Summary: There was no fault in the way the Council responded to Miss X’s reports of safeguarding concerns related to her late father. The Council was also not at fault for how it considered Miss X’s request for a Safeguarding Adult Review.

The complaint

1. Miss X complained about matters related to her late father, Mr Y. In particular, she complained the Council:
1. did not take a joined-up approach to safeguarding concerns and it did not take appropriate action to safeguard Mr Y, who was a vulnerable adult, from domestic abuse and neglect;
2. refused to undertake a safeguarding adult review (SAR); and,
3. social workers shouted at and bullied Mr Y during a home visit in May 2024 which resulted in him refusing important domestic abuse intervention.
2. Miss X said as a result of the Council’s actions Mr Y did not receive the support he should have received to stay safe, and she was caused distress, frustration and missed out on more time with her father.

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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. We consider whether there was fault in the way an organisation made its decision. 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)
5. When considering complaints we make findings based on the balance of probabilities. This means that we look at the available relevant evidence and decide what was more likely to have happened.
6. 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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What I have and have not investigated

7. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
8. 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)
9. Miss X complained to us in April 2025 about matters that took place in late 2022, 2023 and early 2024. Miss X’s complaints about events of 2022 and 2023 are late. It was open to her to come to us at that time and there are no good reasons to investigate these now. I have investigated her complaint from late March 2024 onwards when Mr Y was admitted to hospital.

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How I considered this complaint

10. I spoke to Miss X and considered the additional evidence she provided.
11. I also considered the Council’s response to our enquiries as well as relevant law, policy and guidance.
12. Miss X and the Council had an opportunity to comment on the draft decision. I considered any comments before making a final decision.

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What I found

Relevant law and guidance

Safeguarding

13. A council must make enquiries if it thinks a person may be at risk of abuse or neglect and has care and support needs (whether or not it is meeting any of those needs) which mean that the person cannot protect themselves.
14. The purpose of the adult safeguarding enquiry is to enable the council to decide whether any action is required in the adult’s case to protect them, and if so, what and by whom. An enquiry could range from a conversation with the person who is the subject of the concern, to a more formal multi-agency arrangement (section 42, Care Act 2014).

Safeguarding Adults Review

15. Each council must establish a safeguarding adults board (SAB) for its area. Section 44 of the Care Act 2014 states that the SAB must arrange a review of a case involving an adult if:
1. There is a reasonable cause for concern about how the SAB, its members or other persons with relevant functions worked together to safeguard the adult, and
2. Condition one or two is met.
16. Condition one is met if:
1. The adult has died, and
2. The SAB knows or suspects that the death resulted from abuse or neglect (whether or nor it knew about or suspected the abuse or neglect before the adult died).
17. Condition two is met if:
1. The adult is still alive, and
2. The SAB knows or suspects that the adult has experienced serious abuse or neglect.

Mental capacity

18. The Mental Capacity Act 2005 is the framework for acting and deciding for people who lack the mental capacity to make particular decisions for themselves. The Act (and the Code of Practice 2007) describes the steps a person should take when dealing with someone who may lack capacity to make decisions for themselves. It describes when to assess a person’s capacity to make a decision, how to do this, and how to make a decision on behalf of somebody who cannot do so.
19. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:

• because they make an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

20. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.

What happened

21. This section sets out the key events in this case and is not intended to be a detailed chronology.
22. Miss X’s late father Mr Y lived with his partner for whom he was a carer. Mr Y also had health issues.
23. In late March 2024, Mr Y was admitted to hospital with confusion and unexplained injuries. The ambulance service raised concerns about Mr Y. The Council decided the threshold was met for a safeguarding enquiry. The Council notes recorded the hospital considered Mr Y’s bruising was consistent with a fall and Mr Y said he was not being abused and wanted to return home. The care agency also said they had no concerns.
24. Mr Y’s social worker visited Mr Y regarding creating a protection plan. Records showed that the Council held a joint visit with Miss X and Mr Y. They noted that Mr Y was clear that he was not being abused. They agreed a protection plan which aimed for Mr Y to continue living at home safely and actions to meet this aim including Mr Y’s GP to follow up concerns about his health and continued twice daily visit from carers who would report any concerns to the Council. Mr Y agreed for the plan to be shared with the GP and care agency.
25. Mr X was discharged from hospital and then readmitted shortly after with suspected delirium although he returned home later that day. The social worker visited again to discuss the protection plan. Mr Y and his wife remained happy with it. The actions agreed included for Mr Y to explore increased support with household tasks, they consider increasing their care package and continued monitoring through the care agency. It also included arrangements for a weekly meeting between Mr Y and Miss X and another of their relatives.
26. Between mid and late April 2024, Miss X contacted the Council on many occasions to say that Mr Y’s protection plan was not working – she said that his health and wellbeing was deteriorating and he was not following the plan.
27. In late April 2024, the Council made numerous telephone calls to Mr Y to arrange a review of the protection plan but he did not answer. In early May the Council spoke with his partner who agreed to a visit in mid-May.
28. In mid-May 2024 the Council social workers visited Mr Y and his partner at their home. Both agreed they needed more support around the house and were looking at other care options. Mr Y acknowledged he had not been visiting relatives as per the plan. Mr Y’s social worker emailed Miss X to inform her that they had reviewed Mr Y’s current protection plan during their recent home visit and had discussed respite options for Mr Y. Records showed that Mr Y said he was considering this option and had been to look at different residential homes. The social worker told Miss X that Mr Y was able to make his own decisions and arrangements regarding his care and support provisions, and the Council’s adult social care department could not force him to attend a respite placement.
29. Mr Y’s social worker also told Miss X that a protection plan had initially been implemented as an aid to safeguard Mr Y following the allegations he made about his injuries from his partner. However, Mr Y had since withdrawn these allegations and told the social workers that he did not feel that a protection plan was needed. The social worker reiterated that Mr Y was able to make this decision and added that their support for Mr Y would end soon.
30. In late May 2024, Miss X emailed the Council social worker to say that Mr Y had agreed to seek support from a domestic abuse charity.
31. In late May 2024 the Council social workers visited Mr Y alone. The Council records of the meeting showed that the social workers discussed Mr Y’s home circumstances in addition to the domestic abuse program.
32. The Council also contacted Mr Y’s GP and was told his case was discussed during a clinical meeting and that they had “no knowledge or concern about domestic abuse.” The GP added that Mr Y’s alcohol consumption alongside his medication caused confusion and affected his cognition, and that he had experienced falls in the past related to alcohol use. The GP also added that while Mr Y experienced confusion it did not impact his decision-making.
33. Miss X said following the social workers’ most recent visit, Mr Y called her to say that he “felt bullied and shouted at in the meeting and that he was asked to say that his partner had ‘attacked’ him.” Miss X added that Mr Y said if he said no then social services would not support the referral to the domestic abuse program.
34. Miss X contacted the Council about this and said that domestic abuse was not just violence but also controlling behaviours therefore Mr Y was entitled to seek this support. In response the Council social worker told Miss X that Mr Y had not provided consent for them to discuss their meeting in detail with anyone else therefore they were unable to disclose anything further – Mr Y had said he would contact Miss X directly to share any information regarding his personal matters. The social worker reiterated that Mr Y was able to make his own decisions and that the adult social care department had to follow his wishes. They reassured Miss X that “there was no bullying.”
35. In June 2024 Mr Y was admitted to hospital following a fall at home. The Council records showed the hospital reported he had made no allegation of domestic abuse or mentioned any worries related to his home to the hospital staff. The Council notes also showed that Mr Y was able to make the decision to go home following his discharge.
36. In early July 2024 the Council’s locality team completed a home visit and agreed that the protection plan had ended and was no longer needed. It was also noted that Mr Y was due to move into a retirement/assisted living facility soon. He moved there with his partner later that month.
37. The Council records noted that Mr Y was referred to adult social care for a care needs assessment following concerns about abuse raised by Miss X. Mr Y had moved to the assisted living facility and did not want formal support from adult social care. It was also noted that it had carried out several visits to investigate the safeguarding concerns and concluded that there was no evidence of abuse. It closed the case.
38. In September 2024 Mr Y was admitted to hospital after suffering a fall. The Council completed a care needs assessment and made referrals to other services for hearing and a mobility and aids assessment. It was noted that there was no need for ongoing formal support from the Council at that time as Mr Y and his partner had private support in place.
39. In late October 2024 Miss X and the ambulance service raised concerns about domestic abuse in relation to Mr Y. In response the Council said it checked with carers who visited Mr Y’s partner regularly in their home – they confirmed they had not observed any concerning behaviours or situations. It told Miss X that it would continue to monitor the situation closely to ensure Mr Y’s wellbeing.
40. The Council contacted Mr Y’s assisted living facility which said that it had not observed any concerns regarding Mr Y’s wellbeing. The Council records also showed that following a referral from Miss X to the police, it carried out a visit and noted no domestic violence concerns.
41. In early November 2024 Mr Y was admitted to hospital due to confusion and the ambulance service put in a referral stating safeguarding concerns and that Mr Y may need a further assessment and review of mobility aids and more support. The Council social worker visited Mr Y in hospital and decided not to progress the safeguarding alert as Mr Y did not think there were any issues to explore and wished to return home.
42. Records during Mr Y’s hospital stay showed that the doctors assessed his mental capacity and had no concerns. It also showed that Mr Y agreed to accept assistance with personal care in the mornings. The Council confirmed a referral to ICRS (Integrated Crisis Response Service) and to reablement support which started Mr Y’s package of care after he was discharged a couple of days later. The Council records during this period also showed that the police confirmed that it was not taking any further action on the safeguarding alert raised.
43. Mr Y was admitted to hospital in mid-November 2024. Miss X contacted the Council to raise safeguarding concerns. The Council social worker visited Mr Y in hospital to discuss discharge and safeguarding concerns. The Council records showed that Mr Y was able to make his own decisions and there were no concerns raised regarding domestic abuse. It also showed that the Council liaised with a domestic abuse support service to discuss Mr Y’s case which confirmed that it had seen Mr Y on several occasions and that he had not disclosed any domestic abuse concerns.
44. The Council records of late November 2024 and early December 2024 showed that reablement support restarted following Mr Y’s hospital discharge and referrals were made for aid equipment to assist with mobility.
45. In late December 2024 Mr Y was admitted to hospital due to his health. Miss X contacted the Council to say he had unexplained extensive bruising and that his partner had withheld food and drink. She also raised further concerns of domestic abuse. She said she had alerted the police, but Mr Y was too unwell to speak and was being treated for sepsis and pneumonia. Mr Y passed away due to these reasons a couple of days later.
46. The Council initiated a section 42 enquiry to investigate Miss X’s safeguarding concerns made at the time of Mr Y’s hospital admission. The Council records said that Mr Y reported he had fallen at home. It noted he was on medication that might cause or contribute to bruising. It also noted that Mr Y’s GP was involved and aware that he had “gone off food” and was becoming unwell. The police had attended and concluded that its involvement was not needed. The Council also noted that the hospital staff had not shared any concerns in relation to Mr Y’s personal relationship. It noted that there was no coroner involvement and Mr Y’s cause of death was health reasons. It closed the safeguarding alert.
47. In March 2025 Miss X asked the Council to undertake a Safeguarding Adults Review (SAR) – she said she believed that the Council did not handle Mr Y’s case properly and that the various agencies involved did not work together to safeguard him from domestic abuse.
48. In early April 2025 the Council wrote to Miss X and said that her request did not meet the threshold for a SAR. It told Miss X to contact us. It told us that Miss X’s request did not meet the threshold because there was no evidence to support a view that safeguarding partners did not work together to safeguard Mr Y when allegations of harm and abuse were received and Mr Y’s cause of death was not as a result of harm or abuse.
49. In late April 2025 Miss X complained to us.

Findings

Safeguarding

50. Records showed that the Council took the concerns raised by Miss X seriously. In response to safeguarding alerts raised by Miss X and the ambulance service, the Council properly investigated the concerns. It visited and spoke to Mr Y to ensure his safety and liaised with other agencies and professionals involved with him, including health professionals, the police, the care agency and the independent living facility. It decided that there were no safeguarding concerns requiring any action. There was no evidence of fault in the way the Council responded to the safeguarding concerns.

Safeguarding Adults Review

51. The law sets out the conditions that need to be met for a Safeguarding Adults Review (SAR) when an adult has died (condition one) – that is if it knew or suspected that the death resulted from abuse or neglect. Mr Y’s death was recorded as resulting from his health needs and not as a result of harm or abuse therefore the threshold to carry out a SAR was not met. There was no fault in how the Council made its decision to refuse Miss X’s request for a SAR.

Allegations of bullying

52. The Council’s record of the May 2024 meeting with Mr Y noted relevant matters related to domestic abuse were discussed and the officers asked Mr Y appropriate questions. Mr Y did not want the details of this meeting to be shared therefore I have not included any detail of this meeting in my decision statement. The Council record of this meeting summarises what was discussed and does not suggest Mr Y was pressurised to disclose or not disclose information.
53. Miss X says Mr Y told her he felt bullied and shouted at during this meeting which caused him to refuse domestic abuse support. The Council reassured Miss X that this did not happen, and the Council records of this meeting and of contact with Mr Y did not show any information that raised such concerns. As Mr Y has since died and neither I nor Miss X were present at the meeting I cannot, even on the balance of probabilities, make a finding in relation to Miss X’s concerns about the conduct and tone of the meeting.

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Decision

54. I found no fault causing an injustice.

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Investigator's decision on behalf of the Ombudsman