Summary: We will not investigate this complaint about the Council’s response to a safeguarding referral. Any fault in the Council’s actions did not cause the injustice Miss X claims.

The complaint

1. Miss X complained the Council took too long to consider a safeguarding concern raised about the family by the hospital, causing her mother (Mrs Y) to be kept in hospital longer than necessary despite being medically fit for discharge. She says the Council failed carry out a Deprivation of Liberty Safeguards assessment.
2. Miss X says Mrs Y died in hospital due to an infection she caught there. She says the matter has caused significant distress to the family. She wants the Council to carry out a safeguarding adults review and make service improvements.

Back to top

The Ombudsman’s role and powers

3. We investigate 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 continue an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• any fault has not caused injustice to the person who complained.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

Back to top

How I considered this complaint

4. I considered information provided by the complainant.
5. I considered the Ombudsman’s Assessment Code.

Back to top

My assessment

6. Mrs Y was admitted to hospital after suffering an injury. The hospital sent a safeguarding referral to the Council, relating to Mrs Y’s family’s management of her nutrition and moving and handling needs. The hospital wrote on its referral form that it was awaiting guidance from the Council regarding whether Mrs Y needed to stay in hospital pending any investigation by the Council.
7. The Council contacted the hospital three days later, asking it whether
   Mrs Y’s medical needs required her to still be in hospital, and whether it had made a Deprivation of Liberty Safeguards (DoLS) referral. The information I have seen indicates the hospital issued an urgent DoLS authorisation that day, providing a seven-day period during which the hospital would self-authorise
   Mrs Y’s hospital detention, pending the Council’s DoLS assessment.
8. However, Mrs Y died that day. The Council therefore did not have an opportunity to consider whether a DoLS standard authorisation was necessary.
9. Miss X believes the cause of Mrs Y’s death was wrongly recorded as aspiration pneumonia. The coroner is in the process of considering the matter further.
10. There were three days between the safeguarding referral and the Council contacting the hospital. We do not have sufficient information to come to a sound decision about whether this was fault. The Council did not have reason to believe Mrs Y was in immediate danger, as she remained in hospital where any risk relating to the referral it had received could be managed.
11. Had the Council contacted the hospital sooner, it could have clarified the circumstances, including whether Mrs Y was medically fit for discharge. It could have then decided whether it needed to make any interim decisions about where Mrs Y should be accommodated, to manage any immediate risk to her. The information I have seen indicates the Council did not make any decision that
    Mrs Y must remain in hospital.
12. However, we will not consider this further. This is because, ultimately, any delay in the Council’s response to the hospital’s safeguarding referral was not responsible for Mrs Y’s death. We could not say Mrs Y’s death was due to an infection caught in hospital, as Miss X claims. This is because it is the coroner, not the Ombudsman, who is responsible for determining the cause of death. We could not say Mrs Y would have returned home had the Council contacted the hospital sooner. We also could not say Mrs Y would not have died had she returned home or moved elsewhere during those three days.

Back to top

Final decision

13. We will not investigate Miss X’s complaint because any fault in the Council’s actions did not cause the injustice Miss X claims.

Back to top

Investigator's decision on behalf of the Ombudsman