Summary: Mr C complained about the way the Council carried out a safeguarding investigation about an incident involving his son, Mr D at a care facility. We found fault with the Council: it delayed excessively in completing the investigation, notifying Mr C of the outcome and its communication with him was poor throughout. The Council has offered to pay Mr C £500 and has improved its procedures for the future.

The complaint

1. Mr C complained that Essex County Council (the Council), in respect of a safeguarding investigation following an incident at a care facility involving his son Mr D:
• failed to carry out a proper investigation, failing to visit the site or carry out face-to-face interviews;
• was biased towards the Care Provider (CP), accepting its version of events without question;
• failed to include Mr C’s points in the safeguarding report;
• failed to communicate with Mr C about the process;
• delayed excessively in completing the report and sending Mr C a copy of it; and
• failed to notify Mr C when the enquiry was closed.
2. Mr C says his son no longer wishes to attend respite care, so he and his wife, Mrs C, do not get a break. The lengthy process has caused them both significant stress. They would like to Council to review and rewrite the enquiry and to make service improvements.

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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 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)
4. 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(1), as amended)

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How I considered this complaint

5. I considered evidence provided by Mr C and the Council as well as relevant law, policy and guidance.
6. Mr C 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

Safeguarding

7. 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)

What happened

8. Mr C’s son Mr D has care needs. Mr C and his wife, Mrs C, are his main carers. In October 2023 Mr D went into respite care for a week at a facility run by CP. Mr D has capacity but prefers Mr C to communicate with people on his behalf.

Incident – October 2023

9. On 24 October 2023 Mr C reported an incident where Mr D’s wheelchair had not been properly secured in transport, putting him at risk of injury.
10. On 28 October there was an incident at the facility where Mr D was injured: While waiting to go onto the transport Mr D, was left unattended on a slope in his wheelchair. The wheelchair tipped backwards, and Mr D injured the back of his head. CP called an ambulance, and the paramedics treated the injury on site. Mr D did not need to go to hospital as there were qualified medical professionals on site to monitor him. Mr C was informed two hours later.
11. Mr C collected Mr D from the facility the following day and he returned home. CP contacted Mr C on 30 October to find out how Mr D was and said he would be carrying out an investigation into the incident and would raise a safeguarding concern with the Council.
12. The Council contacted the manager of the facility on 9 November. They said the worker involved said they had applied the brake but then saw Mr D disengage it. The manager also said Mr C had raised concerns about the wheelchair at a previous meeting.
13. The Council also contacted Mr C. He raised several concerns about the facility and said he was unhappy with the care Mr D received. He said Mr D had never had any problems with the wheelchair in over 14 years and it had been serviced in September. The Council talked to Mr D during the call: he said it should not have happened and he had been left in the wheelchair without the brakes on, so it tipped backwards and he hit his head. He also raised the issue of his wheelchair not being properly secured on a previous trip.

Safeguarding investigation – November 2023

14. On 9 November, the Council agreed to progress the case to a full enquiry for more information-gathering and allocated it to a social worker (SW). It noted there was conflicting evidence from CP and Mr C about the wheelchair and the brake. The Council requested that CP complete a safeguarding report. The CP completed the report on 13 November and sent it to the Council on 23 November but not directly to SW until 8 December. CP repeated the view of the worker that Mr D has disengaged the brake, and the report included the alleged concerns raised by Mr C about the wheelchair.
15. The CP sent the report to Mr C on 15 December, and he responded on 18 December with a detailed document detailing his concerns about the report. He said the investigation was inadequate and biased towards the CP. He maintained that Mr D had not disengaged the brake, and he had never raised concerns about the wheelchair. He sent a long document back to SW with his views on the incident.
16. On 24 January 2024 SW telephoned Mr C and offered to visit the facility with him. He sent an email saying he would like to accept the offer and looked forward to hearing from SW.
17. There was no further communication until 18 March when SW emailed Mr C to apologise for the lack of contact (which was due to illness) and asked him to provide possible dates for a visit to the facility. Mr C replied the same day saying he had just had an operation and would get back to her in a week or so with availability. He followed up with another email on 20 March requesting copies of supporting documents from the facility. He also requested the meeting be held in a more central location due to his recovery. He did not receive a response and chased SW on 28 March. On 4 April Mr C said he could not meet until early June due to his own medical issues.
18. On 16 April SW had a meeting with her manager about the facility and Mr D’s case. On 18 April SW offered Mr C a home visit to discuss the investigation. Mr C declined due to work and other commitments. He also asked for clarification on the status of the investigation as SW said she had reached her conclusions whereas he was not aware than investigation had taken place. He requested the documents previously asked for and a copy of the investigation report before they could meet. He also asked for confirmation that SW had informed the Care Quality Commission (CQC) of the incident.
19. On 20 May, having received no response, Mr C made a complaint about SW and the conduct of the safeguarding investigation. The team manager (TM) spoke to SW then called Mr C to discuss the complaint. TM explained that SW was trying to arrange a meeting with him to discuss the investigation as she felt it would be better face-to-face. In respect of the action Mr C wanted taken against CP, TM explained that this was not really the safeguarding role which looked at whether the concerns were substantiated and whether the risk to the person or anyone else had been mitigated. TM suggested Mr C complain directly to CP and/or seek legal advice if he wished to challenge CP further.
20. Mr C felt CP’s initial report misrepresented what had happened and SW had believed it as fact. TM said this was not the case and SW had recorded Mr C’s points of disagreement. The fact the SW had upheld the enquiry as substantiated neglect indicated she considered CP was in the wrong and had recommended improvements to its procedures and training to ensure it did not recur. SW would contact the organisational safeguarding team to see if it would be taking any other action against CP. TM confirmed the Council would also share a copy of the outcome with CQC once the investigation was complete. TM agreed that SW would contact the Council’s data protection department to check if the report (which was about Mr D) could be released to Mr C. SW would also make contact to book a meeting with Mr and Mrs C.
21. There is a note on the case record in June asking for Mr C to be called back, but no further details are provided.
22. On 1 August 2024 there was email contact between SW and Mr C appearing to refer to Mr C’s request to remove some information from the safeguarding report. SW says she could not do this because it was information recorded by the person who received the original safeguarding referral. SW also asks Mr C for a date for an online meeting in the next two weeks. Mr C said he could not arrange a meeting until he received an updated copy of the final safeguarding report without the inaccurate allegations from the CP presented as fact. He referred the matter to TM.
23. TM replied explaining that Mr C had not yet received a final copy of the safeguarding report and SW was keen to meet him to discuss the outstanding issues. He urged Mr C to agree to this so the matter could be finalised. Mr C replied saying he could not meet until September and again requested a copy of the updated report. He did not understand why his points of disagreement could not be included in the report in the same way that CP’s had been. TM replied saying the process could not be completed until SW was able to include Mr C’s comments and concerns. TM offered a multi-disciplinary meeting with CP. He acknowledged Mr C’s frustration with the process. Mr C continued to question why he couldn’t have a copy of the updated report.
24. Mr C chased a response on 12 September. TM responded to Mr C’s email on 13 September and apologised for the delay (due to SW’s absence). He said when SW returned to work, she would arrange a visit to the facility and would then complete her report as soon as possible. Mr C chased TM on 10 October. TM said the visit would be taking place the following week.
25. SW visited the facility and spoke to CP on 18 October 2024. Mr C requested a copy of the updated report on 21 October. CP said it was closing down in November.

Final report - December 2024

26. The final report was sent to Mr C on 19 December 2024. The report said the outcome had been decided on 27 September, the report completed by SW on 11 November and authorised by TM on 16 December 2024. It concluded the concern was substantiated as neglect. It said Mr D had been injured when he was left in his wheelchair unattended on a slope and the incident could have been avoided if someone had supported and escorted him onto the vehicle. It noted that CP did not have individualised risk assessments at the time. Since the enquiry the Council was satisfied that CP had taken steps to improve its procedures for the future and produced three new policies within weeks of the original incident. The conclusions noted Mr C’s view that the brakes were not applied and did not include the view that Mr D had disengaged the brakes.

Formal complaint - January 2025

27. Mr C sent an email on 22 January 2025 expressing strong concerns about the report. He said it was not robust or fair, contained inaccurate information, was excessively delayed, did not contain his views, was biased towards the CP and contained slurs about him and his wife. Mr C made a formal complaint on 7 February.
28. The Council responded on 28 March. It upheld his complaint and:
• apologised for the time taken to complete the safeguarding enquiry.
• confirmed that the allegation of neglect had been substantiated and the case closed.
• confirmed it had reviewed Mr C’s concerns and updated the report but not provided Mr C with an updated copy. It apologised for this failing.
• said it did not support the CP’s original suggestion that Mr D’s wheelchair may have been faulty.
• apologised for the delay in dealing with the complaint which was due to a misunderstanding about whether there was an open safeguarding investigation.
• enclosed a copy of the updated report which included Mr C’s email of 22 January and other correspondence to and from Mr C.
29. Mr C then complained to us in April 2025.
30. The Council in responding to my enquiries, recognised that its communication with Mr C during the safeguarding enquiry had not met its expected standards. While the Council had confirmed the process to Mr C at key points, its communication had been inconsistent; Mr C had chased the Council on many occasions and not received timely responses. The Council accepted there were delays and gaps in communication which caused Mr C avoidable frustration and uncertainty. It said it has reviewed its procedures and taken steps to ensure individuals involved in safeguarding enquiries are kept appropriately informed at every stage.
31. The Council also acknowledged the delays in completing the enquiry and in notifying Mr C that the case had been closed. It said it had apologised to him in its complaint response.
32. On a wider level it has implemented a tracker to monitor all safeguarding cases exceeding 90 days and arranged training on communication standards in safeguarding enquiries.
33. In recognition of the impact on Mr C it has suggested a payment of £500.

Findings

October 2023 to January 2024

34. I understand the incident in October 2023 must have been extremely upsetting for Mr D, Mr C and Mrs C. However, the purpose of the safeguarding enquiry was to establish what happened, take steps to protect Mr D and anyone else at risk and to improve procedures to prevent it recurring. It was not intended to apportion blame or reach a finding on every aspect of the incident.
35. I consider the Council, up to January 2024, took reasonable steps following the initial safeguarding referral: it spoke to CP, Mr C and Mr D and established as fact that the accident had occurred. It noted the conflicting evidence about the brake on the wheelchair and asked the CP to provide its own investigation report. It sent a copy of this report to Mr C and noted his comments on it. CP had also reviewed and introduced new procedures regarding individual risk assessments, wheelchair protocols and registration procedures.
36. At this stage it concluded that the failure to supervise Mr D and escort him onto the vehicle was avoidable neglect which caused the accident. I do not consider it was necessary for the Council to visit the site at this point as it had already established the basic facts of the incident and concluded the allegation of neglect was substantiated. Neither do I consider it was necessary for the Council to establish whether or not the brake had been applied or disengaged as the whole situation could have been avoided with proper supervision. I do not consider the Council was biased towards CP or accepted its view on the events as fact; it included them in its records as CP’s view on what happened.

January 2024 onwards

37. SW intended to arrange a meeting with Mr C to discuss his comments and concerns shortly after 24 January 2024 and Mr C was keen to agree to this. If this meeting had taken place, it is likely the enquiry could have been concluded soon afterwards. However, SW then went on sick leave and did not contact Mr C again until 18 March, nearly two months later. No-one else picked up the case in the meantime. This was fault which caused distress and frustration to Mr C and contributed to his loss of faith in the process.
38. While Mr C initially said he would provide dates even though he had recently had an operation, he also asked SW to answer some queries and provide a number of documents. SW did not reply for a month and then offered a home visit. Mr C said he could not meet until June and again requested documents including a copy of the investigation report.
39. SW again did not reply so Mr C made a complaint to her manager, TM, a month later on 20 May. I consider TM responded promptly and constructively to Mr C’s complaint, explained the purpose of the safeguarding investigation, directed Mr C to make a complaint against the CP if he was unhappy with its version of events and agreed SW would progress the case with some specific actions including releasing a copy of the investigation report to Mr C once she had consulted the data protection team. However, there is no record of any action by SW for over two months. This was fault which caused Mr C distress and frustration and further eroded his trust in the process.
40. Mr C continued not to agree to a meeting, but the Council let the situation drift and did not complete the report or conclude the investigation until December 2024, over four months later. This was an excessive amount of time with no further material information being gathered. Part of the delay was due to SW’s absence due to illness and the decision to visit the facility, which by this point appears to have added little to the process. This delay was fault which exacerbated Mr C’s distress and frustration.
41. The first version of the final report was sent to Mr C in December 2024, 14 months after the incident occurred. I consider the report at this stage accurately described the outcome and the reasons for this decision. It recognised Mr C’s disagreements and concerns but did not list them all and made clear it did not support the CP’s view that Mr D disengaged the brake.
42. Following Mr C’s complaint, it reviewed the report and included Mr C’s complaint in its entirety along with more of the events which led to the complaint. I consider this document was a reasonably accurate summary of the information gathered during the enquiry and included Mr C’s views, but it took another three months to send this to Mr C. This delay was further fault which exacerbated Mr C’s injustice.

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Action

43. I welcome the Council’s offer to pay Mr C £500 in recognition of the injustice he experienced as a result of the delays and poor communication over an extended period of time. I consider it is reasonable and proportionate and is at the higher end of the amounts recommended in our guidance on remedies for distress.
44. So I recommend within one month of the date of my final decision that the Council apologises to Mr C and makes a symbolic payment of £500.
45. The Council should provide us with evidence it has complied with the above actions.
46. As the Council has already outlined the steps it has implemented to improve its procedures, I have not made any service improvement recommendations.

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Decision

47. 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