Summary: Yhere was fault in the way the Council investigated a safeguarding concern relating to the provision of care by a care home. As a consequence, Mr and Mrs D will always have the uncertainty that the outcome of the enquiry could have been different if the fault had not occurred. The Council has agreed to apologise and to pay a small symbolic sum.

The complaint

1. Mr and Mrs D complain on behalf of Mrs D’s mother, Mrs C, who died in September 2019. Mrs C had been living in a care home (the Home).
2. Mr and Mrs D complain about the care provided by the Home, the Council’s safeguarding enquiry into the care provision and the Council’s response to their complaint about the safeguarding enquiry.

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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 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)
4. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, 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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What I have and have not investigated

6. As the Home’s fees were funded by the NHS at the time of the complaint, the complaint about the Home’s actions is being investigated by the Parliamentary and Health Ombudsman (PHSO). The Local Government and Social Care Ombudsman cannot investigate the actions of the NHS.
7. The LGSCO’s investigation is therefore limited to the Council’s safeguarding enquiry and the Council’s investigation into the complaint about the enquiry.
8. I have agreed to look back at events that happened from August 2019 onward as the Council’s safeguarding enquiry and then the investigation into this enquiry only ended in December 2023 so Mr and Mrs D could not have complained earlier to the Ombudsman.

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How I considered this complaint

9. I have discussed the complaint with Mr and Mrs D. I have considered the evidence they and the Council have sent. This included the Council’s safeguarding enquiry reports, the minutes of the enquiry outcome meeting, the Council’s investigation report into the complaint and the correspondence between the Council and Mr and Mrs D.
10. I have considered the comments from Mr and Mrs D and the Council on the draft decision.
11. I have not seen the case records of the Home as I have not investigated the actions of the Home, only the actions of the Council.

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What I found

Law, guidance and policies

12. The Care Act 2014 and the Care and Support Statutory Guidance 2014 set out the Council’s safeguarding duties. The Council also has its own policies.
13. Section 42 of the Care Act 2014 says the local authority should start a safeguarding enquiry if an adult in its area:
• has needs for care and support;
• is experiencing, or at risk of, abuse or neglect and
• as a result of those care and support needs is unable to protect themselves from either the risk of, or the experience of abuse or neglect.

Background

14. Mrs C was an older woman who had advanced dementia. She died in September 2019. She had two daughters, Mrs D and Mrs E who held a Lasting Power of Attorney for health and welfare for Mrs C with their husbands, Mr D and Mr E.
15. Mr and Mrs D complained about the care the Home provided to Mrs C in the weeks before Mrs C’s death. They said the Home’s nurses had an end of life care plan to withhold fluids from Mrs C. They said this plan had not been discussed or agreed with them and was part of a wider policy at the Home to apply the Liverpool Care Pathway to residents. (Note: the Liverpool Pathway was an approach to care for people who were in the final weeks of life but has been abolished since around 2013.)
16. The Council carried out a safeguarding enquiry into the concerns raised by Mr and Mrs D. Mr and Mrs D then complained about the safeguarding enquiry and the Council investigated the safeguarding enquiry.

