Summary: The Council was at fault for failing to deal with safeguarding reports about Mrs B properly. It also failed – for six months – to find a new placement for the person in Mrs B’s care home who was a risk to her, despite its best efforts. These failings contributed significantly to harm Mrs B suffered over a nine-month period. The Council has taken steps to improve its service, and it has now also agreed to make a symbolic payment to Mrs B’s estate to recognise her injustice.

The complaint

1. The complainant, whom I refer to as Mrs C, complains on behalf of her late sister, whom I refer to as Mrs B. Mrs B lived in a care home until she died in July 2023.
2. Mrs C says Mrs B was assaulted on a number of occasions by another resident in the care home, and the Council took no action to ensure her safety for several months.
3. I refer to the other resident as Resident X.

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The Ombudsman’s role and powers

4. 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 significant injustice, or that could cause injustice to others in the future we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
5. Service failure can happen when a council fails to provide a service as it should have done because of circumstances outside its control. We do not need to show any blame, intent, flawed policy or process, or bad faith by a council to say service failure (fault) has occurred. (Local Government Act 1974, sections 26(1), as amended)
6. 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

7. I considered:
• Information from Mrs C and the Council.
• Relevant government and regional procedures.
• The Ombudsman’s guidance on remedies.
8. Mrs C 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

The Council’s responsibilities

9. A council’s safeguarding duties apply to an adult who has care needs, is experiencing (or at risk of) abuse or neglect, and who cannot protect themselves. (Care and support statutory guidance)
10. If a council reasonably expects that someone meets these criteria, it must make enquiries, or ensure others do so. These can be formal enquiries, or an informal conversation with the person or their representative. (Care and support statutory guidance)
11. Any enquiries should establish whether and what action needs to be taken to prevent or stop abuse or neglect. (Pan-London safeguarding procedures)
12. The Council says its process for dealing with safeguarding referrals – even those received by non-safeguarding officers – is to pass each referral onto officers whose role is specifically to decide whether formal safeguarding enquiries should be made. It appears this role is referred to as ‘screening’.

The Ombudsman’s guidance on remedies

13. We do not punish councils in the way a court might. This means we do not award ‘damages’ or ‘compensation’.
14. Instead, we can ask a council to make a payment to ‘symbolise and acknowledge’ the injustice someone suffered because of what it did wrong.   
15. If a complainant claims injury or harm to health as their main injustice, this is usually a matter for the courts to decide. But sometimes it is appropriate for us to acknowledge that the impact of a council’s mistake included harm, or the risk of harm. If we decide it is appropriate, we may recommend a symbolic financial remedy.
16. If a council has placed someone at risk of harm, we normally recommend a remedy payment of up to £1,000.
17. But, if the risk was particularly severe, or harm actually occurred – particularly if it affected a vulnerable person or lasted for a long period of time – we may decide a higher remedy payment is justified.

What happened

18. In May 2022, Mrs B was pushed and hit on the back by Resident X. Her care home monitored her for bruising. It also reported this to the council on a quality assurance form which contained the text, “Do not use this form if the matter relates to a Safeguarding Incident”.
19. Later the same day, Mrs B was pushed over by Resident X, and she banged her head on the wall. The care home called an ambulance and, again, referred the incident to the Council on a quality assurance form.
20. Two days later, Mrs B was pushed by Resident X. The care home made a safeguarding referral to the Council (using the correct form).
21. Another two days later, Mrs B sustained bruising under her eye after another incident with Resident X. The care home sent another safeguarding referral to the Council.
22. The Council did not refer any of these incident reports for screening.
23. However, it did put extra support in place for Resident X (to help manage the risk). It also agreed that they needed to move to a different setting.
24. The care home completed Mrs B’s safety plan in June, and her risk assessment in July. It then reviewed her risk assessment in August. None of these documents referred to her being at risk from Resident X.
25. The Council began looking for new placements for Resident X in September, but it had no success.
26. At the end of September, Mrs B was pushed over by Resident X. There were no injuries. The care home reported this to the Council.
27. The Council did not refer this incident report for screening. Instead, its quality assurance team decided no further action needed to be taken. The reason they gave for this was that the care home had updated Mrs B’s risk assessment.
28. However, there is no evidence that the assessment was updated, or that it addressed the risk from Resident X to Mrs B.
29. In October, Resident X hit Mrs B, leaving a red mark on her cheek. The care home monitored Mrs B for a head injury and reported the incident to the Council.
30. Again, the Council did not refer the report for screening. Instead, its quality assurance team (in its ‘contract monitoring’ role) visited the care home. No further action was taken.
31. In November, Resident X punched Mrs B in the head. The care home, again, made a safeguarding report to the Council.
32. Again, no screening took place. The Council’s quality assurance team visited the care home and decided no further action should be taken. They noted that the care home had changed how it supported Resident X, and that this had helped reduce the risk.
33. In January 2023, Mrs B sustained a black eye after being assaulted by
    Resident X. The care home sought medical attention and reported the assault to the Council. It also served notice on Resident X’s placement.
34. The Council did not refer the assault for screening. Instead, its quality assurance team visited the care home and decided the staff had acted appropriately.
35. The quality assurance team did advise the manager of the care home to submit a further safeguarding referral to the Council, but this did not happen.
36. In February, Mrs B was slapped by Resident X. The care home monitored her for an injury and reported this to the Council as a safeguarding incident.
37. The Council informed the Police of the incident and moved Resident X out of the care home. As Resident X had gone, the Council then decided no further action was needed to protect Mrs B.
38. Up to the point that Resident X left the care home, the Council had contacted 42 different providers, none of whom had agreed to offer Resident X a place.
39. In October, the Council confirmed to its quality assurance team that all safeguarding alerts should be referred for screening.

My findings

40. It is not the Ombudsman’s role to decide whether safeguarding action was needed – or what action should have been taken – in specific cases.
41. However, we do expect councils to follow their procedures, consider evidence properly, and make timely and reasonable decisions on how to deal with safeguarding concerns.
42. In Mrs B’s case, the Council received eight reports that she had been, to differing degrees, assaulted (and, in some cases, injured) between May 2022 and January 2023. But it did not follow the national and regional procedures (or its own).
43. This means the Council did not consider, at any point during this nine-month period, whether formal action was needed to protect Mrs B.
44. Instead, the safeguarding reports were dealt with by the Council’s quality assurance team, who do not have a safeguarding role.
45. The involvement of the quality assurance team is partly explained by Mrs B’s care home initially sending reports on the wrong paperwork. But this was not always the case, and, in any event, the screening process should have been unaffected by the paperwork on which a report was received.
46. This was fault by the Council.
47. Another problem with the Council’s handling of Mrs B’s safeguarding reports was that, although it decided her care home had taken suitable action by amending her risk assessment, there is no evidence of any such amendment. Her risk assessment does not mention Resident X at all.
48. For this reason, I cannot support the Council’s view that Mrs B was protected by an updated analysis of the risk she faced. This was also fault by the Council.
49. The period in which Mrs B suffered physical abuse was extended by the Council’s failure to find a new placement for Resident X. This was not because of a lack of effort by the Council, which made extensive efforts to identify a new placement without success. A shortage of local placements for high-risk residents is not a situation unique to the Council.
50. However, the Council agreed to move Resident X, and it failed to do so for six months. This was a service failure, for which it was at fault (whatever the reason for the delay).
51. This caused Mrs B an injustice. During the six-month search for a placement, Resident X assaulted her five times.
52. It is reasonable to draw a link between the lack of proper safeguarding action, the delay in finding a new placement for Resident X, and the fact that the assaults Mrs B suffered – while initially unexpected and possibly even unavoidable – continued to take place repeatedly and over an extended period of time.
53. I am satisfied, therefore, that the Council’s failures contributed significantly to the harm Mrs B suffered. And, because of the nature of what she went through, her distress was likely considerable.
54. Our remedies guidance is underpinned by the principle that, when a council has made a mistake, we expect it to try and put the complainant back where they would have been without that mistake.
55. This is not possible in Mrs B’s case. So the Council should make a symbolic payment to her estate which recognises her injustice.
56. This payment should be in line with our remedies guidance. It should also recognise that Mrs B was vulnerable, and that the harm she suffered – while mostly sporadic – happened over a long period of time.
57. The Council has taken steps to improve its service (by reminding its staff of the correct way to deal with safeguarding referrals). Time will tell whether this is effective.

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Agreed actions

58. Within a month, the Council has agreed to make a symbolic payment of £2,000 to Mrs C, on behalf of Mrs B’s estate, to recognise that it could have done more to protect Mrs B from physical abuse in her care home. Its failure to do so contributed significantly to harm she suffered over a period of nine months.
59. The Council will provide us with evidence it has made this payment.

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Final decision

60. The Council was at fault, and Mrs B suffered an injustice.

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Investigator's decision on behalf of the Ombudsman