Summary: Ms D complained about the way the Council dealt with safeguarding concerns about her late father, Mr F. We have found no fault by the Council. We intend to complete our investigation and not uphold this complaint.

The complaint

1. The complainant, whom I shall call Ms D, complains about faults in the Council’s original 2022 safeguarding enquiry relating to her late father (Mr F) and the Council’s 2023 review of the enquiry. Ms D says the original enquiry was not thorough enough and the review was inadequate. She says the faults have caused her significant distress and have affected her mental health. Ms D would like the Council to give her more detailed answers and justifications. She would also like the Council to accept accountability for what happened.

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The Ombudsman’s role and powers

2. 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)
3. 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)
4. 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

5. Mr F was in a care home in Cambridgeshire County Council (the Council’s) area. Another local authority (Council Z) had placed Mr F in the care home and remained responsible for the care he received. However, Cambridgeshire County Council is responsible for dealing with safeguarding concerns in its area. We have investigated a separate complaint about Mr F’s care because Council Z was responsible for this.
6. Part of the complaint is ‘late’ because Ms D had concerns about the safeguarding enquiry more than 12 months before first complaining to us in July 2023. We considered Ms D had good reasons for taking longer to complain to us. This is because she first tried to get her concerns resolved through various organisations’ local complaints processes, as well as through the Care Quality Commission (CQC, the adult social care regulator in England) and the coroner’s office. We have therefore decided to investigate her complaint despite elements of it being late.
7. As part of our investigation, we have considered:
• information Ms D has provided in writing and by telephone;
• the Council’s response to our enquiries, including relevant records, policies, and procedures; and
• relevant law and guidance. We have referred to this as appropriate in the main body of the decision statement, below.
8. Ms D and the Council have had an opportunity to comment on a draft version of this decision. I took their comments into account before making a final decision.

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What I found

Background summary

9. 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)
10. In early April 2022, the Council received a concern relating to Mr F from CQC. The concern related to Mr F being admitted to hospital with suspected sepsis (a potentially life-threatening complication of an infection) a few days earlier. CQC sent the concern after Ms D told it that the hospital had told her Mr F had a urinary tract infection (UTI), and that it would have taken two to three weeks for him to become this ill. Ms D was therefore concerned that the care home had failed to spot signs of an infection in good time. Ms D also told the Council that she had in the past contacted Council Z with concerns about Mr F’s care there. Mr F died in hospital on the day the Council received CQC’s safeguarding referral.

Original safeguarding enquiry

11. The Council was aware that Mr F had died soon after receiving the safeguarding report. This meant there was no action it or others could take to protect Mr F. However, the Council decided to open a safeguarding enquiry because there was a potential risk of harm to other residents of the care home.
12. The Council contacted:
• CQC to ask questions and to ask it to gather information;
• the hospital to ask for information, including whether Mr F’s death had been referred to the coroner and for comments on the concerns Ms D had reported;
• Council Z to ask for information; and
• the care home to ask for information.
13. The Council then considered information provided by CQC, Council Z, the care home and the hospital. In summary, the key pieces of information the Council took into account were:
• the care home’s records and account of concerns Ms D had raised about Mr F’s care before his admission to hospital;
• Council Z’s records of the concerns Ms D raised with it before Mr F’s hospital admission, and its reasoning for not referring these as safeguarding concerns to the Council;
• information from the hospital confirming urosepsis (sepsis caused by a urinary tract infection) as the cause of Mr F’s death and that Mr F’s death had not been referred to the coroner; and
• information from the hospital stating it did not have a record of telling Ms D that Mr F would have had an infection for two or three weeks before the hospital admission.
14. Having considered the information, the Council decided to close its enquiry because:
• the concerns Ms D raised with Council Z about Mr F’s care did not meet the threshold for a safeguarding enquiry and were addressed by Council Z and the care home;
• the hospital had no record of having the concerns Ms D had reported to CQC about Mr F’s infection being longstanding;
• the hospital had not referred Mr F’s death to the coroner which indicated medical professionals did not consider his death was unexpected or preventable; and
• the care home had provided evidence of consulting with a GP and dietitian in the weeks leading to Mr F’s hospital admission.
15. The Council emailed CQC to advise it of the decision to close the safeguarding enquiry and its reasons for doing so. Its email told CQC the Council had not been in direct contact with Ms D. The Council said it would contact Ms D about the outcome unless CQC had already done so. CQC said it would share the outcome with Ms D as it was already dealing with concerns from her about several regulated services. The Council nevertheless emailed Ms D the following day, with the outcome of the enquiry and its reasons for closing it.
16. The Council formally closed its safeguarding enquiry at the end of April 2022. Ms D was dissatisfied with this and complained to the Council. She was concerned Mr F’s urosepsis had been caused by inadequate care in the care home, for example not changing his incontinence pads regularly. The Council contacted the care home again to ask for evidence of personal care for Mr F in the two weeks leading to his hospitalisation. The records the care home sent indicated Mr F’s pads were checked or changed every day and the frequency varied, from hourly to eight hours. The most common check/change times were every two hours.
17. The Council also responded to Ms D’s complaint in July 2022. The Council concluded that there were no flaws in the safeguarding enquiry process.

Review of safeguarding enquiry

18. Ms D’s MP wrote to the Council in June 2023 explaining she remained dissatisfied with the Councils original safeguarding investigation and its complaint response.
19. In August 2023, the Council agreed to carry out a senior management review of the safeguarding enquiry. When agreeing to do this, the Council said the review could not:
• offer any clinical recommendations;
• comment on Council Z’s commissioning of the care home place for Mr F;
• determine whether the care home acted neglectfully; or
• determine if the advice the care home sought and received from the GP was correct.
20. The Council said the purpose of its review was to:
• consider if it needs to take any further action or make recommendations;
• re-open the safeguarding enquiry if there was new evidence that was not available at the time of the original enquiry or if it considered the original enquiry had failed to properly consider evidence at the time;
• determine if there is anything the Council needs to learn from what happened; and
• report to Ms D.
21. The Council looked again at the evidence considered by the original 2022 safeguarding enquiry. It wrote to Ms D in September 2023 with the outcome of its review. The review concluded the 2022 safeguarding enquiry had not been flawed. The Council therefore decided not to open a fresh safeguarding enquiry. I have summarised its reasons for this below.
• Food and fluid charts indicated Mr F’s intake had been steady until the end of March 2022, when it decreased.
• There were records of the care home acting on Ms D’s concerns and seeking medical advice from a GP, nurse and dietitian service in the weeks and days leading up to Mr F’s hospital admission.
• The Council could not take a view on whether the medical professionals had made the right medical decisions about Mr F’s care before he went into hospital. However, there were records showing health professionals oversaw and were involved in Mr F’s medical care in the weeks and days leading up to his hospital admission.
• The original safeguarding enquiry properly considered the relevant information.

Was there fault causing injustice?

22. We have considered the information the Council looked at as part of its 2022 safeguarding enquiry and the 2023 review. We have also considered the Council’s reasons for closing the enquiry in 2022 and deciding not to re-open it in 2023. Having done so, our provisional view is that there was no fault in the way the Council reached its decisions. Our reasoning is set out below.
23. The Council has discretion under section 42 of the Care Act and associated Government guidance to carry out proportionate safeguarding enquiries. This means the Council does not need to look at every possible piece of evidence, but rather only what it considers relevant to decide whether any action needs to be taken relating to the adult in question. The Council saw the care home’s records relating to Mr F’s food and drink, its communication with the GP, nurse and dietitian service. It also saw information from the hospital indicating no concerns about neglect. It also considered Council Z’s reasoning for deciding Ms D’s earlier concerns about Mr F’s care did not meet the threshold for a safeguarding enquiry. The Council was entitled to consider this was enough to close the 2022 enquiry and take no further action, without seeking more records, for example GP medical records. Nothing in the Council’s records or reasoning indicates it missed relevant evidence, took irrelevant information into account, or failed to follow the law and associated guidance. We therefore cannot question the outcome of the 2022 safeguarding enquiry.
24. The review was not a fresh safeguarding enquiry, but rather a check on the way it had conducted the earlier one. The Council was therefore correct to explain to Ms D the review’s limitations and possible outcomes when it first agreed to the review. There is no evidence the Council’s review missed any relevant new evidence. The Council’s outcome letter to Ms D following the review explains what evidence it reviewed and gave reasoned explanations for deciding the original enquiry was not flawed. We therefore cannot question the outcome of the 2023 review.

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Final decision

25. I have found no fault in the Council’s actions. Therefore, I do not uphold this complaint and have completed my investigation.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman