s room, which she did. The MHT referred to the Police and raised a safeguarding concern. That evening, two uniformed police officers visited Mrs Y and Ms X. Ms X says this visit was “unannounced, unwarranted, intrusive, insensitive, disproportionate and outrageous” and it terrified Mrs Y.
15. The Council did not receive the email from the MHT with the safeguarding concern because the email address was wrong. However, the MHT called the Council the next day and gave basic details over the phone. This concern was triaged and referred for a full section 42 enquiry, but no actions immediately required because action had already been taken to reduce the risk. This referred to the call, police visit and an imminent health professional visit to Mrs Y. When the MHT sent further information about the health professionals’ visit to Mrs Y, the Council sent it on to the team who should have been dealing with the concern.
16. Two days after the concern was raised, the MHT asked the Council to urgently allocate a social worker. Later that same day, following the visit to Mrs Y by a psychiatrist and a health specialist, her GP advised Ms X to keep Mrs Y comfortable, and said they had spoken to the safeguarding lead. The GP said the MHT would not return. The MHT closed the case. The GP advised Ms X, but the Council was not aware of this.
17. A week after receiving the concern, and following a call from Ms X about it, the Council referred Mrs Y for an independent advocate to support her with the enquiry. Three days after this, the MHT told the Council it had closed its concerns.
18. Nearly two weeks after the concern was raised, the specialist agency supporting Mrs Y with her health condition, chased the Council for a safeguarding update. The Council advised it had not yet allocated a social worker. Another ten days later, the MHT telephoned the Council to advise that it had closed the case.
19. Sadly, soon after this, at the beginning of September, Mrs Y died. The Council received notification of this a few days later.
20. Ms X complained to the Council in mid September. It apologised and said the actions she had complained about all related to the MHT and the Council’s input was minimal. It said it would have expected some contact to have been made with Mrs Y when the referral was made. It also said it had “taken steps” to review processes and procedures for responding to referrals to ensure more timely responses in future. It said there had been no available social worker to process the section 42 enquiry.
21. Ms X was unhappy with the Council’s response and wanted to know why the Council had not let the family know it had begun a section 42 enquiry. She also asked why it was not escalated to someone senior when no social worker was available and why the enquiry was not completed. In November, Ms X met with a senior officer to discuss her complaint.
22. In December, following the Council’s apology and offer of charitable donation on Mrs Y’s behalf, the Council made a £250 donation as agreed with Ms X. It also set out the actions it had identified to improve the process.

Was there fault which caused injustice?

23. Had a social worker been allocated, and this should have happened swiftly, this would have prevented the uncertainty caused by an open and incomplete enquiry. It should also then have had all the information it needed to decide this within two days of the concern being raised, before it began the section 42 enquiry. This also led to unnecessary time handling Ms X’s complaint which caused her further dissatisfaction. Mrs Y would also not have needed an advocate. All this arose because it did not allocate a social worker promptly. The Council was at fault here and caused significant and avoidable distress to Ms X and her family. However, the Council has already offered and agreed a suitable remedy in the charitable donation.
24. In response to my draft decision, the Council advised that it has already submitted this case to the Safeguarding Adults Board and the case is being used as a learning activity for both health and social care. I have seen evidence of this.

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Agreed action

25. To remedy the injustice identified above, I recommended the Council:
• Apologise again to Ms X and her family.
• Complete this recommendation within one month of my final decision and submit evidence of this to me. Suitable evidence would include a copy of the apology.

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Final decision

26. I have completed my investigation and uphold Ms X’s complaints that the Council:
• Did not properly deal with a safeguarding matter involving her late mother;
• Did not provide an advocate or social worker to help her make decisions about her care and medication in the last weeks of her life; and
• Did not inform family what was happening.

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Investigator's decision on behalf of the Ombudsman