Summary: Mrs X complains on behalf of her late mother Mrs Y, that the Council failed to tell her the outcome of a safeguarding review. Mrs X also says the Council failed to administer her mother’s medication which led to her going into hospital and damage to her property. Mrs X says this caused both her and her mother extreme distress. We have found fault in the actions of the Council for not confirming the outcome of the safeguarding review and for failing to ensure that Mrs Y’s medication was administered correctly. We recommend the Council apologises to Mrs X, pay her a financial remedy and implement a service improvement.

The complaint

1. Mrs X complains on behalf of her late mother Mrs Y, that the Council failed to tell her the outcome of a safeguarding review in mid-2022. Mrs X also says the Council failed to administer her mother’s medication which led to her going into hospital and damage to her property.
2. Mrs X says this caused both her and her mother extreme distress.

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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. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, section 25(7), as amended).
5. 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

6. I considered the information provided by Mrs X and discussed the complaint with her. I made enquiries of the Council and considered the information it provided.
7. Mrs X and the Council have provided their comments on the draft decision. I considered any comments before the final decision was issued.

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What I found

8. 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)
9. The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 set out the fundamental standards those registered to provide care services must achieve. The Care Quality Commission (CQC) has issued guidance on how to meet the fundamental standards below which care must never fall.
• Regulation 10 ensures people using services are treated with dignity and respect at all times. 
• Regulation 12 states care and treatment must be given in a safe way and prevent avoidable harm or risks. It states the care provider must assess health and safety risks and do all they can to mitigate any risks.

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What happened

10. Mrs Y lived at home and received care from a care provider acting on behalf of the Council. Mrs Y’s family also provided some care for her. Her medication was administered by both her family and carers.
11. The family member who usually visited Mrs Y in the evenings could not do so for a few days over a weekend in May 2022. The family member asked the care provider if it would administer Mrs Y’s medication over the weekend. The care provider agreed to this.
12. Unfortunately, due to some confusion, the care provider did not administer Mrs Y’s medication for two consecutive nights over the weekend.
13. Mrs Y’s family member visited her property on the Monday morning following the weekend and found her in a confused state and the property in a mess. Mrs Y went into hospital and made allegations of an assault which had taken place.
14. The care provider sent Mrs Y’s GP an email telling them the medication had been missed. A medical professional contacted by the safeguarding team said the missed medication could have contributed to Mrs Y’s confusion.
15. Due to the allegations of assault made, the Council completed a safeguarding review and made enquiries.
16. The Council completed a safeguarding review and wrote to Mrs X in July 2022 to say the social worker had provided her with the outcome.
17. Mrs X did not receive the outcome of the safeguarding review and the Council wrote to her again in January 2023 to say they would follow up with the social worker. Mrs X says she did not receive the outcome of the review until May 2023.

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Analysis

18. The care provider confirmed to Mrs Y’s GP that it had not administered Mrs Y’s medication for two consecutive nights. This was despite Mrs Y’s family member asking them to do so. I accept there was some confusion over this however, the care provider should have ensured that staff were aware of who was responsible for providing the medication. This is fault and would also be a potential breach of regulation 12. It would have caused Mrs Y and Mrs X a considerable amount of distress.
19. I cannot say the medication not being administered solely caused Mrs Y’s property to be in the state it was when her family member visited. Although it is noted the missed medication could have caused Mrs Y to become more confused again, it would be speculative to say this was the main contributing factor. I accept that Mrs X has been caused uncertainty about whether the outcome would have been different if the medication had been administered correctly.
20. While the Council took the action I would expect to see following a safeguarding concern, I cannot see it advised Mrs X of the outcome of the safeguarding review. The Council told Mrs X it had/would provide feedback on the outcome and then did not do so. This is fault and would have caused Mrs X further of distress due to the nature of the concerns. Mrs X would have also been frustrated the Council said it was going to do something it then did not.
21. As Mrs Y has now died, there is no possible way to remedy the injustice caused to her by the Council’s actions. However, Mrs X also suffered injustice for which she should be provided with a remedy.

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Agreed action

22. Within one month of a final decision the Council should:

• Write to Mrs X to apologise for the faults identified.
• Pay Mrs X £300 to recognise the distress and frustration caused to her.

Within two months of a final decision the Council should:

• Write to care provider acting on the Council’s behalf to remind staff of the importance of correctly following instructions for administering medication and keeping accurate records.

23. The Council should provide us with evidence it has complied with the above actions.

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Final decision

I have found fault in the actions of the Council for failing to confirm the outcome of the safeguarding review and for failing to ensure that Mrs Y’s medication was administered correctly.

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Investigator's decision on behalf of the Ombudsman