Chronology

17. I have set out a chronology of the events that were the subject of the Council’s safeguarding enquiry, based on the documents I have read.
• 11 August 2019. Mrs C was ‘very sleepy and not her usual self.’ Staff were concerned that she may be in pain and rang 111 for advice. Mrs C ate breakfast in the morning, but did not eat or drink in the afternoon.
• The out of hours GP visited Mrs C at 8.43 pm. Mr and Mrs D were present. The GP recommended that Mrs C should be given high sugar drinks and should be encouraged to drink fluids, when she was alert enough.
• 12 August 2019. Nursing staff contacted Mrs C’s GP as Mrs C was not eating or drinking apart from fluid from a syringe. The GP visited Mrs C.
• The GP notes recorded the following. Mrs C was deteriorating, not eating. Only drinking from a syringe.
• The GP discussed the situation with Mr and Mrs E. The GP said Mrs C was deteriorating and ‘likely approaching end of life’. She appeared to be in pain and he would prescribe a transdermal pain patch but she may need subcutaneous medication if her situation deteriorated. The GP said he would issue ‘anticipatory drugs.’ (Note: anticipatory medication is end of life medication to address anticipated needs/symptoms.)
• 13 August 2019. Mrs C continued to be very sleepy and was declining food and fluids when staff tried to give these. Staff had difficulties given Mrs C her medication and Mrs C would not open her mouth for medication. Staff continued to attempt to give fluids and provide mouth care. The nursing staff contacted the GP because of the continuing deterioration in Mrs C’s presentation.
• From the visitors log (updated information provided at the outcomes meeting): Mr and Mrs D and Mrs E visited Mrs C on 13 August. Their visits overlapped.
• 14 August 2019. Mrs C was struggling to eat or drink. Mrs C would not open her mouth for medication. Nursing staff contacted the GP because Mrs C was refusing food and fluids. The GP said he would attend on the following day. The GP notes said: ‘Advised end of life.’ Mrs C received mouth care when she would not tolerate drinks. During a visit to Mrs C, Mrs D put a wet sponge in Mrs C’s mouth so she could suck on it but staff said this may be risk if Mrs C was unable to swallow the fluid.
• From the visitors log: Mr D, Mrs D, Mr E and Mrs E visited Mrs C on 14 August. Their visits overlapped for 10 minutes.
• 15 August 2019. The record said there was very little oral intake, mouthcare was being done. The GP visited Mrs C and said oral medication should be stopped. He advised that end of life care should continue to be provided. Staff at the Home entered a note later in the day on Mrs C’s daily record saying ‘nil by mouth, given mouthcare only’.
• From the visitors’ log: Mr and Mrs D visited Mrs C on 15 August.
• 16 August 2019. Mr D, Mrs D and Mrs E visited Mrs C. The nurse had a discussion with the daughters about giving Mrs C a drink. The nurse advised against this as she said that Mrs C was not alert enough at the time and this may cause Mrs C to aspirate. The record (16 August 2019) noted: ‘Mixed views from daughters on certain issues.’ The record noted: ‘Mouth care given. [Mrs D] would like [Mrs C] to have a drink which I have advised against at this time.’
• It was also recorded that Mrs D gave Mrs C some pineapple juice on 16 August. The social worker initially wrote 500 ml. but then realised she read the record wrongly and said it was 100 ml.
• The Home kept a ‘comments and concerns’ document . The nurse wrote on the following day, 17 August 2019: ‘Family called me regarding [Mrs C] and drinking fluids using a sponge: I explained to both [Mrs C’s] daughters … and [Mrs D’s] husband who were present that … [Mrs C] may not be able to swallow drinks at this stage and may be at risk of choking. [Mrs D] responded that she was prepared to take that risk after my advice. This then upset her sister [Mrs E]. I left the room.’
• From the visitors log: Mr and Mrs D and Mrs E visited Mrs C on 16 August. Their visits overlapped.

End of life care plan – 16 August 2019

18. An end-of-life care plan was written by the nurse on 16 August 2019. The plan said:
• If desired or tolerated, offer fluids/foods regularly. Record intake.

Mr E’s safeguarding referral - 17 August 2019.

19. Mr E made a safeguarding referral to the Council on 17 August 2019. He said the family had been told that Mrs C was not to be given any fluids and Mrs D disagreed with this plan. He said he and Mrs E were concerned that Mrs D was putting Mrs C at risk.
20. The Council officer rang the Home’s nurse after receiving the safeguarding referral from Mr E. The nurse explained that the current plan was that Mrs C should be assessed each time to see if she could tolerate fluids and the nursing staff were doing this. There was no plan to not give her fluids at all or to refuse fluids.
21. Mr E rang the Home on the same day and told them he had made a safeguarding referral about the administration of fluids. The Home explained to Mr E that, from a nursing point of view, Mrs C’s condition was variable and she may tolerate fluids at some points so the decision to give her fluids or not had to be made on each occasion.

Palliative nurses’ involvement – 18 August 2019

22. The Home made a referral to the palliative care team on 18 August 2019 and asked them to visit Mrs C. The palliative nurse visited and noted: ‘I spoke with staff nurse [X] who advised me [Mrs C] was on the end-of-life pathway and that they have only been giving mouth care.’ The staff nurse said there had been an episode earlier in the week when Mrs C appeared to choke on the fluid.
23. The palliative nurse assessed Mrs C’s ability to swallow and said Mrs C was able to swallow with no problem so the palliative nurse said fluids should be given with a spoon. The nurse noted that Mrs C clamped her mouth down on the sponge during mouthcare so she said the use of the sponge should be stopped and a small toothbrush used instead. Staff should check Mrs C every two hours to see if she was alert enough to have fluids and nursing staff should advise about the appropriateness of giving fluids at each intervention.
24. Around this time, the jug of water (which was normally available in Mrs C’s bedroom) was removed from the bedroom. The jug was placed back in the room around 22 August 2019 on the advice of the palliative nurse.
25. The Council decided that the safeguarding referral with the allegation against Mrs D did not meet the threshold for a section 42 safeguarding enquiry and closed the matter on 18 August 2019.
26. In the days after 18 August 2019 Mrs C took a small amount of fluids on some days and only mouthcare on other days. Mrs C died on 7 September 2019.

