Summary: We will not investigate this complaint about the Council’s failure to raise safeguarding concerns about an injury to the complainants mother’s knee injury. This is because further investigation would not lead to a different outcome.

The complaint

1. The complainant, who I will call Mrs X, complains about how the Council dealt with safeguarding concerns about her mother’s care. I will call Mrs X’s mother Mrs Z. Mrs X says the Council failed to initiate a safeguarding investigation, when it became aware of a fracture to Mrs Z’s knee in August 2018. Mrs X says the Council’s actions have caused her distress and that there are lessons to be learnt from.

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The Ombudsman’s role and powers

2. The Ombudsman investigates complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or may decide not to continue with an investigation if we decide further investigation would not lead to a different outcome. (Local Government Act 1974, section 24A(6))

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How I considered this complaint

3. I considered information provided by the complainant and the Council.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. In August 2018, Mrs Z was admitted to hospital after she fell at home. Upon her discharge the Council commissioned a Care Agency to meet Mrs Z assessed needs. Ten days later Mrs Z was readmitted to hospital where, upon arrival, healthcare staff noticed pressure sores to Mrs Z’s heels. The hospital therefore made a safeguarding referral to the Council.
6. We previously investigated a complaint from Mrs X about how the Council dealt with the safeguarding referral from the hospital, and we found considerable fault in how the Council dealt with the matter. This included significant delays starting its investigation, failure to carry out a meaningful investigation and failure to keep Mrs X informed of the outcome.
7. In response to our investigation, the Council agreed to our recommendations to implement several service improvements. These included making its staff aware of the procedures for carrying out safeguarding investigations. Refresher training was subsequently offered to all relevant staff.
8. The Council also agreed to apologise to Mrs X for the faults identified and to offer to make a payment to her of £1000 to acknowledge the distress, uncertainty, frustration and the time and trouble the Council’s faults had caused her.
9. Mrs X subsequently raised a further complaint that the Council had failed to instigate a safeguarding investigation when it became aware of the fracture to Mrs Z’s knee. The Council say it was informed of the injury to Mrs Z’s knee in August 2018, but no safeguarding investigation took place because the information it had suggested that the injury occurred when Mrs X was at home alone, and therefore there was no evidence of neglect or harm caused by another person.
10. I will not investigate Mrs X’s complaint, because I do not consider that further investigation would not lead to a different outcome. In response to our previous investigation the Council has implemented appropriate service improvements regarding its handling of safeguarding matters and has also agreed to make a suitable payment to remedy the distress its mishandling of safeguarding matters caused Mrs X. Having considered these points, and the fact that Mrs Z has now sadly passed away, I do not consider that a further investigation could reasonably achieve anything meaningful.

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Final decision

11. We will not investigate Mrs X’s complaint because investigation would not lead to a different outcome.

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Investigator's decision on behalf of the Ombudsman