Summary: There was fault by the Council. It failed to inform Ms X about safeguarding concerns against her, failed to keep a record of decision-making, failed to liaise with another agency, failed to tell her it had ended a safeguarding enquiry and delayed responding to her complaint. This caused her avoidable distress and time and trouble. The Council will issue a symbolic payment and a written reminder to relevant council staff.

The complaint

1. Ms X complained the Council:
1. Carried out a safeguarding enquiry without giving her the chance to respond to allegations against and failed to inform her of the outcome
2. Made an inappropriate referral to the Office of the Public Guardian (OPG) and failed to respond the OPG’s request for information promptly.
3. Ignored her complaint and only provided a response when the LGSCO became involved.
2. Ms X said this caused avoidable distress, adversely affected her health, made her role as her late mother’s attorney more difficult and posed a risk to her professional status.

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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 Ms X and the Council as well as relevant law, policy and guidance.
6. Ms X 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

Relevant law and guidance

7. Regulations on handling complaints about adult social care expect councils to:
• Investigate and resolve a complaint speedily and efficiently and keep the complainant updated as to progress of the investigation
• Send a report within six months of receiving the complaint (or longer if the complainant agrees). (Local Authority Social Services and NHS Complaints (England) Regulations, 2009, Regulation 14)
8. Our Principles of Good Administrative Practice set out our general expectations of councils. They say councils need to be open and accountable. This includes keeping proper and appropriate records and stating the criteria for decisions and giving reasons.
9. A Lasting Power of Attorney (LPA) allows another person (attorney) to make financial, health and welfare decisions for a person who cannot make their own decisions.
10. Mental capacity is the ability to make a decision and understand its implications and consequences. If a person lacks capacity to make a decision, their LPA can make it on their behalf.
11. The Office of the Public Guardian (OPG) registers and supervises LPAs and investigates concerns about attorneys or deputies who have been appointed. 
12. Councils must make enquiries (or arrange for others to do so) if they reasonably suspect an adult with care and support needs is, or is at risk of, being abused or neglected (Care and Support Statutory Guidance (CSSG), paragraph 14.76 and Care Act 2014 section 42)
13. An enquiry is action taken in response to a concern about abuse. It could be a conversation with the adult through to a multi-agency plan. The purpose is to decide whether someone should do something to help or protect the adult (CSSG paragraph 14.78)
14. The objectives of an enquiry into abuse or neglect are to:
• establish facts;
• ascertain the adult’s views and wishes;
• assess the needs of the adult for protection, support and redress and how they might be met;
• protect from the abuse and neglect, in accordance with the wishes of the adult;
• make decisions as to what follow-up action should be taken with regard to the person or organisation responsible for the abuse or neglect; and
• enable the adult to achieve resolution and recovery. (CSSG paragraph 14.94)
15. Decisions on sharing information must be justifiable and proportionate, based on the potential or actual harm to the adult and the rationale for decision-making should always be recorded. (CSSG paragraph 14.131)
16. If someone has concerns about the LPA, they should contact the OPG (CSSG paragraph 14.61)
17. Council adult safeguarding processes have stages which may include some or all of the following: referral/concern, strategy meeting, safeguarding enquiry, enquiry report, conference, protection plan, review of action plan and closure.
18. The Council’s safeguarding procedures say:
• Safeguarding enquiries should be objective, based on findings of facts and be thorough enough to ensure a balanced perspective.
• An enquiry officer will gather and evaluate various sources of information including interviews with the adult at risk and interviews with the person alleged to have caused harm.
• Enquiries should be completed within 28 days of the strategy meeting. Where a case conference is needed, a draft report should be shared with a manager beforehand.
• Wherever practicable, a person alleged to have caused harm should be enabled to respond to allegations and the enquiry findings in respect of his or her conduct. However, there will need to be consideration as to the timing that a person is informed so as not to prejudice any enquiry or place anyone at risk.
• A decision must be made at the Case Conference Discussion/Meeting about what feedback should be provided to the person alleged to have caused harm and who should provide it.
• The primary focus of the safeguarding adult’s procedure is to support people to person safe from future harm.
• The safeguarding procedure can be ended at any point where it is appropriate to do so.
• The person alleged to have caused harm should know the process is concluded and be made aware of any decisions relating to themselves.

What happened

19. Ms Y had care and support needs and lived in a council-funded care home. She died at the end of November 2024. Ms X and another sibling, (Ms M), were Ms Y’s attorneys for health and welfare and finances.

2024

20. The Council’s funding panel met in April and May 2024 to discuss funding for Ms Y’s care and support. The panel recommended the following actions:
• To raise a safeguarding concern due to possible neglect/acts of omission due to Ms X refusing to allow Ms Y to receive medication to manage her pain and control her behaviour and refusing to allow medication to be given covertly.
• To make a referral to the OPG due to a concern that Ms X was not acting in Ms Y’s best interests.
21. There was no referral to the OPG at this stage. The Council told me this was because circumstances had changed and Ms X was felt to be appropriately exploring alternative accommodation options in Ms Y’s best interests. However, in July, following Ms Y’s admission to hospital, matters had not progressed as hoped and some concerns remained. The Council also told me:
• It should have recorded the reason for not pursuing an OPG referral and the safeguarding concern in Ms Y’s records; and
• It should have made Ms X aware of the safeguarding concern at the time it was raised. Information sharing is assessed on a case-by-case basis according to risk. In this case there was no increased risk to Ms Y and so the concern should have been shared with Ms X.
22. Managers met in July to discuss the case. They noted a referral to the OPG had not been sent. The minutes noted the following actions to be taken:
• Referral to the OPG.
• Progress to a section 42 enquiry in relation to potential abuse of power and acts of neglect.
• Invite relevant professionals for an urgent safeguarding strategy meeting.
23. The Council submitted a written concern to the OPG in July 2024. The Council’s concern was the LPAs did not agree on some important aspects of Ms Y’s care, medication and accommodation, and may not be acting in Ms Y’s best interests.
24. There was a safeguarding strategy meeting in the middle of July. The minutes noted:
• Both LPAs had now agreed Ms Y’s needs would best be met in placement A
• The hospital discharge team had said it would go to the Court of Protection if the LPAs could not agree. Ms M had emailed the Council to say she now agreed with Ms X.
• The next steps were to await the outcome of the OPG referral and progress with the safeguarding enquiry by updating the enquiry officer.
25. There was never a safeguarding case conference. The case notes indicate the reason for the lack of progress on the case was because the Council was ‘awaiting information from the OPG.’ The records say both LPAs were made aware of the safeguarding concerns. (This is incorrect)
26. An email exchange between council officers and the OPG investigator in August indicates the OPG emailed the Council a form with questions on 5 August and the Council sent it back via a secure email on 20 August and sent the OPG a further email in 30 August asking it to confirm receipt.
27. There is no evidence of any liaison by the Council with the OPG about the OPG’s investigation between September and December 2024.
28. Ms X told us she only found out about the Council’s safeguarding enquiry late in 2024 when a social worker referred to it in a meeting.
29. Ms Y died at the end of November 2024.

2025

30. The Council ended the safeguarding enquiry in January 2025 as Ms Y had died. As the enquiry ceased before conclusion, the papers did not record an outcome. The Council told me Ms X should have been made aware the enquiry had ended.
31. The OPG wrote to Ms X saying it had no authority to continue its investigation due to Ms Y’s death. It went on to say had the investigation concluded, there would have been no action taken because the OPG received no evidence up to the date of Ms Y’s death, to substantiate the concerns raised.
32. Ms X complained to the Council in January 2025 about the matters she has raised with us. She chased the Council, but it did not respond.
33. The Council did not respond to Ms X’s complaint, although she and we chased it up several times. The Council eventually responded in August 2025, by which time we had assessed her complaint and decided to investigate. The Council’s response to the complaint said:
• It was sorry for the confusion it had caused by failing to respond to her complaint.
• It made a referral to the OPG in July 2024 because of the ongoing dispute between her and Ms M which was impacting decisions about Ms Y’s care, accommodation and medication. Both of them were highlighted in the referral. The OPG is the body best placed to investigate such concerns.
• The Council made no findings about her conduct and the referral asked the OPG to investigate.
• The Council also started a safeguarding enquiry. This is now closed with no action taken against either attorney.
• It did not inform her about the OPG referral at the time because (1) it was a confidential process and (2) the safeguarding enquiry meant there were restrictions on what could be shared.
• Communication could have been better and it was sorry for this. It should have informed her once the matter was closed.
• Where there are reasonable concerns about whether attorneys are acting in a person’s best interests, it was correct to refer to the OPG.

Comments from Ms X

34. Ms X told me:
• Section 42 of the Care Act says a council must act where there is ‘reasonable cause to suspect.’ The Council had no evidence or credible information to support the suspicion
• The decision to start a safeguarding enquiry was made for an improper reason and at a finance panel meeting, which was inappropriate
• She disputes all the allegations.

Findings

The Council carried out a safeguarding enquiry without giving her the chance to respond to allegations against her and failed to inform her of the outcome

35. There was no fault in dealing with the concerns within the adult safeguarding framework. Those concerns did not have to be factually evidenced at the time they were raised because testing of the allegations takes place at a later stage during the enquiry. Factual findings are then made at a case conference.
36. There was fault by the Council as it failed to:
• notify Ms X of the safeguarding concerns against her, did not allow her to provide comments and evidence and failed to tell her it had ended the enquiry. This was not in line with paragraph 14.131 of CSSG or its own safeguarding procedures which say a person alleged responsible should generally be made aware of allegations.
• record the reason for not making the referral to the OPG or reporting the safeguarding concerns internally to the safeguarding team in July 2025. It also inaccurately recorded Ms X had been told about the safeguarding concerns. This was not in line with our expectations as I have set out in paragraph eight.
• seek updates with the OPG about the progress of the OPG investigation post August 2024 after sending information to the OPG.
37. The Council explained it paused the safeguarding enquiry because of the OPG’s involvement. This is a matter for the Council and I have no grounds to criticise it. However, the Council should have sought updates from the OPG so the Section 42 enquiry could either progress to a case conference or be discontinued. There was drift and inaction on the safeguarding enquiry from the end of August to December 2024. This is fault.

The Council ignored her complaint and only provided a response when the LGSCO became involved

38. The Council delayed responding to Ms X’s complaint. This was not in line with the Regulations set out in paragraph seven and is fault.

The Council made an inappropriate referral to the Office of the Public Guardian (OPG) and failed to respond the OPG’s request for information promptly

39. There was no fault in referring the concern to the OPG. This is in line with paragraph 14.61 of CSSG. It was then for the OPG to take action to investigate the information received from the Council within its own powers. The OPG‘s role and remit is beyond the scope of this investigation.
40. There is no evidence of any delay in the Council responding to the OPG. The records available indicate the Council responded within two weeks of its request.

Injustice

41. The faults I have identified above caused Ms Y avoidable distress and time and trouble. She also missed out on the opportunity to respond to allegations made against her.

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Agreed Action

42. Within one month of my final decision, the Council will issue:
• A symbolic payment of £250 to reflect Ms X’s injustice.
• A written reminder to safeguarding officers that the Council’s safeguarding procedures require it to inform a person alleged responsible for harm to have a chance to respond to allegations unless this is not practicable or places the vulnerable adult at greater risk.
43. Ms X has asked us to recommend to the Council that it removes the allegations against her from Ms Y’s records and completes the safeguarding investigation. I have not made these recommendations because:
• there was no fault by the Council in raising safeguarding concerns and the records are clear there were no factual findings made.
• the main purpose of a safeguarding investigation is to protect the adult at risk. Ms Y is dead and so there is no ongoing risk to her. This would therefore be an unnecessary and disproportionate action for the Council.
44. I may also have recommended a written apology to Ms X, but I did not because Ms Y said she did not want an apology.
45. The Council should provide us with evidence it has complied with the above actions.

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Decision

46. 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