Mr and Mrs D’s safeguarding referral – 11 September 2019

27. The Council received a safeguarding referral from Mr and Mrs D on 11 September 2019. Mr and Mrs D said:
• Three/four weeks ago the Home decided to take away fluids from Mrs C because she was at risk of choking. Before that the family had been providing Mrs C with fluids through a syringe. The family was told to stop providing fluids and all fluids were removed from Mrs C’s room. This went on for seven days.
• Nothing happened until the palliative nurses were called in and they reinstated the fluids.
• The Home had not given an adequate reason for the decision to withdraw fluids.

The Council’s safeguarding enquiry

28. The social worker considered the following records of Mrs C in the enquiry:
• Care plan
• Daily records
• End of life care plan
• Fluid charts
• Records of any contact (visits and calls) between the Home and the palliative care team
• The Home’s ‘comments and concerns’ document where any person can write comments.
• The Home’s visitors’ log
• The Council’s records
• The GP’s records

Records of conversations

29. The social worker included the record of her conversation with the family, the palliative care nurses and the GP in the report. She also spoke to staff but did not include records of those discussions in the report.
30. The social worker asked Mr and Mrs D when they thought the withdrawal of fluids had started. Mr and Mrs D said the decision to treat Mrs C as ‘end of life’ was made after the GP’s visit on 12 August and the disagreement between Mrs D and Mrs E happened on 13 August, not on 16 August.
31. The social worker spoke to Mr and Mrs E and they said they had no concerns about fluids being withdrawn from Mrs C or about the care provided to Mrs C.
32. The social worker spoke to the GP. The GP said the Home’s recording of ‘nil by mouth’ was inaccurate as he did not advise this. The GP said he did not know that Mrs D and Mrs E did not speak to each other. He had spoken to Mrs E about Mrs C’s deteriorating condition but not Mrs D.
33. The social worker spoke to the palliative care team. They said they had no concerns about the way the Home had provided care to Mrs C.

The social worker’s analysis in the safeguarding enquiry report

34. The Council wrote 3 different versions of the safeguarding report. I will set out the differences both in terms of the structure and the conclusions.

Safeguarding report – July 2020

35. In the analysis section of the report the social worker said:
• ‘It is clear that some things have not been recorded as clearly as they have been in relation to advice given by professionals.’
• This made it difficult to establish whether Mrs C did not receive fluids because she was not offered fluids or because she could not tolerate them.
• The notes were unclear at time about specific advice given, for example, in relation to fluids.
• The decision to remove the jug of water was made by staff, not by the palliative care team. There was no reason why the jug had been removed and felt this should not happen in the future.
• Mr and Mrs D raised concerns about the care provided, but neither the palliative care team nor Mr and Mrs E had any concerns.
• There was no intention by the Home’s staff to ‘deny [Mrs C] fluids or to intentionally cause her harm’. However, the documentation could have been better to make the situation clearer for all involved.

Safeguarding report – December 2020

36. The social worker added information regarding the earlier safeguarding referral made by Mr E.
37. The report concluded:
• There was disagreement between family members whether fluids should or should not be given to Mrs C.
• There was no suggestion from the Home that fluids had been stopped. The nursing staff had advised staff that Mrs C should be assessed at each intervention to see if she could tolerate fluids.
• There was a lack of clarity around the recording of ‘nil by mouth’ on 15 August 2019. It was not clear whether this was an observation of Mrs C’s condition or the instruction given by the GP.

