Summary: Mr X complained about how the Council conducted a safeguarding investigation when he was the subject of allegations that he financially abused his mother. We upheld the complaint, finding the Council conducted an inadequate and biased investigation. This caused Mr X and his mother unnecessary distress, when the Council sought to impose limits on his contact with her. The Council accepted these findings. At the end of this statement, we set out a series of actions it agreed to take to remedy Mr X’s injustice. This included providing him with an apology, a symbolic payment, a review and correction of its records. It also agreed to make service improvements to try and prevent a repeat.

The complaint

1. Mr X complained about the Council’s investigation of allegations that he financially abused his mother Mrs C. Mr X said the Council’s investigation was not fair or balanced and placed unreasonable restrictions on his contacts with Mrs C.
2. Mr X said the events covered by this complaint caused him and his mother significant distress.

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The Ombudsman’s role and powers

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. 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)
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 considered evidence provided by Mr X and the Council, as well as relevant law, policy and guidance.
7. I gave Mr X and the Council an opportunity to comment on a draft version of this decision statement. I considered any comments they made in response before finalising the statement, which we first issued in July 2025. We then re-opened the case and issued the statement again, when Mr X made us aware of a mistake in its content. This statement therefore contains amendments from that issued in July.

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What I found

Legal and Administrative Considerations

8. Section 42 of the Care Act 2014 requires a local authority to make enquiries:

• if it has reason to suspect an adult who has care and support needs is subject to, or at risk of, abuse or neglect; and
• they cannot protect themselves against the abuse, neglect or risk because of their needs.

9. The purpose of a safeguarding investigation is to decide if the Council (or any other organisation or person) should act to protect the vulnerable adult from abuse or neglect, or risk of the same.
10. To decide this the council may need to make enquiries. Enquiries can range from speaking with the individual who is the subject of the concern to a much more formal multi-agency investigation.
11. Enquiries should:

• establish facts;
• find out the individual’s views and wishes and seek consent;
• assess the need of the adult for protection, support and redress;
• decide if any person or organisation responsible for any abuse should become the subject of any follow-up action.

12. If a concern involves a potential crime, the council should tell the police force, which will then have a duty to investigate.
13. Government guidance says Councils must have their own policies and procedures for undertaking adult safeguarding enquiries.
14. The Council has provided me a copy of its Multi-Agency Safeguarding Policy. Of relevance to this complaint the policy says the Council may “in some circumstances […] involve the person alleged to have caused harm” in its investigation. But it says it will not usually do this if there is a concurrent police investigation.
15. Also, the Council has Practice Quality Standards it aims to meet in delivering its social care services. Of relevance to this complaint is Standard 8 which refers to safeguarding and Appendix 2 which refers to ‘key performance indicators’ in this area of work. It says that when the Council carries out enquiries after receiving a safeguarding concern, it will aim to complete those within 30 working days. And if it goes on to devise a safeguarding plan, it will aim to complete that within the following 10 working days.

Background

16. Mrs C lives in the Council’s area. At the beginning of the events covered by this complaint she lived in her own home, which she shared with her husband Mr C. Mr X is Mrs C’s son. He lives in a different local authority area more than 250 miles away.
17. Another person involved in the events of this complaint is Ms G. She is not a blood relation to Mrs C but has looked on her as her mother over several decades. Mr X says that Mrs C has always looked on Ms G, as her daughter also.
18. Mr and Mrs C are both elderly and have care needs. At the beginning of the events covered by this complaint Mrs C was in hospital following a stroke. Mr X says before her stroke, Mrs C was independent in many aspects of her life, including driving her own car, undertaking some of her own shopping and banking. Mr X would support her with online shopping and some financial tasks that required work online, such as researching and buying insurance.
19. In January 2023, the Council received a safeguarding alert. The alert said Mr X:

• brought friends to Mr and Mrs C’s house when he visited and let them stay and take food from the house;
• took money from Mrs C;
• required Mrs C to keep a car even though neither she nor Mr C drove; the alert said Mr X used this for his personal use when he visited;
• had access to a safe in the house. The alert said Mr C reported money missing from that.

20. The Council decided it would carry out enquiries under Section 42 of the Care Act.
21. During February 2023 the Council alerted the police to the report it had received.
22. In early March 2023 Mrs C left hospital and later that month Mr X visited Mr and Mrs C. The Council next received a report that Mr C had not wanted Mr X’s visit. It also received a report that Mr X planned to sell Mrs C’s home and car.
23. In April 2023 the Council undertook two capacity assessments, believing Mrs C would have “substantial difficulty” taking part with its enquiries. The social worker spoke to Mrs C with Mr C and other family members present.
24. The first assessment considered if Mrs C could manage her own finances. The Council social worker recorded that Mrs C did not appear to understand questions about her finances and decided she did not have capacity to do so. The assessment form recorded Mr X giving his view on Mrs C’s capacity to manage her own finances.
25. The second assessment considered if Mrs C had capacity to understand the safeguarding enquiry and express her own views. The social worker recorded that Mrs C showed a general understanding of the safeguarding concerns. But she could not retain information. So, they assessed Mrs C did not have capacity in this regard either. The assessment form did not record the Council consulting Mr X on this matter.
26. Moving forward the Council recorded Mrs C “happy” with a suggestion it provide her with an independent advocate in her best interests.
27. The social worker recorded speaking to Mr X towards the end of April and put some of the allegations to him. Mr X denied taking any money from Mrs C for personal use and said he only used her car to take her out for shopping, visits and so on when he visited Cornwall. He also reported the family had now sold Mrs C’s car (without his knowledge at the time) and expressed concern about another family member’s suitability to manage Mrs C’s finances. He said he never asked Mrs C to give him money, although he had accepted money for train fares (but not every time he travelled). During the call Mr X explained how hurt he was by the allegations that were put to him. He also said that in 2022 other family members had tried to persuade Mrs C to change her will to their advantage, which she refused.
28. There is no record the social worker put to Mr X the allegation he bought friends to Mrs C’s house and let them stay. He told me that if the Council had put the allegation to him, then he would have explained he occasionally supported Mrs C’s friends to visit her. There is also no record the Council asked Mr X if he had access to Mrs C’s safe. Mr X said if he had been asked he would have explained that he did not know where Mrs C kept the key.
29. In May 2023 Ms G got in touch with the Council, saying that other family members prevented her seeing Mrs C. She wanted to take Mrs C to a nearby caravan for a few days, an activity they had done together for many years. Ms G reported other family members saying the safeguarding enquiries prevented this. She also said she could no longer speak to Mrs C on the telephone.
30. Following intervention by the Council, it was agreed Mrs C could go to the caravan with Ms G. It also agreed that Mr X could stay there.
31. Around the same time the Council contacted the local police force to ask what action it had taken. The police reported their enquiries remained ongoing. There are no further records of liaison between the Council and the police.
32. In an email sent in May 2023 Mr X said Mrs C was afraid of another family member. He implied he had told the Council this previously. Later in the month the Council received another report from Mr X reporting that how that family member spoke to Mrs C caused her distress. In another contact Mr X said a neighbour who regularly visited Mrs C could no longer do so.
33. Later in May 2023 the advocate provided their views. They said Mrs C was happy for another family member to take on her financial management and become her Deputy. But they said Mrs C was unhappy at any suggestion of limiting Mr X’s visits to her.
34. At the start of June 2023, the Council held a meeting to consider:

• how to manage Mrs C’s finances;
• drawing up a “safety plan” for when Mr X visited Mrs C.

35. All the family were present in person except Mr X who attended via phone with his partner (the Council did not invite Ms G). Mr X sent me a recording of that meeting.
36. Everyone present apart from Mr X and his partner wanted one family member to manage Mrs C’s finances. Mr X reported previously helping Mrs C with her finances (as explained above) and again raised concerns about the other family member’s suitability. The social worker said Mr X’s concerns were irrelevant as they related to events several years before. Also, during the meeting Mr X asked about money in Mr and Mrs C’s safe and his understanding of money Mrs C had put in there. The social worker said they had no knowledge of this and cut short discussion. She said Mr X wanted to discuss matters from when the Council assumed Mrs C had capacity. Later in the meeting Mr X asked about why family members sold Mrs C’s car. The social worker again cut off discussion.
37. The social worker said she gave weight to the advocate’s view following their meeting with Ms C. And during the meeting Mrs C said she agreed with the other family member managing her finances moving forward (via an application to become a Deputy through the Court of Protection). So, the Council proposed this was in Mrs C’s best interests. Mr X reluctantly agreed to the proposal. As part of its rationale the Council later recorded there were “safeguarding concerns around financial management / abuse in regard to [Mrs C’s] finances”.
38. In the discussion around Mr X’s contacts with Mrs C the social worker said Mr C felt uncomfortable and distressed by Mr X’s visits. When Mr X challenged this and tried to raise his concerns about how other family members had behaved in 2022 the social worker put a stop to the discussion. She said there were no concerns about the support given to Mr and Mrs C by other family members. Giving her reasons the social worker said she had made “several visits” to Mr and Mrs C and “spoken to several health professionals”. At this point the social worker said Mrs C had initially proposed different family members manage her finances.
39. Next, the social worker asked Mr C for his views on Mr X visiting. Mr C said Mr X was “most welcome” as long as he did not upset Mrs C. When someone queried this Mr C said he had concerns about some of Mr X’s recent behaviour. He said Mr X was “bringing strangers along, knocking the door and walking away, using the phone and putting it back”.
40. A family member then interrupted Mr C who asked him how long he wanted Mr X to stay. The social worker asked Mr C if he was comfortable with Mr X staying overnight and he said he was. He was then asked the same question again and appeared confused. He then said he did not want Mr X to stay overnight.
41. Following this exchange Mr X’s partner asked for more clarity about what made Mr C anxious when Mr X visited. The social worker cut off any discussion on this saying she had conversations with Mr C where he had expressed this. She said she was Mr C’s social worker as well as investigating the safeguarding concerns. The social worker suggested Mr X limit any visits to one day which they would later review. When Mr X pointed out the distance he had to travel the social worker said Mr X could stay overnight (but not at the home) and visit a second day to take Mrs C out.
42. During the meeting the social worker repeatedly said the Council would review these arrangements, after Mr X next visited Mrs C.
43. The social worker went on to draw up a ‘safety plan’. In the case notes this said:

• Mr X should contact Mr C before any visit and only visit during daytime;
• that family members could take Mr C out of the house during Mr X’s visits to limit any anxiety he felt;
• that Mr X could not stay in the home overnight, but if he stayed overnight elsewhere, he could visit Mrs C again the next day;
• that “once a visit has occurred we will all meet, gather feedback as to how the process went and look at how this can be increased going forward in a safe and respectful manner”.

44. During June 2023, the Council made final entries on a log of its actions back to February 2023. On a page headed “enquiry conclusions” the social worker said:

• “my view at this time is that the safeguarding concerns around financial abuse, although the police investigation is ongoing, is inconclusive as there does not appear to be enough evidence to ascertain what has been happening”; and
• “due to the concerns which centred around [Mr X’s] attitude, threats and behaviours when requesting money from [Mrs C] a safety plan has been discussed, agreed and implemented in regards to how safe contact can be initiated between [Mr X] and [Mrs C] which would align to [Mrs C’s] wishes to maintain contact, but also respect [Mr and Mrs C’s] health and wellbeing and not increase [Mr C’s] anxiety or place him at risk of harm”. The same passage also referred to allegations of “psychological abuse” by Mr X saying it had received allegations he was “verbally aggressive and threatening”.

45. Also, during June 2023, the Council completed a separate “safeguarding enquiry closure” form. In this the Council said the allegation of financial or material abuse was “fully substantiated”.
46. The social worker also completed a third document in June 2023; a safeguarding risk assessment. In this they wrote “there is clear evidence of a loving bond between [Mrs C] and [Mr X] who was the perpetrator of financial abuse”.
47. As part of my investigation Mr X has sent me emails he sent to the Council which are not on its safeguarding files. All appear correctly addressed and the social worker replied to one (her email also not being on the file). In June 2023 Mr X asked for details of the police officer investigating concerns. The social worker said they would check and revert to Mr X, unsure if they could give that information. Four times (later in June and in July 2023) Mr X sent further emails chasing a reply to that question.
48. In those later emails Mr X also raised further concerns that:

• Mrs C was not receiving visits from care workers following a decline in her health;
• that he found Mrs C locked alone in her home when Mr C had a medical emergency while out with family;
• that Mrs C no longer received visits from a hairdresser or chiropodist and needed new clothes;
• that despite his understanding other family members did not want Mr X staying overnight, a relation had stayed there.

49. Mr X also asked for confirmation about the status of the safeguarding investigation.
50. I note that on its case notes, at the end of July 2023 the Council recorded Mr X leaving a telephone message which alluded to some of these concerns. In another message it recorded Mr X saying: “he wants to visit his mum but doesn't know if he’s allowed to”. One of its social workers (not the caseworker) sent Mr X a copy of the safety plan and said he should make a safeguarding referral if concerned for Mrs C’s wellbeing. However, the copy of the safety plan sent to Mr X omitted the final bullet point which referred to meeting again to review progress. An email Mr X sent around the same time referred to his understanding he was “not allowed” to stay with Mrs C following the “mediated meeting”.
51. In November 2023 the Council received contact from Mr X’s local authority. Its safeguarding team received contact from a professional supporting Mr X concerned for the impact on his health of the events of the previous months. A safeguarding manager from Mr X’s local authority asked the Council to look into the case again, after setting out Mr X’s concerns about the behaviour of other family members. The information included details of neighbours and friends reportedly not allowed to see Mrs C, including Ms G. The email noted Mr X’s understanding he could not stay overnight at the family home following the Council’s safeguarding investigation.
52. In December, Mr X’s local authority went to on to send the Council a recording of the June 2023 meeting. It asked senior officers at the Council to listen to it, saying the recording identified “practice issues” in how the social worker chaired the meeting (without being specific).
53. The next contact the Council recorded from Mr X was in December 2023. He said the police had fully investigated concerns around Mrs C’s finances and he now wanted an “outcome” to the safeguarding investigation. The Council said Mr X remained welcome to visit Mrs C and take her out but could not stay overnight. It said this followed a “decluttering” of the property and this was Mr C’s request.
54. Consequently, when Mr X visited Mrs C at Christmas he had to rent holiday accommodation at a cost of £875 for five nights. Mrs C stayed with him. He said he chose the accommodation due to its close proximity to the family home (less than two miles) and its disabled access. Shortly after the visit the Council said again Mr X could visit Mrs C but “as per the meeting previously” he was “unable to stay the night due to no room being available”.
55. By now the Council had become significantly involved in Mrs C’s case again following a decline in her health. In January 2024 she moved to a care home.
56. In January 2024 Mr X set out his concerns in a complaint to the Council. In this, Mr X explained:

• his concern about the allegations made against him;
• his concern about the actions of other family members;
• his concern at the ongoing management of Mrs C’s finances; that no-one would investigate his concern about money he understood had been kept in the safe in the family home;
• that he wanted to be able to visit Mrs C for longer, not just overnight;
• that he did not know if there remained an ongoing safeguarding investigation.

57. In its reply, sent in April 2024, the Council said it had closed the safeguarding investigation in June 2023. It said that its actions had recognised the important relationship between Mr X and Mrs C and enabled him to visit. It said there were no restrictions on Mr X visiting Mrs C. It had given this information to his local authority also. It denied there was any bias in its investigation.
58. In general comments on this complaint, the Council said that since the events covered by the investigation it had updated its safeguarding enquiry form. This now requires it to detail each allegation made that an adult may be at risk of harm. And its social workers must provide “evidence and narrative” in response to each allegation. It also says that it has put a new practice assurance framework in place, which means it will audit its work regularly and has a senior officer in place with oversight of this.
59. My investigation did not explore decisions around Mrs C entering a care home nor a decision this would become permanent. Nor any further involvement between Mr X and the Council after January 2024, except for its complaint response. However, Mr X made me aware of further contacts he had with the Council about Mrs C’s care, including best interest meetings. He said in one of these meetings he was described as a perpetrator of financial abuse.

