Summary: We will not investigate this complaint about an adult safeguarding investigation, because it is unlikely we could add to the Council’s investigation or reach a different outcome.

The complaint

1. Ms B is unhappy with the outcome of a safeguarding investigation into her mother’s (Mrs F’s) care. Ms B would like this to be investigated further. Ms B says the Council’s actions have had an impact on her mental health.

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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:

• any fault has not caused significant injustice to the person who complained to justify our involvement, or
• we could not add to any previous investigation by the organisation, or
• 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.
4. I considered the Ombudsman’s Assessment Code.

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My assessment

5. Safeguarding is protecting an adult’s right to live in safety, free from abuse or neglect.
6. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs which mean the person cannot protect themselves. An enquiry is the action taken by a council in response to a concern about abuse or neglect. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement. A council must also decide whether it or another person or agency should take any action to protect the person from abuse. (section 42, Care Act 2014)
7. The Council completed a safeguarding enquiry following Mrs F returning home from a respite stay at a residential care home with a pressure sore, dehydration, and a urinary tract infection.
8. The outcome of the safeguarding was inconclusive, which means there was insufficient evidence to reach a conclusion on whether there was abuse or neglect.
9. It is unlikely that further investigation by the Ombudsman would reach a different outcome. It is not our role to redo the safeguarding investigation, but to consider whether there was fault in the way the Council conducted it that has resulted in a significant injustice.
10. The Council says it looked at care records, spoke with Mrs F’s granddaughter, and with relevant professionals involved in Mrs F’s care. The Council accepts it did not speak with Mrs F directly and has apologised for not doing so. As Mrs F has since died, this cannot be rectified. But given the Council obtained information from Mrs F’s granddaughter on her behalf it is unlikely that speaking with Mrs F would have changed the outcome of the safeguarding investigation.
11. The Council has reminded its staff it should not exclude an individual from the safeguarding process because they have dementia.
12. The Council shared its findings with the Care Quality Commission (CQC) who are the regulator of care homes in England and inspect to check care homes are meeting fundamental standards.
13. The Council has given Ms B a thorough response to her complaint, acknowledging where it got things wrong, such as delays and poor communication, and made appropriate apologies for its errors. It has shared information with CQC and explained the actions it will take to improve its service.

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Final decision

14. We will not investigate Ms B’s complaint because it is unlikely we could add to the Council’s investigations or reach a different outcome. Though Ms B is upset with the inconclusive outcome that is not a significant injustice to warrant the Ombudsman’s involvement, especially where it is unlikely we could achieve anything further.

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Investigator's decision on behalf of the Ombudsman