Safeguarding report – May 2021

38. The report now included information from the GP’s records, the visitors log, a discussion with the GP and an analysis of the Home’s actions compared with the National Institute for Health and Care Excellence’s (NICE) Guidance for end of life care.
39. The report noted the following:
• On 12 August 2019 the GP said Mrs C was likely at the end of her life. The GP discussed this with Mrs E, not with Mrs D.
• On 15 August 2019 the GP said medication should not be administered orally. A member of staff at the Home wrote ‘nil by mouth’ into Mrs C’s record on the same day. The GP said he did not recommend ‘nil by mouth.’ This record was misleading and could be misinterpreted by staff.
• There was a written end of life care plan dated 16 August. This plan was written without any consultation with Mr and Mrs D.
• The end-of-life care plan of 16 August 2019 which recommended that staff should offer fluids contradicted the ‘nil by mouth’ record.
• There was a lack of clarity in the communication and a lack of understanding by the family and staff about what the protocol was between 16 August 2019 and 18 August 2019. The plan was that staff should assess Mrs C each time to determine whether it was safe to give her fluids, but the family thought that the plan was that she should not be given any fluids at all.
• There were no records relating to the removal of the jug from Mrs C’s room so it was not known who ordered this or why. The Home should have written this decision in the care plan and should have set out the reasons why the decision was made and the person who made the decision.
40. The social worker concluded earlier in the report:
• ‘Based on the information gathered and analysis of this information, there is no evidence to suggest that [Mrs C] was denied fluids.’
41. However, she also made statements which appeared to contradict this conclusion, for example:
• ‘However, as per [Mr and Mrs D’s] statements – had the removal of fluids remained in place [Mrs C] would likely have died far sooner.’
• ‘On these grounds – you could argue that the conversation had indeed taken place on 16 August 2019 – and that a clear decision has been made to apply a policy of no fluids.’

Safeguarding outcome meeting – October 2021

42. The Council held a safeguarding meeting on 14 October 2021. Mr and Mrs D did not attend as they felt that this would imply that they agreed with the report and the meeting was based on ‘false reports, inaccurate timelines, accusations and lies’.

Mr and Mrs D’s complaint

43. Mr and Mrs D complained to the Council about the safeguarding enquiry. Their first complaint related to the quality of the investigation. They said:
• The scope of the investigation was too narrow. It focussed too much on withholding fluids, not on the general care and not on the failure to involve them in the decision making even though they held an LPA.
• They had asked for the involvement of the GP but this was denied.
• They provided additional information, supported by other professionals, and comments but the Council failed to take these into account. The Council relied too heavily on the Home’s evidence and dismissed their evidence.
• Mrs D was portrayed as a negative person in Mrs C’s life and care.
• They prepared a statement for the meeting on 14 October 2021 but this was neither read out nor considered at the meeting.
• Their desired outcomes had not been met.
44. Mr and Mrs D’s second complaint related to delay as it took the Council 19 months to complete the safeguarding process.

Investigation report – February 2023

45. The Council commissioned an investigation into the complaint. The outcomes of the investigation dated 3 February 2023 were as follows.
46. The investigating officer recommended that the complaint about the quality of the safeguarding enquiry should be partially upheld and said:
• The initial scope of the investigation had not included the failure to involve Mr and Mrs D in the decision making but this was included in the later versions of the report.
• There was no record that Mr and Mrs D asked for the GP to be involved at the beginning and that the Council refused this. The GP was involved in the later versions of the report.
• However, the fact that there had been three versions of the report indicated that the initial scope had not been clearly set out and contributed to the delays in obtaining the final report.
• The conclusions in the final report were not clear to identify from the analysis.
• There was a disagreement between the Council and Mr and Mrs D about the dates and the Council did not come to any conclusions regarding this. The first report did not include this disagreement, but the final report did.
• There was no suggestion that Mrs D was seen as a negative person in Mrs C’s life.
• Mr and Mrs D’s statement was not read out at the meeting and the statement was not provided to the attendants.
47. The officer recommended that the complaint about delay should be fully upheld.
48. The report also noted that the social worker had spoken to staff at the Home but some staff were unavailable due to sickness.
49. Mr and Mrs D had asked for the following outcomes:
• An acceptance that the enquiry was ‘deeply flawed’ and ‘not fit for purpose’.
• A ‘written recognition of bad practice’.
• The report to be amended with clear responses to unanswered questions.
• A written response how the Home’s existing end-of-life care policy will be re-written with ‘respectful involvement of family and legal attorneys.’
• An explanation of the connection between the Home and other agencies and professionals in meeting end of life care.
• A written response on whether the recommended service improvements at the Home were implemented.

