Summary: Ms X complains the Council failed to properly safeguard her father who lived alone. I have not found fault by the Council.

The complaint

1. Ms X complains that the Council failed to effectively safeguard her father, Mr X who died after having an accident in his home. Ms X says she made many efforts to alert the Council that her vulnerable father was at risk living alone.

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The Ombudsman’s role and powers

2. 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)
3. 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

4. I have discussed the complaint with Ms X and considered the information she provided. I have made enquiries of the Council and considered the comments and documents it provided. Ms X 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

5. 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)
6. Mr X was living on his own at home. He was diagnosed with dementia. The Council had arranged a package of care. The care provider visited three times a week to assist with domestic tasks and ensure Mr X took his medication.
7. Ms X visited her father every day to provide care and support. The Council had completed a carer’s assessment of Ms X and provided guidance and a small budget to support her. Ms X’s sister also visited to help her father.
8. In February 2023 Mr X’s GP contacted the Council and asked it to consider his needs and whether Mr X’s home was safe for him. The GP said that Mr X’s behaviour had changed, and he may be becoming socially isolated. Ms X and her sister were burnt out and had their own health issues.
9. The Council’s social worker visited and agreed an increase in care and support visits. This was an extra 30 minutes to assist Mr X to walk to the shops with a carer and complete his shopping.
10. The Council agreed it would put in place 40 hours rolling respite per year using the current care provider. This enabled Ms X to request respite care as and when she needed it. The Council noted that it also discussed a befriending service with Mr X and Ms X.
11. At the end of April 2023 Ms X contacted the Council and said she needed respite care because the family were going to start building works at Mr X’s home.
12. The Council visited on 10 May 2023. The social worker spoke to Mr X and Ms X. The social worker noted that was no reason to doubt Mr X’s mental capacity. Mr X said he agreed to respite care in a home. But he wanted to return to live in his own home.
13. The Council noted Ms X had not yet used the rolling respite it had agreed. The Council recorded that:
• it explained it would not provide respite care for Mr X while building works were done, as respite was meant to be for carers to have a break. However, Ms X could consider using the current carers for rolling respite during the works.
• it would support Ms X’s request for three weeks respite care for Mr X in a 24 hour care home in July when she had work commitments.
• It would consider respite care from the end of June 2023.
• It sent a care home vacancy list to Ms X.
• It would consider adding an evening care call to Mr X.
14. Later in May, Ms X called the Council and explained Mr X was behaving irrationally and was eating out of date food. She said that it was very stressful for her. The social worker said carers could check for out of date food and dispose of it. The social worker contacted the care provider and advised them to do this.
15. In early June Ms X called the Council and advised the family could not keep going. Mr X was very demanding and the family could not support him. Ms X said the family had reached crisis point. The social worker called back and, as Ms X said that Mr X struggled to stand, advised the family to contact his GP.
16. On 12 June 2023 the social worker called Ms X and explained she was waiting for a copy of the residential vacancy list from the Council’s commissioning service. She said she would contact the homes to see if they were suitable for Mr X. Ms X said that the family could not pay a top up fee.
17. On 14 June 2023 Ms X requested an urgent call back because the family needed respite care. Ms X said the family could not keep up with Mr X’s needs, and he could not be left alone. The social worker called back and said she was still waiting for a vacancy list for the period starting 26 June. Ms X said she had visited one care home but it was not suitable.
18. The social worker also said that she would contact the care agency the next day and ask if it could increase its care calls from one to three a day.
19. On 15 June 2023 the social worker sent Ms X the residential care home vacancy list by email. The next day the social worker called the Care Provider and asked if it could increase its care calls. It said it would check into this.
20. On 21 June 2023 Ms X called the Council again and said she had not heard back from the social worker regarding the respite care vacancy list. She wanted to know what respite provision had been put in place. She said she was exhausted. A senior social worker apologised that the social worker had not got back to her as she had unexpectedly gone on leave. The senor social worker sent a further copy of the care home vacancy list and advised that:
• The social worker had contacted the care agency about increasing the number of visits per day. The Council would let Ms X know about this.
• She was not sure of the amount of respite that had been agreed but the social worker would advise Ms X.
• Ms X could start looking at potential placements as respite care had been agreed.
• The Council would need to consider the least restrictive option for Mr X before looking at longer term residential care.
21. On 22 June the care provider agreed it could increase its care calls to 3 a day but it could only start this on 27 June.
22. On the same day Ms X called Council and said Mr X had a fall while visiting a care home. He had seen his GP and was back home. But Ms X said he needed crisis care because she feared he would fall again, and he was refusing to sleep downstairs. The social worker noted that the stairs had handrails to support Mr X going upstairs. She also arranged for a visit that evening and in the morning by a care agency crisis service to check on Mr X.
23. The social worker called Ms X the next day to advise that she had contacted a care home that could provide respite care. However, Ms X said that she could not afford the top up fee. The social worker advised Ms X to contact other homes on the list she had sent. Ms X explained Mr X had seen the GP the previous day but was very confused.
24. The next day Ms X told the Council her father had suffered a fall and had been admitted to hospital. Ms X said she had raised the risks to her father with the Council, but nothing had changed.
25. In July Ms X complained that Council had not responded regarding her concerns about a vulnerable adult. She said she had made 27 calls in a month, but the Council had not done anything. In her view the Council had not safeguarded her father despite her telling it about the dangers and risks to him.
26. The care agency raised a safeguarding concern against the Council on the grounds of neglect and acts of omission. It said Ms X had concerns that something serious would happen. But the Council had not listened to Ms X and had put Mr X at risk because he was not safe at home.
27. Sadly, Mr X passed away four weeks later.

Safeguarding investigation

28. As the safeguarding alert was against the Council’s adult social care team, it carried out an internal investigation. This was overseen by a senior safeguarding officer.
29. The Council completed its investigation in September 2023. An officer visited Ms X in October to advise her of the outcome. The Council said on balance of probability the allegations of neglect and omission were unsubstantiated. The Council wrote to Ms X in November 2023 with its outcome letter.

The Council’s response to Ms X’s complaint

30. In July 2023 the Council explained it was considering the matter as a safeguarding alert. Once that was completed Ms X could pursue any outstanding concerns via a complaint.
31. Ms X asked the Council for a response to her July 2023 complaint. The Council replied in January 2024. The Council noted Ms X complained about delays in responding to her complaint. It said that it had paused the complaint investigation while the safeguarding enquiries were completed. In addition, it said a senior manager had been unexpectedly on leave. It upheld the complaint and apologised for its delay.
32. The Council noted Ms X complained it failed to take action when her father was at risk. It said it had put rolling respite in place from March 2023 and that it had arranged a small package of care. The Council’s social worker had visited Mr X in May 2023 and she had discussed his case several times with her manager. The Council noted Ms X had spoken to the worker over a three week period from May 2023 as Ms X was concerned he may need more support.
33. The Council had a plan for Mr X to go into respite care from 26 June 2023. However, the social worker was unexpectedly on leave in mid June, and Ms X contacted the Council for support. The Council’s senior social worker had contacted Ms X and assisted in arranging respite care. The Council concluded that the social worker sought advice and guidance and acted appropriately to reduce risks. The Council did not upheld Ms X’s complaint.

The Council’s response to our enquiries

34. The Council confirmed that it had noted Mr X had a second banister rail in place when it visited in February 2023 and that he had Telecare. It said that no other equipment was recommended and no other concerns were raised.
35. The Council accepted Ms X may have had difficulty contacting the social worker in mid June 2023. However, the senior social worker assisted Ms X about respite care and confirmed on 22 June that additional carer visits would start on 27 June.

Analysis

36. It appears Mr X’s behaviour and needs changed in the months between February 2023 and June 2023. Based on the information I have seen the Council responded and considered his needs. It noted that he had a banister rail in place when it visited in February. The Council arranged additional carer visits and agreed rolling respite. It is not clear why Ms X did not use the rolling respite. This could have addressed the carer stress that she was experiencing.
37. The Council agreed respite care in a care home for three weeks in July and brought this forward to June 2023 when Ms X contacted the Council.
38. It appears Ms X was visiting care homes with Mr X but had not yet identified a suitable home. The records that I have seen show the Council assisted Ms X. It sent her a list of care homes on 15 June 2023, but it is not clear that Ms X received this. The Council sent a further list on 21 June.
39. There was a short period where Ms X was unable to contact Mr X’s social worker, in mid June 2023 but I do not consider this was fault. The Council agreed and arranged increased care visits, but unfortunately this could not be put in place immediately. I do not consider that the break in communications led to the delay in the care being increased. I have not found fault by the Council here.
40. Sadly, Mr X fell at home before Ms X was able to identify a care home for respite care and before the increased care visits were put in place.

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Final decision

41. I find no fault by the Council. I have completed my 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