Summary: Mrs B complained about the actions of the Council in respect of her late uncle, Mr C following a safeguarding investigation which led to him being moved into respite care where he died shortly afterwards. Mrs B says the Council’s actions were wrong and damaging. The whole family has been caused significant distress and do not understand why the Council took the action that it did. We cannot find fault with the actions the Council took.

The complaint

1. Mrs B complained that Hertfordshire County Council (the Council), in respect of her late uncle, Mr C:
• failed to provide adequate care to Mr C prior to his death;
• placed Mr C in respite care without justification and falsely accused his carer, Mr D, of possible abuse;
• assisted Mr C with financial transactions including removing Mr D’s power of attorney and opening a new bank account;
• said Mr C had capacity to make decisions about his finances and care, without providing any evidence and contrary to the view of his family;
• failed to communicate with the family or include them in any of these decisions about Mr C’s care;
• inappropriately suggested that the family request a post-mortem for Mr C, on the day of his funeral; and
• failed to respond to the family’s complaint about these issues.
2. These events have caused the family considerable distress and frustration and prevented them from properly grieving for their uncle.

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The Ombudsman’s role and powers

3. 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)
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)

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How I considered this complaint

5. I have spoken to Mrs B, considered the complaint and the documents provided by Mrs B, made enquiries of the Council and considered the comments and documents the Council provided. Mrs 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

6. In 2019 Mr C was living in a property with his brother-in-law, Mr D (Mrs B’s father).
7. Following information from a third party and with Mr C’s consent, the Council started a safeguarding investigation in respect of Mr C.
8. The Council carried out an assessment of Mr C’s needs and supported him to move to a supported living flat with a package of care. Mr D also moved to a flat nearby and continued to care for Mr C.
9. Mrs B’s husband, Mr B, was involved in setting up a bank account for Mr C to enable him to pay the Council his assessed contribution towards his care package. No family member had a formal power of attorney to act on Mr C’s behalf.
10. The Council continued with the safeguarding investigation in October 2019 and took some actions to protect Mr C. It was satisfied Mr C had the capacity to agree to the actions.
11. Mr B complained to the Council in October 2019 about the actions of the social care officer in respect of her involvement with Mr C’s case. The Council offered to meet with Mr B and other members of the family, but Mr B wished the meeting to take place at the weekend which the Council could not do.
12. In early November 2019 the Council visited Mr C to check on his wellbeing. Following events during the meeting involving Mr D, the Council visited Mr C again later in the day with a community support officer from the police. After discussion with Mr C, he agreed to move to a care home for some respite from the situation at home.
13. Mr B asked the Council to respond to the complaint without a meeting. He provided signed consent from Mr C to do so. The Council was not satisfied that Mr C understood what he had consented to.
14. The Council spoke further with Mr C, carried out mental capacity assessments and decided it was in Mr C’s best interests to remain in respite care, while it obtained further information about his health. It also decided that the address should not be disclosed to the family at this time. In total it assessed Mr C’s capacity to understand and make different types of decisions on 13 occasions and undertook a best interests decision on his behalf three times.
15. In December 2019 the Council arranged for Mr C to have telephone contact with his nieces. Mrs B said she was concerned about how Mr C sounded and felt the social worker intervened in the conversation inappropriately. Mr C attended a family meal on Boxing Day. Mrs B was very concerned about his appearance and hygiene. She was concerned he was not being cared for properly. There is evidence in the case records that other people did not have concerns about Mr C on Boxing Day and said the meal had gone well.
16. The care records for the respite care show that Mr C’s medical needs were known about and attended to: Mr C was accompanied to a variety of medical appointments and was prescribed additional medication when necessary. The records also show that Mr C had baths, hairwashes and shaves while he was there. There is a record of a GP confirming Mr C was eating well and his BMI was good. The weight charts show he put on weight between November and December 2019. Arrangements were being made for Mr C to see a dentist about a broken front crown.
17. Towards the end of December 2019, the Council advised a family member that they were looking to facilitate Mr C to return home to his supported living flat and was in the process of arranging a review meeting with some family members before doing so.
18. In early January 2020 the Council accompanied Mr C to the bank to try and resolve a financial issue. This was unsuccessful and the Council arranged another visit for later in the month.
19. On 13 January 2020 staff at the respite care noted Mr C was chesty and off his food. A doctor visited and prescribed some medication which was started the following day. On the morning of 15 January 2020 staff went into Mr C’s room to administer his medication. On four occasions they noted he was asleep and snoring and decided not to wake him. He did not receive his medication and did not have anything to eat or drink. A member of staff went in at lunchtime but noted he was unresponsive and called an ambulance. Mr C was admitted to hospital. He died on 18 January 2020.
20. The Council opened a safeguarding investigation into the care home, which it upheld on the basis that neither medication, food nor fluids were given to Mr C on the morning of 15 January 2020. The coroner declined to take any further action. The Council closed the safe-guarding case and the care provider confirmed it had taken steps to ensure its policy of waking residents to give medication was implemented by all staff.
21. The case records show that the Council sent an email to another family member on 13 February 2020 apologising for the late email, but it had only just been informed by the coroner of the process the family should follow ‘should they wish to request a post-mortem’ because of the missed medication on the morning of 15 January 2020. It added that a member of staff at the coroner’s office had given her opinion that the missed medication was unlikely to have influenced the outcome but only a doctor could confirm that.
22. The case records also show that the Council, on 17 February 2020, explained to another family member the issue with the bank in early January 2020 and assisted with the difficulties the family were having in accessing the account.
23. In late July 2020 the Council responded to the executors of Mr C’s estate, one of whom was Mrs B and offered a meeting. It provided the executors with the details of the account a third-party organisation (which helped vulnerable people manage their money) had set up. It did not have details of any other accounts. It also denied suggesting that the family arrange a post-mortem of Mr C, but rather the officer wanted to make sure that the family was aware that Mr C had not received his medication on the morning he went into hospital. It also provided details of the safeguarding investigation and outcome.
24. Mr B complained to the Ombudsman. We initially sent the complaint back to the Council to respond to. In October 2020 the Council declined to respond to the complaint because it did not consider Mr B was a suitable representative. The Council considered its complaints procedure was complete. Mrs B made a complaint to us.

Analysis

failed to provide adequate care to Mr C prior to his death

25. Apart from the failure to wake Mr C on the morning of 15 January 2020, there is no evidence to support this claim. The records show that Mr C was content in the placement, attended medical appointments, received appropriate personal care, and was eating and drinking well.
26. I accept the failure to wake Mr C to give him food, drink or medication has caused Mrs B considerable distress. The Council upheld its safeguarding investigation on this point, ensured the care provider took steps to improve its procedures and advised the family how to request a post-mortem if they wished to. I consider these actions were appropriate in the circumstances.

placed Mr C in respite care without justification and falsely accused his carer, Mr D, of possible abuse

27. The Council has provided evidence to support and explain the actions it took, and I cannot identify any fault in those actions. I am satisfied Mr C gave his informed consent to the temporary respite care. The Council also recognised the need for Mr C to return home and it was taking steps to achieve this in a safe manner from December 2019. Unfortunately, Mr C died before this could happen.

assisted Mr C with financial transactions including removing Mr D’s power of attorney and opening a new bank account

28. The Council has provided evidence to support and explain the actions it took, and I cannot identify any fault in those actions.

said Mr C had capacity to make decisions about his finances and care, without providing any evidence and contrary to the view of his family

29. The Council has provided evidence to support and explain the actions it took, and I cannot identify any fault in those actions. It noted that no family member had formal power of attorney for Mr C. It assessed Mr C’s capacity to understand and make different types of decisions on 13 occasions and undertook a best interests decision on his behalf three times.

failed to communicate with the family or include them in any of these decisions about Mr C’s care

30. The Council communicated with members of Mr C’s family, when it could and when it was able to, while taking into account the issues which had arisen as part of the safeguarding investigation. From December 2019 it involved family members in discussions about Mr C’s care.

inappropriately suggested that the family request a post-mortem for Mr C, on the day of his funeral;

31. There is evidence in the case records that the Council contacted a family member the day before Mr C’s funeral to advise them of how to apply for a post-mortem if they wished to do so. The notes do not support the claim that the Council suggested the family should request a post-mortem.

failed to respond to the family’s complaint about these issues.

32. In November 2019 the Council offered to meet with family members on a weekday to discuss the issues raised in the complaint. Mr B declined this offer.
33. The Council responded to the complaint and questions from the family in July and August 2020. I consider it has responded to the questions and issues as far as it is able to.

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Final decision

34. I have completed my investigation into this complaint as I am unable to find fault causing injustice in the actions of the Council towards Mr C or Mrs B.

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Investigator's decision on behalf of the Ombudsman