Summary: Ms D complains about faults in the Council’s safeguarding investigation into her mother’s injury. We find fault by the Council regarding its handling of the investigation. It has agreed a remedy.

The complaint

1. Ms D complains on behalf of her mother Mrs X that the Council failed to properly consider and progress a safeguarding enquiry regarding the cause of bruising Mrs X sustained while in a care home.
2. Ms D says the Council did not:
• include Mrs X’s family in the Strategy Discussion
• share full information with the family at the earliest stage
• engage the family in decisions about risk.
• take its safeguarding procedures into consideration.
• consider all information during a safeguarding enquiry/conference into Mrs X’s injuries.
• check records for two months in relation to the inquiry.
• make timely enquiries and did not engage with the family.
3. As a result, Ms D says Mrs X was potentially left in an unsafe placement longer than necessary and the family were caused distress, frustration and uncertainty.

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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 how the organisation made its decision, we cannot question the outcome. (Local Government Act 1974, section 34(3), 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 have discussed the complaint with Ms D and considered the information she provided. I have made enquiries of the Council and considered the comments and documents it provided. Ms D and the Council had an opportunity to comment on my draft decision. I considered their comments before making a final decision.

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What I found

Safeguarding

7. 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).

The Council’s safeguarding policy

8. The Council’s policy is set out in the Hertfordshire Safeguarding Adults Board, Safeguarding Adults at Risk (August 2022). This provides timescales for taking action during an enquiry and sets out the steps the Council should take.

Summary of key events

9. Mrs X was living in a care home in 2022. She was living with dementia and did not have mental capacity to make decisions about where she lived.
10. In September 2022 she went into hospital for a short period and on discharge she returned to the care home.
11. Three days after Mrs X was discharged, the home raised a safeguarding concern about bruising it found in three places on Mrs X’s body. It said it had checked Mrs X when she came back from the hospital and saw the bruising. It provided photos. The home said the hospital had not disclosed any information about bruising.
12. Two days after receiving the concern, the Council decided to start safeguarding enquiries. It considered the hospital discharge letter. This did not note any bruising at discharge. The Council wrote to the hospital to ask it to check its records regarding any bruising it had seen. It asked the hospital to carry out an internal investigation regarding the cause. The Council also asked the care home and the hospital to provide body maps of the bruising.
13. The Council noted under “action to minimise harm” that Mrs X was currently at the care home.
14. Two weeks later the Council contacted Ms D. The Council noted Ms D said she was aware of the safeguarding concern. She said she was concerned the hospital did not have a record of the bruising or know how it had occurred. Ms D says the officer simply asked for her consent to continue the enquiry, as Mrs X did not have capacity to agree. She expected the Council to discuss the issue with her in more detail, as Mrs X’s representative, and advise her about its plans.
15. On the same day the Council noted it received body maps from the care home.
16. In mid-October, Ms D says she saw a further bruise on her mother’s knee which caused Mrs X pain. Ms D raised it with the care home, but no one had noticed it and they did not know how it had happened.
17. On 19 October 2022, just over three weeks since the first safeguarding enquiry was raised, the hospital told the Council it had no record of any injuries being seen in the hospital.
18. Ms D removed Mrs X from the care home in late October due to concerns about her health and safety, following the latest bruise.
19. In mid-November 2022, the Council’s safeguarding officer asked the care home whether Mrs X was on any medication that could easily cause a bruise. The care home responded that she was not. The Council also asked the home when it took the photos it had provided.
20. On 21 November the Council called Ms D. She reported a new safeguarding concern about the further bruising to Mrs X’s knee. She told the Council Mrs X had moved from the home due to concerns about her care and safety. The Council registered the new safeguarding concern and linked it to the first.
21. In late November the safeguarding officer recorded his professional analysis that the care home could not provide evidence it had taken the photos on the day Mrs X was discharged. He considered the photos the care home provided were taken three days later. He noted the care home manager confirmed the body map it provided was delayed. The Council decided to have a meeting of relevant professionals and representatives.
22. In January 2023 Ms D had not heard from the Council. She emailed expressing her concerns about the delay in the proposed meeting. It does not appear the Council responded to her email or a chaser she sent in February.
23. In March 2023 the Council’s safeguarding meeting chair contacted Ms D about the meeting. Ms D says this was also the first time the Council advised her that there was a three-day delay between Mrs X’s discharge and the care home taking photographs of the injuries and reporting it to the Council.
24. On 30 March the Council held a safeguarding conference which Ms D attended. She said she received the photos showing the injuries the day before. The notes of the meeting show the Council found there were no records by the care home about it finding the bruising on the day of discharge. The Council said it was more likely the bruising occurred in the care home. The Council concluded the concern that acts of neglect or omission were substantiated against the care home. It considered that acts of physical or sexual abuse were unsubstantiated.
25. The Council identified lessons learned and actions for the home including reviewing its policy for unexplained bruising, ensuring that record keeping was updated, and better communication between staff and family.
26. The Council says it effectively concluded its safeguarding investigation in March 2023. However, it did not send Ms D the minutes of its conference until May 2023.
27. In July 2023 Ms D complained that she was dissatisfied with the Council’s investigation. She said there were significant delays. The Council did not follow its own policy, Hertfordshire Safeguarding Adults Board, Safeguarding Adults at Risk (August 2022). She said the Council did not involve her as Mrs X’s representative. In her view it had not properly considered whether Mrs X continued to be at risk.
28. In August 2023 the Council replied to Ms D. It partly upheld her complaint. It said:
• Ms D said the Council did not meet timescales or ensure Mrs X was not in danger. The Council replied it focused initially on the injury occurring in the hospital. At that point Mrs X was not in hospital. It then became evident the injury occurred in the home, and by then Mrs X had moved out of the home. The Council would mitigate the risk if Mrs X had remained in the home, but this would not necessarily mean removing her from the home. The Council did not consider there was evidence the injury was due to physical assault.
• Ms D said the Council did not hold a strategy meeting within 5 days of the decision to proceed to enquiries, as the policy stated. The Council said it should communicate with the person or their representative and explain the process and what they were considering. The Council agreed it delayed contacting Ms D.
• Ms D said the Council should have held a strategy meeting with her as Mrs X’s representative. It should have shared more information about the injuries, and advised it was possible the injuries took place in the home because of the delay in reporting. The Council replied it could hold a formal strategy meeting, but it now generally held a number of individual meetings. It agreed it could have liaised with Ms D more, sought her views and provided updates about new information.
• Ms D said the Council took three weeks to find Mrs X received likely non accidental injuries in the home. It should then assume she was not safe. The Council replied that everyone involved initially believed the incident occurred in the hospital. But it accepted that due to work pressures the officer did not identify the incident may not have taken place in the hospital as quickly as the Council expected. It said the service aimed to quickly focus on adults where the risk remained. In Mrs X’s case the Council accepted there were delays in the initial liaising with the family, hospital and care home.
• Ms D complained about the delay in arranging the conference. She had asked for it to take place in early February, but it took place on 30 March. The Council agreed there was unacceptable delay and it did not update Ms D.
29. The Council said it had reviewed the safeguarding investigation and noted there was no evidence of medical reasoning on why the bruising may have occurred. It said this was clear neglect and a failure of process and reporting by the home. It said it would check whether the home sought medical advice. It also said it would follow up on the learning from the enquiry, and would ensure the care home followed its policy regarding unexplained injuries. This included reporting unexplained bruising or injuries to the GP and ensuring it completed a body map on admission.
30. Ms D queried the Council response and met with a safeguarding officer regarding her concerns. The officer said he had information from the GP and would seek further information from the hospital regarding its view about a possible side effect of bruising due to prescribed medication.
31. Ms D complained further that the Council:
• did not address in the safeguarding report the question of how the injuries were obtained. The Council had not sought expert or medical opinion. The Council did not explain how physical abuse was ruled out. In addition, she considered the Council should have ensured that medical evidence was included in the report. The Council now confirmed it had GP evidence from September 2022, but it did not refer to this in the report or at the conference in March 2023.
• was quick to accept the care home’s information despite inconsistent evidence. It should have kept an open mind regarding the discrepancy so that it could properly assess the risk. The Council changed its mind by the end of November 2022, but in her view, it had sufficient information within a week of the referral.
• took too long to test and verify incorrect information. In her view Mrs X was potentially left in an unsafe situation.
• did not give her full information until the just before the conference. This meant Mrs X did not have a well-informed representative during the investigation. The Council did not involve the family in a series of conversations.
32. The Council responded to Ms D’s complaint. It said that
• It consulted medical professionals and it expected professionals to offer useful information or insights. But none of the professionals offered an opinion. The Council agreed it could have asked a specific question. It said it would instruct its safeguarding team to ask a specific question on the cause of a bruise.
• It changed its view of the place the injury occurred in October and asked for further information. It then fully shifted its focus in November when the home replied. The Council accepted there was delay by the care home and the Council did not take steps to chase this. This was due in part to workload pressures. The Council apologised for this.
• It agreed it should have contacted Ms D more promptly as part of its information gathering. It apologised for this.
• It had already agreed it did not chase the care home for a response. It noted Ms D’s concern Mrs X was at risk due to the delays. However, as it did not have a clear understanding how the bruising took place it would be difficult to put any measures in place as they may not have been necessary or effective.
• The Council had received recent information from the hospital which appeared to indicate the bruising was caused by medication at the hospital.

Analysis

33. The Ombudsman’s role is not to reach a view on whether the Council’s decisions on safeguarding concerns are correct. Our role is to consider whether the Council followed the Care and Support Statutory Guidance process and considered all relevant information to reach its view.
34. I have found fault by the Council in its handling of the safeguarding enquiry.
35. The Council should have identified more promptly the discrepancy between the home’s report and the photos it provided which were taken three days after it stated it saw the bruising. In my view the fact that the care home made a late retrospective report should have alerted the Council to this. I consider this was fault and delayed the progress of the enquiry. This led to uncertainty for Ms D.
36. The Council accepts it delayed contacting Ms D. This was not in accordance with its policy. This meant that Ms D was aware of the concern but had no information from the Council about the alert it had received or its plans for its investigation. This likely led to uncertainty and distress for Ms D.
37. I note that the Council says it does not hold a strategy meeting, rather a series of discussions. While I do not criticise the format of its contact, I would expect the Council to provide brief information about the concern and its plans to investigate. It should also seek the representative’s views. While the Council noted Ms D views about seeking information from the hospital, it does not appear the Council explained the information it had received late from the care home, or the steps it was intending to take. This was fault.
38. The Council accepts it did not update Ms D or tell her when it revised its view about the place the injuries occurred. This led to her learning much later it had turned its attention to the care home. This was fault and caused Ms D distress and anxiety.
39. The Council said the care home should have sought medical opinion when it found the bruising. It appears that the GP saw Mrs X at the care home shortly after the home raised the concern. However, the Council did not include this information in its report or at the conference. The Council’s complaint response considered the home should have sought medical opinion about the reasons for the bruising. The Council itself then sought the hospital’s opinion which led to a potential cause for the bruising. I consider the Council should have sought information earlier from the home and the hospital about the potential medical cause.
40. Ms D says the Council did not properly consider the risk to Mrs X or take steps to ensure her safety. She says if the Council had advised her earlier, she could have removed Mrs X. While I consider the Council could have progressed its enquiry more swiftly, I do not find fault in the Council’s consideration of this. It did not have evidence the injury was caused by physical or sexual abuse, and did not consider Mrs X was at risk. It explains it is not always necessary or effective to remove a person from a care home while an enquiry is ongoing. In this case Ms D removed Mrs X within four weeks of the alert.
41. The Council recommended learning points for the care home to improve its service in future. I have considered these, and I am satisfied that the Council has taken appropriate steps here.

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Agreed action

42. The Council agrees that within one month of my decision to
• apologise to Ms D for the distress and uncertainty it caused due to the faults I have identified in the safeguarding enquiry. This should be in accordance with our Guidance on Making an Effective apology.
• Pay Ms D £200 as a symbolic payment to recognise the distress and uncertainty it caused Ms D.
43. The Council should provide us with evidence it has complied with the above actions.

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Final decision

44. I found fault causing injustice by the Council. I have completed the investigation and closed the complaint.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman