Summary: Miss X complains the Council did not address her concerns about her sisters’ medication errors in a care home properly, and the Council did not share information with her when she made a complaint. We find no fault with the Council.

The complaint

1. Miss X complains about the way the Council handled her safeguarding concerns about the care home’s treatment of her sister Miss Y, specifically about medication errors.
2. She says the Council was not transparent and did not share information with her, causing her distress. She felt targeted for raising concerns about Miss Y.
3. Miss X would like the safeguarding process to be transparent, and to ensure no conflict of interest when carrying out an investigation.

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The Ombudsman’s role and powers

4. We investigate complaints of injustice caused by ‘maladministration’ and ‘service failure’. I have used the word fault to refer to these. We consider whether there was fault in the way an organisation made its decision. If there was no fault in the decision making, we cannot question the outcome. (Local Government Act 1974, section 34(3), as amended)
5. We normally name care homes and other providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended) I have not named the care home in this complaint because there is a risk of identifying Miss X as she has made many complaints.
6. If we are satisfied with an organisation’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

7. I spoke with Miss X about her complaint. I made enquiries with the Council and considered the complaint correspondence, safeguarding enquiries and communication between Miss X and the Council.
8. I also considered the relevant legislation and guidance.
9. Miss X 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

Legislation and Guidance

10. If a council has reasonable cause to suspect abuse of an adult who needs care and support, it must make whatever enquiries it thinks is necessary to decide whether any action should be taken to protect the adult. (Care Act 2014, section 42)
11. Care and Support Statutory Guidance sets out a council’s responsibilities when responding to concerns about potential abuse in a regulated care setting (such as a care home). Paragraph 14.69 says "where a local authority has reasonable cause to suspect that an adult may be experiencing or at risk of abuse or neglect, then it is still under a duty to make (or cause to be made) whatever enquiries it thinks necessary to decide what if any action needs to be taken and by whom. The local authority may well be reassured by the employer’s response so that no further action is required. However, a local authority would have to satisfy itself that an employer’s response has been sufficient to deal with the safeguarding issue and, if not, to undertake any enquiry of its own and any appropriate follow up action (for example, referral to CQC, professional regulators)”.

What happened

12. I have included a summary of relevant events and records below.
13. Miss Y is living at a care home (the Home). She has a number of medical conditions, including epilepsy and impaired communication.
14. Miss X is Miss Y’s sister and only family. Miss Y is under the Court of Protection which restricts Miss X from having input into Miss Y’s medical matters, and has placed limits around her contact with Miss Y.

1st report of time change to medication

15. In October 2022, Miss X made a report to the Council about a time change to eye medication for Miss Y, along with other concerns.
16. The Council raised a safeguarding concern but missed the eye medication.
17. Miss X responded to the Council questioning this decision, and the Council raised a new safeguarding concern including the time change for the eye medication.
18. The Council said it had received sufficient reassurance from the Home about each concern, so this will not progress to a S42 enquiry. However a Safeguarding Practice Advisor would visit the Home to ensure the reassurance given is accurate.
19. The Council responded to each of Miss X’s emails within 24 hours.

2nd report of time change to medication

20. In November, Miss X and a family friend took Miss Y out for dinner. When they left the Home Miss X noticed that she didn’t have Miss Y’s 5pm epilepsy medication.
21. She called the Home and her friend went to pick up the correct medication. However Miss X saw the medication given to her friend was one that Miss Y should take at 8pm, not 5pm.
22. Miss X called the Home and spoke to the Manager, saying she had the wrong tablets. The Manager checked the medication chart and confirmed that it was the correct medication.
23. Miss X challenged this as she knew Miss Y should take this medication 12 hours apart, as she had been taking it for the last ten years.
24. The Manager confirmed the times from the medication chart for Miss Y were from the pharmacy.
25. Miss X told me she felt she had no choice but to give them to Miss Y. Miss X said she asked the family friend to report this to the Home. She felt the Home would not take her complaint seriously and was afraid to raise further concerns.
26. Miss X contacted the Safeguarding Team a week later after receiving an email from the Home to accept there had been an error.
27. The Safeguarding Team responded to Miss X saying the Home reported the error to them directly. It was not going to be progressing to a safeguarding enquiry as the Home had already investigated the issue and shown that appropriate action was taken to correct the mistake and manage the risk.