The Council’s response to the investigation into the complaint – June 2023

50. The Council responded to the investigation report on 14 June 2023 and accepted its findings and recommendations.
51. The Council agreed to:
• Apologise in writing to Mr and Mrs D for the faults identified.
• Provide a summary of the findings of the enquiry, the recommendations and whether the recommendations had been carried out.
52. The Council agreed to carry out service improvements to its safeguarding enquiries. It would:
• Ensure the scope of the enquiry was agreed, timescales set and responsibilities identified at the beginning of the enquiry.
• Revise its procedures to ensure that reports were written clearly and easier to read.
• Follow up the actions that had been recommended at safeguarding enquiries.
• Ensure that statements provided by persons who did not attend a meeting were circulated to the attendants.
53. In terms of Mr and Mrs D’s requested outcomes relating to a change in the Home’s end-of-life care policy and an explanation of the Home’s connection with other agencies in meeting end of life care, the Council said the End of Life Care Pathway was commissioned by the NHS Integrated Care Board and explained the process. (I presume this meant the Home did not have its own end of life policy). Senior managers of the ICB, the Council and the Home offered a single joint meeting with Mr and Mrs D to discuss this further.
54. The Council offered a symbolic payment to recognise the distress caused by the fault totalling £500.

Mr and Mrs D’s complaint to the Ombudsman

55. Mr and Mrs D were not satisfied with the Council’s response and came to the Ombudsman. They said the Home’s end of life care plan was put in place to deny Mrs C fluids and that this was part of a wider, pro-euthanasia policy at the Home. In terms of the Council’s safeguarding investigation into these concerns, they said:
• The investigation was ‘shallow, unreliable, deeply flawed.’
• There had been ‘false reporting’ by the Home. The Council’s report was based on ‘lies, concocted time-lines, scant notes created in retrospect ‘ by the Home’s staff.
• The Council ‘jumped into action once only, on the strength of an accusation that [Mrs D] was mistreating her own mum.’
• Mrs D was wrongly accused of giving fluid between 13 August to 18 August. The personal accusations had been unaddressed and not investigated.

Analysis

56. I have not carried out a safeguarding enquiry as that is not the Ombudsman’s role. I have explained to Mr and Mrs D that my investigation cannot alter the outcome of the Council’s enquiry. I have only investigated whether there is fault in the way the Council carried out its enquiry.

Method of safeguarding investigation

57. In terms of the safeguarding investigation itself, I notice good practice, particularly in the final version of the report. The Council obtained all the relevant records relating to Mrs C from the Home, including her care plan, daily records, end of life care plan and fluid charts. The Council then cross-referenced this with the contacts with the Palliative care team, the Home’s visitors log and the ‘comments and concerns’ document.
58. In addition, the Council also checked the GP’s records to establish whether this matched the Home’s records. This was good investigative practice and was helpful in trying to establish the time-line, especially as Mr and Mrs D disagreed with the timeline and argued that the Home had falsified the records after the event.
59. The Council spoke to staff, Mr and Mrs D, Mr and Mrs E, the GP and the palliative care staff. That was good practice.
60. However, there was also fault in the way the Council carried out the safeguarding.
61. Firstly, as the Council’s investigating officer into the complaint noted, the report had to be rewritten twice and further information added. This suggested that the initial versions of the report were not satisfactory. I agree there was fault in that respect.
62. In particular, the initial safeguarding report did not consider the GP’s records, the initial referral by Mr E, the visitors log and the NICE guidance on end of life planning. The social worker did not speak to the GP until April 2021 and this discussion should have taken place earlier as the GP’s evidence was vital to the investigation. Generally speaking, interviews should take place as soon as possible as people may forget details of what happened.
63. I also agree that Mr and Mrs D’s response to the safeguarding report should have been made available or at least considered at the outcome meeting and this did not happen.
64. A further concern was that the safeguarding report only included records of the discussions with Mr and Mrs D, Mr and Mrs E, the palliative nurses and the GP. There were no records of the discussions with the Home’s staff or the nurses so it is not clear what discussions took place.
65. Mr and Mrs D said that certain nurses within the Home had made a (possibly unwritten) end of life care plan that Mrs C should not be given any fluids at all. Mr and Mrs D also said the Home’s care workers had told them they disagreed with this plan and encouraged them to keep the pressure on the nurses.
66. I would have expected the social worker to speak to the care workers who supported Mrs C in the final weeks of her life and ask them what their understanding of the end of life care plan was, what verbal instructions they had received from the nurses, and what practice they witnessed on a day to day basis.
67. I would have expected a record of those discussions in the report, anonymised. Similarly I would have expected the discussions with the nurses who were alleged to have instigated the end of life care plan to be clearly documented in the report.
68. The failure to do so meant that a crucial part of the investigation was missed and an opportunity to clarify the conclusions was lost.

