Summary: Mrs C complained about the way the Council carried out a safeguarding investigation into concerns she raised against a care provider looking after her relative, Mrs E and counter-concerns raised by the Care Provider. We found some fault in the way the Council communicated with Mrs C about the allegations, some delay in requesting evidence and reaching a conclusion and some confusion on the final complaint response. This caused Mrs C some distress and uncertainty. The Council has agreed to apologise and pay her £200.

The complaint

1. Mrs C complained that Suffolk County Council (the Council), in respect of a safeguarding investigation into the care of her relative, Mrs E:
• failed to properly investigate Mrs C’s concerns around missed medication, control of medication being taken away from Mrs E and failure to provide timely pain medication;
• disproportionately prioritised counter-concerns raised by the Care Provider (around food choices and controlling behaviour) against Mrs C;
• failed to properly understand the impact of diet on one of Mrs E’s health conditions;
• failed to investigate why Mrs E was admitted to hospital in November 2024 against her wishes and without contacting Mrs C first;
• failed to provide Mrs C with the details of the concerns raised against her and delayed in providing her with the outcome of the safeguarding investigation; and
• failed to properly understand the issues she raised in her complaint.
2. Mrs C says this caused her significant distress and uncertainty as to whether the outcome could have been different for Mrs E.

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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 Mrs C and the Council as well as relevant law, policy and guidance.
6. Mrs 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

Background

8. Mrs E was elderly with several health conditions and living in a supported housing scheme with care provision on site. Mrs E received care visits from a Care Provider (CP).
9. Mrs C had power of attorney for Mrs E which meant she could make decisions on her behalf about financial, health and care issues if Mrs E lacked capacity, or with Mrs E’s consent if she had capacity. Mrs C visited Mrs E on a weekly basis, doing shopping and preparing food for the week which was kept in the fridge. Mrs E had a condition which was affected by diet and was on a number of different medications including two types of painkiller: paracetamol to be taken four times a day and the other when required. She also took one tablet for controlling blood pressure, once a day and an ‘as required tablet’ to control sickness and dizziness up to three times a day.
10. Prior to a hospital admission in October 2024 Mrs E had been taking her own medication with supervision from the carers and Mrs C during her weekly visits. She took the two painkillers alternately as she found that was the best way of managing her pain. The carers and district nurse had raised some concerns about whether Mrs E remembered when she had taken her medication and often asked for more soon after she had already taken some. The nurse advised that the CP should take over the medication to ensure Mrs E was taking it safely and correctly. This started on 17 October 2024. The care visits were increased by two to accommodate this and the carers completed medication administration record (MAR) charts.
11. These charts showed that from 17 October 2024 the blood pressure medication was taken once a day on a regular basis. But there was more variation with the two painkillers. Mrs C was concerned that the carers were giving both medications together whereas Mrs E had been taken them alternately to increase their effectiveness.
12. Mrs C was also not happy that she had raised concerns with the CP about only three blood pressure tablets being taken in a week, but no investigation had taken place. She had photographic evidence that only three had been given and said she was clear that she had removed all the excess medication from Mrs E’s home after her first hospital discharge. The charts also showed that the tablet for dizziness was given frequently but not more than three times a day.

Safeguarding concerns

13. At the end of October 2024 Mrs C raised her concerns about the pain relief medication and food intake with the Council as a safeguarding referral. She also checked with the GP how Mrs E’s painkillers should be taken, The GP confirmed that the medications could either be taken at the same time or separately and both options were fine but spacing them out may lead to slightly better pain relief.
14. At the same time the Council also received a safeguarding concern from the CP about Mrs C, alleging she was controlling Mrs E’s food choices and access to finances. The CP did not feel that Mrs C was acting in Mrs E’s best interests.
15. A member of the safeguarding team spoke to both Mrs C and the CP on 4 November to gain further understanding of their respective concerns. They then completed an assessment document which included details from health colleagues and the contracts team about Mrs E’s medication, capacity and care. This confirmed that the paracetamol should be taken four times a day and the other painkiller every four hours when required.
16. There was a note from the GP records dated 24 October stating that there were some untouched tablets from the delivery on 7 October, due to Mrs E going into hospital on 9 October. When she was discharged, she came home with additional supplies of medication. The health records also noted that Mrs E’s short term memory had declined recently.
17. The Council concluded it would carry out a single agency safeguarding enquiry under section 42 of the Care Act into both sets of concerns. It said it appeared that there could be a breakdown in communication between the CP and Mrs C which was leaving Mrs E in the middle. It was concerned Mrs E’s voice was not being heard and she needed to be spoken to as part of the enquiry. The case was allocated to a safeguarding practitioner (SGP).
18. SGP rang Mrs E and arranged a meeting on 8 November, to discuss her care plan, care needs and review all aspects of her care. She also spoke to Mrs C and invited her to attend. SGP was in agreement with this as long as Mrs E’s wishes and views would be heard. SGP also spoke to the CP who agreed to meet with SGP after SGP had met with Mrs E and Mrs C.
19. The next record in the case notes is a call with Mrs C on 11 November after the meeting. Mrs C was by now aware of the allegations against her by the CP and was still concerned about Mrs E’s care. SGP said it was not acceptable that at the meeting both Mrs C and the CP had raised their voices in front of Mrs E due to disagreements over the issues under discussion. SGP said she had asked the carers to give Mrs E choice over her meal options and noted that Mrs E could express herself well and share her views. Mrs C said she had written her own notes into the care plan for Mrs E. SGP said that the CP needed its own documentation and records. SGP said she would be gathering more information and discussing the case with a senior officer.
20. SGP contacted Mrs E’s GP to clarify her medication and her dietary requirements. The GP called back and confirmed the advice that paracetamol should be given four-hourly alongside a different painkiller when required. They could be given together. The GP felt there was no need for a special diet, as Mrs E did not wish to go back into hospital for tests and treatment regarding that condition. She needed a varied diet with limited green vegetables. Both the GP and the dietician agreed that choice and quality of life were the priority for Mrs E. The GP said Mrs E had capacity when she was well but may have some short term memory loss.
21. Mrs C provided information about Mrs E’ dietary requirements following a meeting with the dietician at the hospital and her view on the allegations against her by the CP.
22. SGP spoke to CP on 20 November who advised that Mrs E had been in hospital for several days due to a suspected stroke and the diet-related condition. Mrs E had confirmed she wished to continue living where she was with care visits. SGP advised that CP would manage Mrs E’s medication and keep accurate records on MAR charts, including the frequency of requests. If Mrs E asked for pain relief too frequently CP should ask the GP for a medication review. SGP confirmed that paracetamol should be given four-hourly and the other painkiller when required. The GP had confirmed the dosage instructions on the packets. CP advised that Mrs C had returned the new contract with the increased visits, but it was unsigned.
23. SGP spoke to Mrs C about the hospital admission on 22 November. Mrs C was very clear that Mrs E should not have been taken to hospital as it was against her wishes and that she should have been consulted first. SGP said it was the paramedic’s decision to take her to hospital as Mrs E was displaying symptoms of a possible stroke; not to take her in those circumstances could have been a safeguarding issue.
24. SGP visited Mrs E on 28 November to review the care visits. She found Mrs E to be very happy, and the care visits were working well. She asked the CP to confirm the number and times of the care visits. CP confirmed the times of the six visits but said some visits were taking much longer than the allocated 15 minutes and they would be discussing this with Mrs E for the future. They also discussed Mrs E using the emergency call bell frequently and the cost of this service. CP said Mrs C had not returned a signed copy of the contract.
25. Mrs C said Mrs E telephoned her after this visit and asked her to stop SGP ‘bothering her’ and wondering why SGP kept questioning Mrs C’s involvement in her life. Mrs C said she had returned the contract with a note saying it was signed under duress as Mrs E would otherwise not have received any care.
26. On 10 December, SGP asked the GP when they had prescribed the paracetamol as four-hourly, whether they were aware of any missed blood pressure medication and what Mrs E’s views were about the recent hospital stay. The GP replied on 12 December confirming that paracetamol had always been prescribed four-hourly and never as required. They said the hospital admission had been for the diet-related condition, but Mrs E did not want any further admissions for that. However, she would accept hospital admission for uncontrollable pain. The blood pressure medication had been prescribed since January, and the GP had no record of being informed about missed doses.
27. SGP also asked CP to provide evidence of any missed blood pressure medication in the previous two months and of the notes and records prior to Mrs E’s hospital stay. CP provided the information, including the MAR charts from 17 October which showed no missed doses.
28. SGP closed the case on 9 January 2025 as partially substantiated, due to the paracetamol being given as required rather than every four hours as the GP said it had always been prescribed. It had been added to the MAR chart and after a period of review and monitoring it was being administered effectively. In respect of the blood pressure medication, there were no unaccounted gaps in the records, and the other painkiller medication was given as required. The concerns around Mrs E’s diet were being met with variety and choice via visual clues as to what was available and in accordance with the dietitian and GP advice. It did not substantiate any of the other allegations and noted that Mrs E was very happy to have Mrs C as her power of attorney, but all involved would continue to ask Mrs E for her views and wishes and work together in her best interests.

Formal complaint

29. In January 2025 Mrs C made a formal complaint to the Council about the safeguarding investigation and outcome. The Council responded on 7 February. It apologised that the purpose of the meeting on 8 November was not fully explained to Mrs C and that she was unaware of the allegations against her. The Council said it was not SGP’s intention to put her in a difficult position by discussing the counter-concerns raised by the CP. With hindsight the Council felt it would have been better to have held the meetings separately.
30. It acknowledged the outcome of the enquiry was somewhat confusing as the two sets of concerns had been considered together, but the partially substantiated finding only related to the issue of the paracetamol dosage and not to any of the concerns raised against Mrs C. Mrs E was clear she was very happy for Mrs C to be her power of attorney for her finances. It did not consider it had prioritised the CP’s concerns over Mrs C’s concerns, and it had a duty to consider all the concerns raised which may involve difficult conversation over sensitive issues.
31. Mrs C remained unhappy and escalated her complaint to stage two of the Council’s complaints procedure. During this period Mrs E sadly passed away.
32. The Council replied to the complaint in March 2025. Again, the Council said it would have expected Mrs C to have been made aware of the allegations against her before the meeting on 8 November 2024. It said Mrs C was provided with a summary of the allegations when she was informed of the outcome on 9 January 2025 and that none of them were substantiated. It said safeguarding enquiries often take some time to complete.
33. Mrs C remained dissatisfied, and the Council sent a third response in April 2025. It reiterated the findings in respect of the medication and repeated its view that there should have been two separate meetings in the initial stages. In respect of the allegations against Mrs C it confirmed that Mrs E was happy for Mrs C to advocate on her behalf, and the concern was not substantiated. However, it did say that it was important to ensure the integrity and effectiveness of the investigation process, so it was standard practice to withhold information about accusations from the source of the risk until the investigation was complete.
34. Mrs C complained to us.

Findings

35. It is not my role to carry out the safeguarding enquiry again or to reach a view on the concerns raised by either party. It is my role to look at the way the Council carried out the safeguarding enquiry and identify whether there was any fault in that process which caused injustice to Mrs C.

Medication concerns

36. One of Mrs C’s main concerns raised with us was the change to the control of Mrs E’s medication in mid-October 2024. This was a change advised by a medical professional in response to concerns raised by the carers regarding Mrs E’s recall over which tablets she had taken. The number of care visits was increased to accommodate the change, and the carers were instructed to complete MAR charts so the dosage could be tracked. I understand Mrs C had concerns about the impact of this change on Mrs E, but this decision was made prior to the safeguarding concerns being raised and was based on medical views that are expressed in the health records and supported by the daily care records. The decision was made by the Care Provider and not the Council and was not a key part of the safeguarding investigation. I have not found fault here.
37. The Council as part of the initial safeguarding assessment immediately requested details of Mrs E’s health issues including her prescribed medication. SGP also spoke to the GP within the first week to clarify the dosage and check how they should be taken. SGP agreed with Mrs C that there was a discrepancy in how the paracetamol was being administered. The GP had confirmed it had always been prescribed as every four hours, but the CP said it was to be administered as required. For this reason, SGP ensured the CP changed its instructions and recorded the correct dosage on the MAR chart. She was satisfied after a period of monitoring that the situation had improved. I find no fault in the way the Council considered this issue as part of the investigation.
38. In respect of the allegation that the blood pressure medication had been missed, SGP requested the MAR charts since 17 October 2024 when CP took over the medication. There were no significant gaps. SGP also established that the hospital had given Mrs E extra supplies of medication on discharge which may have accounted for the discrepancy in the number of tablets left.
39. I understand that Mrs C has a conflicting version of events: She believes the Care Provider had altered the MAR charts for the first week of medication administration and she had removed all the extra medication on Mrs E’s return from hospital. It is not my role to decide whether the medication was given correctly or not. SGP was satisfied that it had been based on the MAR charts and the contact with the GP. There is no evidence that any further problems occurred with this particular medication, so there was no ongoing risk to Mrs E. I have not found fault here.
40. In respect of Mrs C’s view that the medication for sickness and dizziness was being over-dosed, she did not raise this as part of the safeguarding concerns but included it in the later complaint documents. The MAR charts for the period of the safeguarding investigation show that this medication was never given more than the prescribed number of times a day and the daily records confirm that Mrs E frequently asked for a tablet due to dizziness. This point was not excluded from the safeguarding investigation as it was not raised, so I do not find fault here.

Diet concerns

41. SGP specifically asked the GP about Mrs E’s diet early in the safeguarding investigation. Both the GP and the dietitian noted in November 2024 that Mrs E did not want to receive any further treatment or be admitted to hospital for the diet-related condition. They both advised a varied diet with limited green vegetables was the best way forward.
42. Mrs C raised a number of concerns about the way the CP was managing Mrs E’s diet, alleging they were wasting food and not following the plan Mrs C had devised, often just giving her toast.
43. SGP considered all these points and resolved the situation by asking CP to provide Mrs E with visual clues as to the choices of food available in the fridge, particularly given her short-term memory problems. This addressed SGP’s concern that Mrs E should be involved, and her voice should be heard as well as ensuring Mrs E could select available options in the fridge to avoid waste. Neither the GP nor the dietitian said a special diet should be followed. I find no fault here.

Counter-concerns

44. The Council received two sets of allegations from Mrs C and the CP in respect of Mrs E and it had a duty to consider both. I have not seen any evidence that the Council prioritised the CP’s concerns over Mrs C’s. The records show that SGP spent most time considering the diet and medication issues. There is little record of ongoing consideration of the CP’s concerns. The Council has explained this was due to the fact that SGP discovered early on that Mrs E was evidently very happy for Mrs C to continue in her role supporting Mrs E and there was no evidence to substantiate CP’s allegations.
45. However, I agree with the Council that it should have informed Mrs C before the meeting on 8 November 2024 that allegations had been made against her and the details of them. This was fault. It was a shock for Mrs C to receive this information during a meeting which she felt had been called for a different purpose. It is likely this situation led to the breakdown of the meeting due to disagreement between Mrs C and the CP.
46. I also consider the Council should have been much clearer that it was not substantiating the allegations against Mrs C and told her this as soon as it had reached this view, which appears to have been well before 9 January 2025. This was fault which caused Mrs C uncertainty and distress.

Hospital admission

47. The CP called the paramedics due to concerns Mrs C may have been having a stroke. The paramedics then decided to take her to hospital. Mrs E later confirmed she was happy to go to hospital if the pain became uncontrollable or for a medical emergency. I do not find fault with the Council’s conclusion that these actions were reasonable.

Delay in providing outcome

48. I consider that the Council had reached its view on most of the investigation by the end of November 2024 and taken action to improve the medication administration and diet arrangements. It had also decided by this point that the allegations against Mrs C were not substantiated. But it did not reach a formal outcome until 9 January 2025 approximately 6 weeks later.
49. This delay appears to have been due to SGP only asking the GP and CP about the missed blood pressure medication on 10 December and not receiving full responses until the end of December 2024. I consider this information should have been requested earlier when initial enquiries were made, so the matter could have been concluded by the beginning of December 2024. This delay was fault which extended the period of distress and uncertainty for Mrs C.

Complaint-handling

50. The Council did not delay in responding to Mrs C’s complaints and it responded on three occasions, covering all the issues Mrs C raised. It agreed that she should have been informed of the allegations prior to the first meeting and apologised for the failure to do so. It also considered it would have been better to have held separate meetings in the initial stages and apologised for not doing so.
51. I consider the third response caused some confusion as it gave a different explanation for not informing Mrs C of the allegations against her and seemed to suggest that it was justifiable, undermining the previous responses. This was confusing and caused additional distress to Mrs C.

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Action

52. In recognition of the injustice caused to Mrs C, I recommend the Council within one month of the date of my final decision:
• apologises to Mrs C and pays her £200.
53. The Council has agreed to my recommendation and should provide us with evidence it has complied with the above actions.

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Decision

54. 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