The Council’s response to the complaint

28. Miss X was not happy with the response she got about the change in medication times so she raised this as a complaint to the Council in December 2022, with other issues. She said she felt forced to give medication to Miss Y despite knowing and trying to voice to the Home that this was wrong.
29. The Council’s complaint response in January 2023 said:
• The Home’s manager checked with the pharmacy about the timings. The pharmacy double checked the records and found the labels were incorrect;
• The pharmacy told the manager the change in timings would not affect Miss Y. But the pharmacy changed them back because the timings had been recommended by a neurology consultant;
• The Home organised retraining for staff, reported the matter to the Care Quality Commission and NHS England. The Home also reviewed its medication risk assessment and medicine procedures;
• It was considering Miss X’s concern about Miss Y not having all the medication for the weekend visit under safeguarding procedures (see paragraphs below).

Missed medication for visit

30. Miss Y went for a weekend visit with Miss X in December. Miss X noticed the Home had not given her Miss Y’s emergency epilepsy medication and asked carers for it. Later she also discovered Miss Y’s eye medication was missing.
31. Miss X raised this with the Safeguarding Team which started a safeguarding enquiry. She also complained to the Council in December.
32. The safeguarding records indicate Miss X previously reported concerns about the Home which were unfounded, causing the relationship between Miss X and the Home to deteriorate. The report of the safeguarding enquiry said:

“Whilst it is important to consider the above information as relevant background information, it remains paramount that any concerns raised are treated on an individual basis and safeguarding adult enquiries are completed where the threshold is met. It is also important to note that an additional medication error occurred in November 2022 where it was established that Miss Y had experienced neglect.”

33. The report concluded that neglect did occur by the Home, but it was an isolated incident due to staff sickness. The outcome was the Home completed its own investigation and had “taken appropriate action to mitigate future risk of further incidents”.

Analysis

1st report of time change to medication

34. Miss X raised this with the Safeguarding Team in October after her visit.
35. The Council assessed the information from Miss X. It decided the concerns did not meet the threshold for a safeguarding enquiry. Section 42 of the Care Act 2014 does not require a council to deal with every matter through a full enquiry. It is open to the Council to decide a matter need not proceed with further investigation and this is in line with the guidance I have set out in paragraph 11.
36. There is also no requirement for the Council to give Miss X detailed feedback on the outcome of safeguarding enquiries because these concern personal third party information which Miss X has no right to have. Further, Miss Y has no legal standing in Miss Y’s health and care which is the responsibility of the Court of Protection.
37. However, we would expect the Council to give Miss X a general update on actions it took. The Council updated Miss X by email which was an appropriate response, so my provisional view is there is no fault.

2nd report of time change to medication

38. The Council responded in a timely way to Miss X’s concerns. It confirmed a safeguarding concern was raised as the Home had reported it themselves.
39. The Council said it would share the concern with Miss X once it was complete.
40. Provisionally, I find no fault with the Council. It kept in contact with Miss X and shared the outcome with her. As I have explained above, Miss X had no right to any detailed explanation or information as the safeguarding record was not her personal information.

Complaint

41. Miss X raised a complaint to the Council in December. The Council responded a month later. The Council’s complaint response gave Ms X detailed feedback on each of the medication incidents as I have summarised in paragraph 29.
42. Provisionally, I find no fault in the Council’s complaint response which addressed all the matters Miss X raised. The response explained there was fault with the Home and pharmacy and set out the actions that had been taken to minimise the risk of further harm to Miss Y. These actions included staff training, a review of procedures in the Home and reporting the matter to relevant regulatory bodies. These actions were all in line with the Council’s duty under Section 42 of the Care Act 2014.

Missed medication for visit

43. Miss X raised this with the Council directly. The Council told the Home so it could investigate and started a safeguarding enquiry. This information was sent to Miss X so provisionally, there is no fault. There was no requirement for the Council to give Miss X any more information about the action that was being taken.

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Investigator's decision on behalf of the Ombudsman