Summary: We will not investigate Mr X’s complaint about how the Council dealt with a safeguarding investigation. This is because there is not enough evidence of fault, and we could not add to the investigation carried out by the Council.

The complaint

1. Mr X complains about the Council’s handling of a safeguarding investigation concerning his late mother, Ms Y, who was discharged from hospital to a care home with pressure sores. He says the investigation did not reach the outcome he hoped for. He says social workers were unprofessional and communication was poor, leaving him and his family unsupported.

Back to top

The Ombudsman’s role and powers

2. We investigate complaints about ‘maladministration’ and ‘service failure’, which we call ‘fault’. We must also consider whether any fault has had an adverse impact on the person making the complaint, which we call ‘injustice’. We provide a free service, but must use public money carefully. We do not start or continue an investigation if we decide:

• there is not enough evidence of fault to justify investigating, or
• we could not add to any previous investigation by the organisation.

(Local Government Act 1974, section 24A(6), as amended, section 34(B))

3. 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)

Back to top

How I considered this complaint

4. I considered information provided by Mr X and the Council.
5. I considered the Ombudsman’s Assessment Code.

Back to top

My assessment

6. Ms Y was admitted to hospital in September 2023 and discharged to a care home in October 2023.
7. The care home raised a safeguarding concern due to the condition of her pressure sores after discharge.

8. Ms Y was readmitted to hospital in December 2023 and sadly died later that month.
9. In January 2024, the Council held a safeguarding planning meeting to discuss the concerns raised. No representative from the hospital was present. Due to a misunderstanding, Mr X’s wife was not allowed to attend. The Council has apologised for this error.
10. In February 2024, an inquest into Ms Y’s death was opened. The Coroner issued their findings in January 2025. The Ombudsman cannot comment on the Coroner’s conclusions.
11. The Council considered the relevant information, including medical records, before reaching a decision. It documented its rationale and determined that Ms Y received appropriate medical care. While Mr X disagrees with the outcome, there is no evidence of fault in how the Council made its decision, so I cannot question the outcome.
12. I will not investigate Mr X’s complaint about the poor communication and professionalism of social workers. The Council has apologised and explained the learning it has taken from this complaint and has said it will ensure that there is a representative from the hospital to ensure that health professionals can address questions. This is a proportionate response by the Council, and we could not add to it.

Back to top

Final decision

13. We will not investigate Mr X’s complaint. This is because there is not enough evidence of fault, and we could not add to the investigation carried out by the Council.

Back to top

Investigator's decision on behalf of the Ombudsman