My findings

60. I began my analysis by finding no fault in the Council’s decision to begin adult safeguarding enquiries under Section 42 of the Care Act 2014. When the Council receives allegations which suggest a vulnerable adult has been, or may be at risk of, abuse then it must take those seriously. Here, it received serious allegations about Mr X’s conduct and could not dismiss those. Properly therefore it decided to investigate.
61. However, I found several faults in its investigation.
62. First, there was significant delay between the Council receiving a report alleging potential abuse by Mr X and it speaking to him about those allegations. It took around three months for the Council to do this, during which time Mr X knew he was the subject of allegations and the Council was doing something to investigate them. But it made neither the allegations nor the purpose of its investigation clear.
63. Council policy does not say how long it aims to take to complete safeguarding enquiries. However, its quality standards say that enquiries should complete within 30 working days, or around six weeks, from the date of receipt of a concern. I considered this a reasonable benchmark. The risks to vulnerable adults of not making timely enquiries are clear. But it will also be difficult for those who are subject to allegations to live with the uncertainty caused by delay. This will add distress to that which is inherent when such investigations begin. The avoidable distress here was an injustice to Mr X.
64. Second, when the Council put allegations to Mr X it did so only partially. At the beginning it received a report Mr X bought friends to Mr and Mrs C’s home and effectively let them take advantage. But it never tested that allegation with Mr X. Nor did the Council talk to Mr X about the suggestion he had taken money from a safe. Nor can I see that it made any enquiries elsewhere about these matters.
65. I found also a wider confusion about what the allegations against Mr X were. In concluding the investigation, the Council reported Mr X was also alleged to have caused psychological abuse through “attitude, threats and behaviours”. Yet there were no detail of such allegations in the case papers I saw. And if such allegations were made, the Council did not test them with Mr X.
66. The Council explained its policy did not require it to talk to the alleged perpetrators of abuse. I accepted that in exceptional circumstances it could potentially justify this. And that it might delay any conversation if waiting for a police investigation to complete. But usually, basic fairness would require it to do so. I could see no valid reason for the Council not putting all allegations to Mr X, especially those not subject to any criminal enquiry.
67. This fundamental poor practice from the Council caused Mr X further injustice. Because the findings of its safeguarding investigation rested on an inadequate and incomplete investigation, this cast doubt on the validity of those findings. If the Council had conducted a more thorough investigation of the allegations, would the outcome have been the same for Mr X? No-one could know the answer to this question. But this uncertainty was a further cause of distress for him.
68. Third, the Council did not adequately investigate those allegations it did put to Mr X. In particular the suggestion Mr X took money from Mrs C’s account inappropriately. Properly the Council referred this matter to the police. But it never followed up enquiries with the local police force. In addition, the Council never adequately explored the allegations around Mr X’s use of the car. These were considerations relevant to deciding if Mr X perpetrated financial abuse.
69. It was fault therefore the Council went on to say Mr X was a perpetrator of financial abuse without considering these matters. This was a further source of avoidable distress to him, and so a further injustice.
70. Fourth, I considered the Council acted with bias in its investigation. When the Council first discussed advocacy with Mrs C it did so with all family members present, except Mr X. This, despite knowing of the close interest he took in her welfare. However, I did not consider I could find fault in this. At the time the Council had not received counter-allegations from Mr X, expressing concern for the influence of those around Mrs C. It would also be bad practice to discuss the safeguarding process with the alleged victim, with the alleged perpetrator present.
71. Nor could I fault the capacity assessments. The social worker properly recorded exploring Mrs C’s knowledge of her finances and understanding of safeguarding. They also took account of Mr X’s views when assessing Mrs C’s ability to manage her finances. While it may have been preferable if the social worker had spoken to Mrs C alone, I had no reason to think this affected the outcome of the assessments.
72. But a clear bias did emerge when I considered the allegations Mr X made about other members of the family. I found sometimes Mr X’s allegations were ‘historic’. So, for example, I did not think the Council could come to any view on what happened in 2022 when Mr X alleged family members sought to improperly influence Mrs C to change her will. But Mr X also made allegations concurrent to its investigation. It failed to investigate:

• the selling of Mrs C’s car;
• what had happened to money in the safe; Mr X explained he understood Mrs C kept money in a safe but he did not know how much;
• Mr X’s allegation that Mrs C reported feeling scared of one family member. It never spoke to her alone about this;
• Mr X’s concern about the suitability of another family member to become Mrs C’s Deputy. Only in the meeting in June 2023 did this matter receive some airing, even though Mr X had tried to raise it before;
• Mr X’s concern that family members prevented Mrs C seeing neighbours. I note the social worker dismissed this suggestion in the June 2023 meeting. Yet the Council already knew that family members had sought to prevent Mrs C going away with Ms G on an assumed misunderstanding the safeguarding investigation prevented this. The social worker did not test if the family sought to block Mrs C’s contact with other people also.

73. My criticism here was not the Council overlooked clear compelling evidence of abuse by anyone else, but that it that it took an unbalanced approach to the investigation. I sympathised with the social worker having to navigate the awkward family dynamic. But that could not be an excuse for systematically ignoring Mr X’s concerns, while following up on those raised by other family members. During the meeting held in June 2023, the social worker repeatedly shut down attempts made by Mr X or his partner to raise a counter-narrative or explore their concerns.
74. There was also a glaring inconsistency to the social worker’s approach to the allegations about Mr X compared to his counter-allegations. When it came to Mr X’s concern family members may have taken money from Mr and Mrs C’s safe, the social worker refused to discuss saying that anything that happened here related to the time when Mrs C had capacity. I note this was despite the Council having an account which placed money in the safe at the start of the investigation (I accept the social worker may have forgotten this detail amid the meeting). But by the same logic therefore the social worker had no reason to pursue investigation into any concerns that Mrs C had given Mr X money before she entered hospital or his use of her car. As the allegations about Mr X also covered the time before Mrs C’s stroke and presumed loss of capacity.
75. Conversely the Council knew when family members other than Mr X sold Mrs C’s car, there were doubts about Mrs C’s capacity to manage her financial affairs. Yet the social worker did not ask family members about this, nor pursue questions about its worth, what had happened to the money and so on.
76. The impact of this bias was that it further undermined any findings the Council reached in this case. Mr X had an understandable grievance the Council never took his concerns as seriously as those raised by other members of the family. His grievance here was not merely a perception of unfairness. The investigation was demonstrably unfair to him and that too added to his distress.
77. Fifth, there was fault in the Council’s record keeping. I was concerned that three statements made at the meeting in June 2023 by its social worker were not supported by its records.

• They said they had met Mr and Mrs C several times. But the record showed the social worker meeting Mrs C in person only twice before the meeting. Once in April 2023 when they completed the capacity assessments and once at the beginning of May to introduce Mrs C to the independent advocate.
• The social worker also said they had spoken to “several” health professionals. But there was nothing on the safeguarding file which recorded them speaking to any health professionals about Mrs C’s care.
• They further said Mrs C had suggested different family members could look after her finances. But there was no record of when or where Mrs C said this.

78. I noted the social worker said they were also Mr C’s social worker. So, perhaps on his case file there was evidence of further visits to the home. But if those visits were relevant to the Council’s consideration of the allegations against Mr X, or his counter-allegations, then they should also have been on the safeguarding file.
79. I was also concerned the series of emails Mr X sent to the Council in June and July 2023 were not on its files. The Council received at least one because Mr X had a reply. I could find no explanation for why the emails were not on the file, as they were addressed correctly and clearly related to the safeguarding investigation. In those emails Mr X was again raising concerns about Mrs C’s safety (see paragraph 48). I recognised that contemporaneous to these reports the Council had suggested Mr X may raise a safeguarding alert. But the Council could itself have done this. It yet again appeared dismissive of Mr X’s concerns for his mother’s wellbeing. This added to his distress and was a further injustice to him.
80. Sixth, I considered the meeting in June 2023 provided further evidence of fault. The Council presented the meeting as being about Mrs C’s wellbeing. But the social worker’s motivation for supporting limits to Mr X’s visits to the family home was for the impact on Mr C. I could not criticise this as a motive, given Mr C’s age and potential vulnerability. But it again brought into focus the inadequacy of the investigation that preceded the meeting. Put simply, where was the evidence that Mr X’s visits to Mr C caused the anxiety claimed. This was something else the Council never tested with Mr X, who repeatedly said he enjoyed good relations with Mr C. It never placed any information it gathered about Mr C’s anxiety in its safeguarding records either.
81. I also noted here the inherent improbability of what Mr C said during the meeting. He alleged Mr X invited people to the home who were knocking the door and running away and running off with the phone. Also, having listened to the recording of the meeting Mr C appeared confused. Throughout the meeting he needed matters repeatedly explained to him and he gave contradictory answers to questions. At first Mr C did not object to Mr X visiting nor staying overnight. Only when prompted to say otherwise by other family members did he oblige.
82. This raised potential questions about Mr C’s understanding and the extent to which others swayed his answers. I was concerned there was no evidence presented which showed the Council’s social worker spoke to Mr C alone or considered if he too needed advocacy.
83. The reason all this was important was because the Council social worker sought an outcome to the meeting that ran contrary to both Mr X and Mrs C’s wishes. The Council repeatedly recorded it knew of the strong bond between Mrs C and Mr X. While at no point did it seek to prevent Mr X seeing Mrs C, the impact of the safety plan was to inevitably lessen the visits Mr X would make to see his mother. This was because he could no longer stay overnight at the house, nor for longer than a night or two despite the distance involved in his travelling to see her. It was clear from the record of Mrs C’s discussion with the advocate this was not what she wanted.
84. I stress that I could not find the Council’s concerns for Mr C’s wellbeing unfounded. It was possible therefore it could still have sought agreement for a safety plan in the same terms, had it investigated without fault. But given the flaws in the investigation, I was not persuaded the plan was proportionate or appropriate. So, I found there was uncertainty that the distress caused to Mr X and Mrs C by the plan was necessary. This was an injustice to both.
85. Seventh, the Council failed to provide clear information following the meeting in June 2023, as follows:

• Mr X clearly did not understand the voluntary nature of the ‘safety plan’. He was free to visit Mrs C and the home at any time as the safety plan carried no legal weight. But the Council missed opportunities to clarify this with him. Its meeting gave him the clear message he could only visit Mrs C for one night at a time. And this would remain the case until it reviewed the document, which it failed to do.
• Leading on from this, the Council social worker repeatedly assured Mr X in the meeting that the Council would review the safety plan. In the version of the plan on its records, that commitment appears. But it was not in the version later copied to Mr X.
• Linked to this also, the Council never told Mr X when it had completed its investigation. I noted the Council’s safeguarding policy gave its officers and social workers no advice on this crucial step in any investigation. But I considered it a matter of fundamental good administrative practice that both those making allegations of abuse, and those alleged to perpetrate abuse, should know when an investigation completes.

86. This poor practice caused avoidable and unnecessary confusion for Mr X, which only compounded his distress further.
87. Eighth, when the Council completed its investigation, it left documentation which in two places identified Mr X as a perpetrator of financial abuse. This contradicted its assertion elsewhere the allegation was “unsubstantiated”. However, I did not consider the references a ‘slip of the pen’. I considered they represented the true view of the Council that it believed Mr X had perpetrated financial abuse.
88. I noted the Council worked to the civil standard of proof or the balance of probabilities. It had to ask was it more or less likely that abuse had occurred? So, it did not need evidence to a criminal standard of proof, beyond a reasonable doubt.
89. But even allowing for this I could not find any basis for it reaching such a conclusion. There was nothing on the Council records showing Mr X took money from Mrs C’s bank account or elsewhere inappropriately. Nor that he used her car inappropriately. Nor that he let friends take advantage of her and Mr C.
90. It was a further injustice to Mr X that these records existed which might in future be accessed by other Council personnel. On their own they caused avoidable and unnecessary distress. But I was also conscious here that following the events investigated, Mr X had further dealings with the Council concerning Mrs C’s care. He feared this flawed investigation could contaminate his later dealings with the Council, given what it recorded about him. I could not find that fear unfounded.
91. Ninth, the Council missed opportunities to consider its own practice in this case when contacted by Mr X’s local authority and following his complaint. Despite knowing the view of another safeguarding professional that Mr X’s recording identified “practice concerns” in the conduct of the June 2023 meeting, the Council showed little curiosity. I was disappointed that having reviewed its practice in this case following Mr X’s complaint, it defended it as fair, given the number of flaws.
92. In summary then, I found multiple failings by the Council in its safeguarding investigation including delay, inadequate investigation, inadequate communication with Mr X, clear bias and unfairness. Most of these resulted in avoidable and unnecessary distress to Mr X, above that inherent in any safeguarding investigation when someone is accused of abuse.
93. I also considered that but for the fault it was uncertain the Council would have limited contact between Mr X and Mrs C during summer and autumn 2023. This arose directly from the Council’s involvement. This was an injustice to her as well as Mr X. I did not ask for a separate remedy for Mrs C aware that her health had declined since these events and she has a diagnosis of dementia. I thought a direct apology to her might cause unnecessary distress. But I asked the Council, when making its apology to Mr X, to also recognise the impact of its actions on Mrs C; to make clear its apology extended to her.
94. I considered a further injustice to Mr X arose from the expense he had in arranging accommodation to stay over Christmas 2023. I could not say that this was necessarily avoidable. I noted the evidence suggesting that by this time Mr and Mrs C’s home no longer had space for visitors. Also, that it may have been Mr C’s genuine view that he did not want Mr X to stay there, which he may have respected.
95. However, against this, I noted Mr X’s understanding he could not stay at the family home arose from a safety plan, the Council had failed to review. And which was, as I have explained the result of a seriously flawed meeting and investigation. Mr X should have had a better understanding of the safety plan, which the Council should have reviewed; the format of which may have looked very different but for the flaws. All of which leads me to find there must be some uncertainty about whether Mr X needed to have the expense of accommodation also. In all the circumstances of the case therefore, I recommended the Council contribute half of Mr X’s accommodation costs.

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Agreed Action

96. The Council accepted the findings set out above. Within 20 working days of our initial decision published in July 2025, it:
1. apologised to Mr X accepting the findings of this investigation. I was satisfied this took account of our guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice;
2. made a symbolic payment to Mr X of £1000 for his distress. This was double what our guidance on remedies typically recommends as a maximum payment for distress. But I took account that in this case Mr X experienced prolonged distress which arose from multiple failings and was therefore compounded. This justified an exception;
3. appointed a senior officer, not previously familiar with this case, to review the Council’s contacts with Mr X since January 2024. That officer considered if the earlier safeguarding investigation had tainted any decision making around Mrs C’s care, involving Mr X. The review considered any information the Council had given to any third parties such as the Court of Protection. The review considered if the Council had relied on information arising from the flawed safeguarding investigation in its decision making or when sharing information.
97. In addition, the Council had agreed to ‘erase’ from its records any finding that Mr X was a perpetrator of financial abuse. And to attach to its safeguarding records a statement directing anyone who views the record that this investigation has taken place and found multiple failings in its conduct. It also said it would send Mr X a copy of its safeguarding records with the changes made.
98. The Council then told us its record system did not permit erasure. But that it could add a clear record to the ‘front screen’ of its records, making clear any finding Mr X had perpetrated financial abuse was incorrect and directing any viewer of those records to this investigation. I considered this a satisfactory outcome, subject to the Council making a further check to ensure no form of ‘erasure’ was possible; for example, through redacting, overtyping, or recording a clear statement next to the offending entries. I also saw no reason the Council could not share what the final record looked like with Mr X, so he could see the corrections made and / or any statement on the ‘front screen’ of its records. It will do this within 20 working days of this reissued decision.
99. In addition, within 20 working days of this reissued decision, the Council will make a symbolic payment to Mr X of £438 as a contribution to the accommodation costs he incurred in December 2023.
100. The Council also agreed to learn lessons from this investigation. I recognised that since the events investigated it had improved its standard enquiry form and introduced more oversight of its adult safeguarding. But I considered there was still scope for further improvement. So, within three months of our initial decision in July (and within 20 working days of this reissued decision), it will:
1. revise its current safeguarding policy to include sections advising on:

• desired timescales for completing enquiries when it has decided to undertake those which can cross-reference the Practice Quality Standards;
• what action social workers should take to inform both those reporting alleged abuse and any alleged perpetrators when it closes an investigation;
2. provide a briefing to all those who conduct adult safeguarding investigations to put across the key learning points from this investigation. I consider these are:
• that investigating social workers must consider the factual basis for allegations;
• that social workers should take seriously counter-allegations and decide whether to investigate those also;
• that there should be clear audit trails of all communications relevant to findings on a safeguarding investigation;
• that findings which record abuse substantiated, must provide a clear rationale for such a finding.

101. The Council will provide the briefing above in person, although it may incorporate this in any pre-existing training events or team meetings. It will provide us with evidence of compliance with all the above actions.

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Final Decision

102. For reasons set out above I upheld this complaint finding fault by the Council caused injustice to Mr X and Mrs C. The Council has accepted these findings and agreed action that I consider will remedy that injustice and help prevent a repeat. Consequently, I have completed my investigation satisfied with its response.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman