Summary: Miss X complains on behalf of Mrs Y that the Council did not deal properly with a safeguarding investigation. The Council didn’t properly communicate with Miss X about what was being investigated. Miss X suffered uncertainty and avoidable distress. The Council should apologise to Miss X and pay Miss X £200.

The complaint

1. The complainant, whom I shall refer to as Miss X, complains on behalf of Mrs Y that the Council did not deal properly with safeguarding enquiry concerns because:
• It took too long
• Was based on partially incorrect information.
• Didn’t provide a copy of the safeguarding enquiry report
• No SAR completed
• Communication was poor
2. Miss X says she suffered avoidable distress.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. Our role is not to ask whether an organisation could have done things better, or whether we agree or disagree with what it did. Instead, we look at whether there was fault in how it made its decisions. If we decide there was no fault in how it did so, we cannot ask whether it should have made a particular decision or say it should have reached a different outcome.
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 Miss X and the Council as well as relevant law, policy and guidance.
7. Miss X and the Council had an opportunity to comment on my draft decision. I considered any comments before making a final decision.

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What I found

Law, guidance and policies

8. 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)

Lambeth Safeguarding Adult Policy

9. Section 44 of the Care Act 2014 requires that the Lambeth Safeguarding Adults Board must arrange for there to be a review of cases involving an adult in its area with needs for care and support (whether or not the local authority has been meeting those needs) when an adult in its area dies or experiences significant harm as a result of abuse or neglect, whether known or suspected, and there is concern that partner agencies could have worked more effectively to protect the adult.

What happened?

10. This is a brief chronology of key events. It does not contain everything I reviewed during my investigation.
11. Mrs Y was admitted to hospital in November 2023. Miss X, her daughter, raised safeguarding concerns.
12. The Council received the safeguarding concerns raised by Miss X in mid February 2024. It decided it met the threshold to conduct enquiries under s42, as outlined above in paragraph 8.
13. The Council met with Miss X in early March 2024 to discuss the safeguarding concerns.
14. A management meeting was held in March to determine how best to proceed.
15. Miss X sent further emails to the Council in April 2024 about additional concerns.
16. Mrs Y passed away in early May 2024.
17. Miss X complained to the Council in June 2024, asking for a serious case review.
18. The Council completed its safeguarding investigation in July 2024.
19. The Council responded to Miss X at stage 1 of its complaints process at the end of August 2024. The stage 1 complaint response summarised the outcome of the safeguarding enquiry, responded to Miss X’s request for a review and her request for a copy of the safeguarding report.
20. Miss X was unhappy with the response and that aspects of the complaint had not been addressed.
21. The Council responded to Miss X’s complaint at stage 2 of its complaints process in October 2024. The Council’s response covered the limits of its complaint coverage, provision of the safeguarding report, her request for a review and her further request for information.

Analysis

Time taken

22. In respect of the safeguarding enquiry, records show the Council:
• decided to undertake s42 enquiries and met Miss X and Mrs Y within three weeks.
• completed its initial enquiries by early April, within 6 weeks.
• Waited to finalise the safeguarding enquiry until a report from Mrs Y’s hospital to the Care Quality Commission (CQC) was available. This became available to the Council in mid May. The Council then finalised its safeguarding enquiry report by early July.
• The safeguarding enquiry report was discussed in September between the authoring social worker and their manager. The manager asked for some content to be summarised instead of being included in full.
23. The Council’s safeguarding enquiry report was substantially completed within 9 weeks. There was a further delay before the report was fully completed due to the Council waiting for a report from Mrs Y’s hospital. This delay was outside of the Council’s control.
24. It took nearly two months for the safeguarding enquiry report to be completed after the Council received the report. I note that at the time the Council was dealing with this, Mrs Y had already passed away two weeks earlier.
25. The Council says there is no statutory guidance to advise a time scale for completing a safeguarding enquiry. It is correct. This is not fault by the Council.

Incorrect information

26. I have reviewed the Safeguarding Enquiry Report. There is no evidence to show the report or its conclusions were based on incorrect information. This is not fault by the Council.

Enquiry report

27. Miss X asked the Council for a copy of the safeguarding enquiry report. There is no requirement on the Council to provide a copy of a completed safeguarding enquiry report to the person who raised concerns. The Council summarised the findings in its stage 1 complaint response and advised Miss X to make a Freedom of Information request. This is not fault by the Council.

Safeguarding adults review

28. The criteria for holding a Safeguarding Adults Review is set out above in paragraph 9.
29. The Council told Miss X that Mrs Y’s case did not satisfy the criteria for a review, because, “A Safeguarding Adults Board (SAB) will arrange for there to be a review of a case involving an adult in its area with needs for care and support, if there is reasonable cause for concern about how agencies worked together to safeguard an adult – where either the adult has died, or the SAB suspects the adult has experienced serious abuse or neglect.

As the Safeguarding Enquiry did not evidence abuse or neglect, the threshold to refer for a Safeguarding Adults Review has not been met. Should new information come to light, this decision can be reviewed.”

30. The Council’s explanation was accurate. This is not fault by the Council.

Communication

31. A management meeting was held between senior managers at the Council and the Hospital Trust in March, to identify how best to proceed. The Council’s record of the meeting says, “[Miss X] does seem to be dissatisfied with care provided on the ward and forms which have been completed but this does not amount to a safeguarding and can be addressed via the PALS complaints service and following the outcome of this Mrs Y’s daughter would have the ability to exercise her right to approach the Health Ombudsman if she felt it necessary. The Council also confirmed that CQC have already been made aware of her concerns as she has written to them and telephone contact with them already and stated the need for them to complete an urgent inspection, something that she feels is an important outcome of the safeguarding enquiry, which can only be met by the CQC and no other party involved.”
32. The Council recorded that on the information gathered to date it would be looking to end the enquiry and inform Miss X that the complaints processes which she was already using via PALS would be best placed to provide a response to the several complaints she had made.
33. An action was recorded to review the information obtained from Miss X and Mrs Y and provide an appropriate response on the outcome of the enquiry.
34. I have found no record that this was communicated to Miss X until the end of August as part of the Council’s stage 1 complaint response, over 5 months later.
35. Miss X continued to provide further information and make additional complaints to the Council in the intervening period. In the absence of clear communication about how the Council intended to proceed, she did so in the expectation that those complaints and further information would be included in the safeguarding enquiry and report.
36. The Council should have communicated with Miss X sooner about how it had determined how her concerns were being addressed. This is fault by the Council. Miss X remained uncertain what the extent of the safeguarding investigation would be and this caused her avoidable distress.

Conclusion

37. The Council’s safeguarding enquiry report covered the issues raised in the initial referral, as determined at the management meeting in March. Other subsequent issues relating to clinical care were either shared with the hospital trust or were clearly already known to it. The Council investigated the issues appropriately.

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Action

38. To remedy the outstanding injustice caused by the fault I have identified, the Council should take the following action within 4 weeks of my final decision:
• Apologise to Miss X for its poor communication. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
• Pay Miss X £200 for uncertainty and avoidable distress.
39. The Council should provide us with evidence it has complied with the above actions.

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Decision

40. I find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman