Summary: Ms Y says the Council failed to act to safeguard Ms X and failed to carry out a needs assessment or provide Ms X with support. The Council accepts it failed to follow the right process when dealing with the safeguarding concerns raised and the request for a care assessment. That meant Ms X missed out on care support and a move to a safer property for more than two years and Ms Y experienced significant distress. An apology, payment to Ms Y and procedural changes are satisfactory remedy.

The complaint

1. The complainant, Ms X, was represented by her sister, Ms Y. Ms Y complained the Council:
• failed to act to safeguard Ms X despite Ms Y raising safeguarding concerns; and
• failed to carry out a care assessment or provide Ms X with any support.
2. Ms Y says the Council’s actions left Ms X in an unsafe property, unable to look after herself and experiencing repeated admissions to hospital. Ms Y says she had to accommodate Ms X for five months and experienced significant distress.

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The Ombudsman’s role and powers

3. 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)
4. 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)
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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What I have and have not investigated

6. I am exercising the Ombudsman’s discretion to investigate what has happened since November 2022 when Ms Y first raised a safeguarding concern. That is because I am satisfied Ms X was vulnerable, Ms Y has not let the matter drop and there is no evidence the Council told Ms Y it had closed the safeguarding investigation until 2024.

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How I considered this complaint

7. As part of the investigation, I have:
• considered the complaint and Ms Y's comments;
• made enquiries of the Council and considered the comments and documents the Council provided.
8. Ms Y and the organisation had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

What should have happened

Care assessment

9. The Care Act 2014 requires councils to carry out an assessment for any adult with an appearance of need for care and support. They must provide an assessment to everyone regardless of their finances or whether the council thinks the person has eligible needs. The assessment must be of the adult's needs and how they impact on their wellbeing and the results they want to achieve.

Mental capacity

10. At the time of the assessment of care and support needs, the council must establish whether the person has the capacity to take part in the assessment. The Mental Capacity Act 2005 says councils must presume an adult has the capacity to make a decision until there is a reason to suspect that capacity is in some way compromised.
11. If a council thinks a person may lack capacity to make a decision or a plan, it should carry out a capacity assessment. If it finds the person lacks capacity to decide, it should make a best interest decision.

Safeguarding

12. 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)

The Council’s care, health and well-being adult social care standard operating procedures

13. The Section 42 duty applies to adults who have care and support needs but may not meet eligibility criteria for care and support needs. Such adults include:
• adults with low-level mental health problems/borderline personality disorder;
• adults with substance misuse problems.
14. When closing a safeguarding referral the Council should inform all relevant parties of the decision to close the safeguarding process and give feedback to the person raising the concern.

What happened

15. Ms Y has raised safeguarding concerns about Ms X’s living circumstances and lack of care support since November 2022. That has included drug dealers taking over Ms X’s property (cuckooing) and concerns about her inability to take care of herself. Ms X has gone in and out of hospital and the Council carried out a brief assessment in April 2025 and put in place a package of care so Ms X could be discharged from hospital. However, because Ms X has various medical conditions and the property was in a poor state following the police evicting squatters Ms X returned to hospital the next day.
16. In June 2025 the Council accepted it needed to complete a Care Act assessment, that Ms X had eligible social care needs and it intended to put in place a care and support plan when Ms X was discharged from hospital. The Council had also referred Ms X’s case to the housing escalations surgery to explore suitable housing as Ms X needed sheltered or warden controlled accommodation to ensure her safety and well-being.
17. Sadly Ms X died before the Council could take any of those actions.

Analysis

18. Ms Y says the Council failed to safeguard Ms X and failed to carry out a care assessment or provide her with support. The Council accepts it failed to properly deal with the safeguarding issues in this case and failed to complete a full care assessment. The Council has accepted the following fault:
• the Council failed to follow its internal safeguarding policy and procedures or the London multiagency adult safeguarding policy and procedures. That is because there was enough evidence to suggest the three-point criteria for carrying out a safeguarding enquiry had been met;
• in considering the safeguarding referrals the Council failed to engage Ms X in conversations about how to respond to her situation in a way that enhanced her involvement, choice and control while improving her quality-of-life, well-being and safety;
• the Council failed to carry out a section 42(2) safeguarding enquiry as it should have done given the continuing risks which meant the coordinated multiagency response and planning process was not triggered;
• the Council wrongly closed the safeguarding enquiries without carrying out a risk assessment, developing a clear risk management plan and without considering the mental capacity implications;
• when the Council closed the safeguarding enquiries it did not tell Ms Y or other relevant stakeholders it had done so;
• the Council failed to complete a formal needs assessment under the Care Act;
• although the Council completed some care assessments those assessments failed to meet the statutory standards as they did not adequately include Ms X, failed to consider the broader well-being principles outlined in the Care Act and had an overemphasis on services rather than a needs led approach;
• the Council failed to identify the need to respond to clear indicators of risk and unmet needs;
• although the Council took some action about Ms X's door locks this was not enough to address the broader and more serious risk of cuckooing;
• the Council failed to undertake or consider carrying out a formal mental capacity assessment given the complexity of the decision about access to sheltered housing and risk of harm.
19. The Council says it has taken the following actions to address the procedural issues that arose in this complaint:
• improved senior management oversight of complex safeguarding enquiries;
• introduced a tracking mechanism to monitor the timeliness and effectiveness of interventions;
• redesigned the safeguarding forms which means feedback to referrers and other relevant stakeholders is now a compulsory field. That should ensure the Council tells all parties about safeguarding outcomes and decisions;
• provided improved training for frontline staff and managers on risk identification, professional curiosity and applying safeguarding thresholds;
• introduced mandatory escalation protocols including the high risk panel for cases involving signs of cuckooing, substance use disorder and self-neglect or unsafe living conditions. That is to ensure timely managerial oversight and interventions;
• introduced revised safeguarding documentation including risk assessment tools and closure forms and letters. That is to ensure risk is clearly recorded, evaluated and addressed;
• implemented a safeguarding case tracker which enables real-time monitoring of communications, progress, timeliness of interventions and management oversight;
• introduced regular communications audits and reflective learning sessions to embed learning from this case and promote continuous improvement;
• introduced improved training on identifying hidden harm and exploitation;
• improved risk assessment protocols;
• introduced mandatory escalation procedures for complex cases involving those with multiple vulnerabilities;
• strengthened its procedures for responding to environmental and situational risks identified by relatives and partner agencies. That includes developing a multiagency escalation protocol to ensure concerns raised by the police, health professionals or housing providers are acted on, particularly where they concern physical safety;
• implemented a risk triage system to prioritise cases involving immediate environmental hazards. That will be supported by staff training and senior management oversight to ensure high risk situations are identified early and addressed;
• begun work with housing providers to improve coordination and ensure vulnerable people are prioritised for appropriate placements.
20. I welcome the extensive procedural changes the Council has introduced. However, I am concerned about the number of failures to carry out the necessary actions in this case over a period of more than two years. The evidence I have seen satisfies me the Council missed many opportunities to identify Ms X's vulnerabilities and the fact she needed help and support. In particular, Ms Y had raised multiple safeguarding enquiries with the Council. Ms X's daughter had also raised concerns about her mother's mental and physical health. There is also evidence of management oversight of the officers involved in the case and none of those resulted in the Council taking appropriate action.
21. I am concerned about that given the Council knew about somebody taking over Ms X's property, the property being in an unliveable state and Ms X being at risk of abuse. Despite that the Council repeatedly closed safeguarding enquiries without carrying out the necessary assessments. The Council also left Ms X in the property and then returned her to it with a small package of care without a proper assessment or any consideration of the suitability of the property. I am also concerned the documentation suggests officers did not act on safeguarding issues as they believed Ms X had capacity to make her own decisions and did not have care needs when the Council had not carried out a proper assessment to reach those conclusions.
22. I do not need to comment any further on the areas where the Council has already found fault. Nor can I now consider a remedy for Ms X as she has sadly died. However, I consider Ms Y has her own, separate injustice. I am satisfied the Council has put in place procedural remedies to address the procedural issues that occurred in this case. I am satisfied those measures are extensive and am pleased to see the Council has taken responsibility for correcting the errors that occurred in this case. I have therefore concentrated on what personal remedy is appropriate for Ms Y.
23. I am satisfied Ms Y experienced distress and frustration as she repeatedly raised concerns with the Council but nothing happened. Ms Y also had the disruption of having Ms X, who had challenging behaviours, living in her property for some of the time when she has young children in the property.
24. According to our guidance on remedies, where we decide it is appropriate, we will normally recommend a remedy payment for distress of up to £500. However, we can recommend higher payments to remedy distress where we decide it was especially severe and/or prolonged and/or taking account of personal vulnerability of those affected. Given Ms Y raised continuing safeguarding concerns with the Council and had to house Ms X for part of the period I consider it appropriate to recommend a higher payment in acknowledgement of the distress caused given the impact on Mrs Y has been more severe.
25. I therefore recommended the Council pay Ms Y £750 to reflect the significant distress she experienced, her frustration and the time and trouble she had to go to pursuing Ms X’s case. I also recommended the Council apologise to Ms Y for the failures that happened in this case. The Council has agreed to my recommendations.

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Action

26. Within one month of my decision the Council should:
• apologise to Ms Y for the distress and upset they experienced due to the faults identified in this decision. The Council may want to refer to the Ombudsman’s updated guidance on remedies, which sets out the standards we expect apologies to meet;
• pay Ms Y £750; and
• provide evidence to the Ombudsman of the procedural changes the Council has undertaken in response to the learning from this complaint, as referred to in paragraph 19.
27. The Council should provide us with evidence it has complied with the above actions.

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Final decision

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

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Investigator's decision on behalf of the Ombudsman