Safeguarding investigation report

69. I uphold the complaint that there was a lack of clarity in the final report and this was fault.
70. Firstly, the structure of the report was difficult to follow. That may partly be because the report was re-written twice and the original structure was lost.
71. The report included a chronological review of the different records the social worker had read. This was helpful in terms of determining where the evidence came from, but the different chronologies and reviews meant that the report was quite repetitive but also slightly confusing.
72. Secondly, it was difficult to determine what the conclusions of the report were. At times, the report would mention two hypotheses of what happened but not say what the conclusions were and this gave the impression that the report included contradictory conclusions.
73. I have listed my understanding of the report’s findings in paragraph 39. The report found failures in the Home’s actions, particularly its failure to involve Mr and Mrs D in end of life planning, failure to keep clear records, misleading care instructions and a lack of understanding by staff of what the end of life care plan was.
74. However, the Council’s safeguarding report did not say, as far as I can see, that there was a plan (written or verbal) that staff should deny Mrs C all fluids. This was the outcome that Mr and Mrs D wanted to see and that is not the outcome they achieved.

Delay in the safeguarding investigation

75. The Council has fully upheld the complaint of delay in the safeguarding enquiry and I agree this was fault.

Safeguarding investigation into allegation against Mrs D

76. Mr and Mrs D said the Council ‘jumped into action once only, on the strength of an accusation that [Mrs D] was mistreating her own mum.’ That is not correct, and it may be that Mr and Mrs D have misunderstood the Council’s actions.
77. The Council received a safeguarding referral on 17 August 2019 from Mr E who made an allegation against Mrs D. The Council decided that this allegation did not meet the threshold for a section 42 safeguarding enquiry and closed the enquiry soon after receipt.
78. The Council then received a safeguarding referral from Mr and Mrs D on 11 September 2019 and decided that this met the threshold for a safeguarding enquiry and opened an enquiry. I find no fault in that respect. The Council had no concerns about Mrs D’s actions so it had no duty to carry out any investigation into her actions. The Council was concerned about the Home’s actions and it opened an investigation into the Home.
79. I also did not get the impression, from the safeguarding report, that the Council was critical of Mrs D. It is true that the report noted that Mrs D disagreed on 16 August 2019 with the nurse’s recommendation that Mrs C should not be given any fluids. But, as it was later established, Mrs D was right to question this as the nurse had poorly communicated the plan. All the people in the room on 16 August (Mr and Mrs D and Mrs E) understood the plan to be that Mrs C should not receive any fluids.

Investigation of complaint about the safeguarding enquiry

80. The Council has undertaken a thorough investigation into the complaint about the safeguarding enquiry and the investigating officer has considered all the relevant evidence so I find no fault in that respect.
81. I note that the Council has, to a large extent, upheld Mr and Mrs D’s complaints about the safeguarding enquiry. I agree with the findings the Council made in relation to the safeguarding enquiry and I have added some further detail on the fault that was found.
82. However, it appears to me that, in making their complaint, Mr and Mrs D were hoping for an outcome that the complaints process could not achieve which was a different conclusion to the safeguarding investigation. This was not an outcome that the Council’s complaints process could deliver.

Injustice

83. I have considered the injustice Mr and Mrs D have suffered because of the fault. There was fault in the way the Council carried out a safeguarding enquiry. As a result, Mr and Mrs D will always have the uncertainty that, if the fault had not happened, the enquiry may have come to a different conclusion.
84. In complaints such as this one, where there is no direct financial loss because of the fault, but the fault has caused distress to the complainant, the Ombudsman can sometimes recommend a small symbolic financial sum for the distress. I note that the Council has already offered Mr and Mrs £500 for distress and I agree that this is a sum in line with the Ombudsman’s guidance on remedies.
85. I also note that the Council has already implemented service improvements in relation to safeguarding enquiries and I therefore do not make any further recommendations in that respect.

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Agreed action

86. The Council has agreed to take the following actions within one month of the final decision. It will:
• Apologise in writing to Mr and Mrs D for the fault I have found.
• Pay Mr and Mrs D £500 (total, not each).

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Final decision

87. I have completed my investigation and found fault by the Council. The Council has agreed the remedy to address the injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman