Summary: Ms X complained the Council failed to notify her it had started a safeguarding in respect of her father and failed to complete the investigation and explain the reasons for this decision. The Council closed the safeguarding investigation prematurely in error, which is fault. It has now completed a retrospective safeguarding investigation reaching a decision that is unlikely to have been different even if it had been completed sooner.

The complaint

1. Ms X complained the Council failed to notify her it had started a safeguarding investigation in respect of her father and failed to complete the investigation and explain the reasons for this decision.
2. Ms X says this leaves her uncertain whether any neglect in respect of her father took place and if so, whether lessons were learnt to ensure others did not suffer.

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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. As part of the investigation, I have:
• considered the complaint and the documents provided by the complainant;
• made enquiries of the Council and considered the comments and documents the Council provided;
• discussed the issues with the complainant;
• sent my draft decision to both the Council and the complainant and taken account of their comments in reaching my final decision.

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What I found

6. Ms X was the main carer for her father, Mr Z, until his death in May 2020. Ms X was concerned about the standard of care provided to her father in the final four months of his life. In response to her complaint, information was shared with Ms X. She says that this information revealed that a safeguarding investigation in respect of her father had been started in April 2020 but never completed.
7. Mr Z was admitted to hospital in April 2020. The day after he was admitted the hospital raised a safeguarding concern. The issues related to skin breakdown, bruising, falls and low nutritional intake. The case was allocated to a hospital social worker the same day.
8. The social worker liaised with hospital staff and also contacted Mr Z. With the assistance of the ward nurse, the social worker spoke with Mr Z on the telephone. Mr Z said he had no concerns about his carer and that he was unable to explain how he got the bruising.
9. The following day, the social worker contacted Ms X. The information provided indicates the social worker spoke with Ms X about her father’s relationship with the carer and about the discharge plan for Mr Z. I also understand the social worker raised concerns with the two care agencies the carer worked for.
10. Notes provided by the Council of a further telephone call between Ms X and the social worker the following day say that Ms X did not want a safeguarding concern raised but thought a change of carer might be the best way forward. The notes say the social worker noted Ms X’s view but said she would need to look into this as the carer also worked with other people and so the Council may have to consider the matter further in the public interest. The notes indicated the social worker discussed with a colleague who advised a safeguarding concern would be in the public interest and should be completed.
11. The social worker discussed the matter again with the care provider who said the carer would not work with Mr Z when he returned home. The care provider also said they would complete spot checks on the carer’s other cases but later decided they would suspend the carer and investigate further. The carer also worked for another care provider, so the social worker contacted it to explain the situation.
12. Just over a week later, the Council decided the safeguarding issue would progress to a Section 42 enquiry. Mr Z remained in hospital and passed away on 25 May while still an inpatient. Ms X made detailed complaints about the care provided to her father. Relevant to this complaint, Ms X queried if a safeguarding investigation was ever carried out.
13. The Council’s response of September 2021 says a safeguarding concern was recorded by the hospital social work team and related to concerns Ms X has raised about the quality of the care and support received by Mr Z. It said that it was raised as a Section 42 enquiry but following Mr Z’s death it appears the investigation was cancelled and it was not aware of any outcome.
14. In November 2021, the Council re-opened the safeguarding concern and carried out a retrospective Section 42 enquiry. The Council says it believes the enquiry was previously prematurely closed in error. The Council sought information from the two care providers who employed Mr Z’s carer. This was Agency A who employed the carer to support Mr Z and Agency B who employed the carer to work with other service users.
15. The safeguarding investigation found the information from Agency A, which included case notes recorded in April 2020, was more useful in respect of the concerns about Mr Z’s care. The information from Agency B was relevant to the wider public interest issues.
16. Agency A completed its own investigation and was satisfied the carer met the requirements of the care visits as detailed on Mr Z’s care and support plan. It found no issues of concern. Agency B reported no concerns in respect of the carer performing his duties.
17. The retrospective safeguarding investigation also noted there were two occasions when staff spoke with Mr Z about his care. Mr Z said there were times when the carer did not always do as he asked but that he had become better at listening and said he was “kind now and listens”. Mr Z said that he liked the carer and did not want to change him. Mr Z said the bruises seen on his admission to hospital were not due to any act by the carer. Mr Z was deemed to have capacity at the time these conversations took place.
18. The Council concluded there was insufficient evidence to show the carer neglected Mr Z’s care as reported by Ms X. It said it was not dismissing Ms X’s concerned but the enquiry was inconclusive. It said no further actions are, or were, required.

Analysis

19. Ms X complained she was not notified about a safeguarding investigation and that it failed to complete the investigation and tell her the outcome. The complaint was made to the Ombudsman before the Council started the retrospective safeguarding investigation. However, I note the Council emailed Ms X on 2 November to inform her this was happening. I am not sure when the Council notified Ms X of the outcome of the retrospective safeguarding enquiry.
20. The information provided shows the safeguarding investigation did not proceed in 2020 following Mr Z’s death. While the safeguarding procedure does allow for an investigation to be closed at any time, it requires the completion of an enquiry closing form detailing the reasons for the closure. No such form has been provided or any other documentary evidence from the time.
21. The documents provided by the Council in respect of the retrospective enquiry in November 2021 mention that the previous enquiry was closed prematurely in error. In the absence of any other information on this point, I have to conclude the safeguarding investigation in April 2020 was closed in error. This is fault.
22. I am pleased to note that following Ms X’s complaint about this and other issues, the Council revisited the safeguarding investigation. The documents provided show that it took the information from 2020 and sought further information from the two care agencies. I am satisfied the retrospective safeguarding enquiry was properly considered and I find no fault in that process.
23. The fault identified above means the safeguarding investigation was not competed until almost two years after the concerns were first raised. I have considered what injustice this caused to Ms X. I note that in 2020 she said she did not want a safeguarding investigation to be completed. She wanted to ensure a different carer worked with her father when he returned home. I note all parties, including the Council and the care agency, agreed to this although unfortunately Mr Z never left hospital.
24. Ms X complains she was not notified of the safeguarding enquiry and only found out when she received documents after making her formal complaint. It seems to me that Ms X may have been aware the Council was considering a safeguarding enquiry but that it never formally notified Ms X of its decision to proceed to Section 42 enquiries. As Mr Z was deemed to have capacity at that time, I am not persuaded there was any obligation on the Council to notify Ms X and so find no fault.
25. When the investigation was finally completed in January 2022, it did not find conclusive evidence of abuse or neglect. I am not persuaded the outcome would have been any different even if the investigation had been completed in 2020. Both agencies carried out spot checks and were satisfied with the carer’s work. So while it was fault to close the investigation in 2020, I am not persuaded the delay in completing it has changed the outcome. Ms X was right to raise the issues and the Council has now concluded there is no impact on other service users.

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Agreed action

26. To remedy the injustice caused to Ms X as a result of the fault identified in this case the Council will, within one month of my final decision, take the following action:

• Apologise to Ms X; and
• Remind staff about the need to properly record the reasons for closing a safeguarding investigation to ensure public interest issues are not missed.

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Final decision

27. I have completed my investigation with a finding of fault for the reasons explained in this statement. The Council has agreed to implement the actions I have recommended. These appropriately remedy any injustice caused by fault.

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Investigator's decision on behalf of the Ombudsman