Summary: Mr X complained the Council failed to investigate safeguarding concerns he raised relating to his relative, Y’s hospital discharge in August 2024. The Council was at fault for not reviewing risks assessments relating to Y’s care sooner. However, the Council’s fault did not cause Mr X a significant enough injustice as the Council used other ways to keep Mr X updated.

The complaint

1. Mr X complained the Council failed to investigate safeguarding concerns he raised relating to his relative, Y’s hospital discharge in August 2024. He further said the Council failed to undertake a meaningful risk assessment or use the Multi-Agency Risk Management (MARM) process following Y’s discharge from hospital. He said the situation caused him and Y significant distress and left Y at risk of harm.
2. Mr X wants an apology from the Council, an independent safeguarding investigation, staff training, compensation, and an updated risk assessment reflecting his views.

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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. 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.
5. 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)
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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How I considered this complaint

7. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
8. Mr 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

Safeguarding and duty to make enquiries

9. Under section 42 of the Care Act 2014, 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 decide whether it or another person or agency should take action to protect the person from abuse.

Multi-Agency Risk Management (MARM)

MARM is a structured multi-agency approach used in adult safeguarding where risks to an adult remain high despite other interventions. It brings professionals together from different services to share information, agree on risk management plans, and work collaboratively to reduce the risk of harm.

• Brings together professionals from multiple agencies (health, social care, police, housing, etc.) to share information and agree coordinated actions.
• Is used for adults assessed as having a high level of risk that hasn’t been reduced through existing single-agency or statutory routes (Section 42 enquiries under the Care Act).
• Enables agencies to identify risks, agree responsibilities, and develop a shared risk management plan.
• Typically involves setting up a MARM meeting or meetings where representatives agree immediate actions and decide if review meetings are needed.

Multi-disciplinary Team (MDT)

10. The role of a MDT in safeguarding is to bring together professionals from different agencies to share information, assess risk, and make coordinated decisions to protect children or adults at risk of harm. By combining expertise, the MDT builds a fuller understanding of needs and concerns, agrees clear actions and responsibilities, and develops and reviews safeguarding plans to ensure timely, proportionate, and effective support that keeps the individual at the centre of practice.

Integrated Care Board (ICB)

11. An ICB is an NHS statutory body responsible for planning, funding, and commissioning local health services, working with councils and partner organisations as part of an Integrated Care System to deliver joined-up care, improve outcomes, and reduce health inequalities.

What happened

Background

12. Mr X’s relative, Y, has a hidden disability and lifelong complex needs. Since March 2024 Y has lived in a supported living care home, placement M co-funded by the Council and the ICB. Y’ s behaviour is often very dysregulated, and due to their complex needs, an MDT meets fortnightly to manage risks, and share updates with Mr X.

Y’s discharge from hospital

13. In late July 2024, Y made a near-fatal suicide attempt at the care home and was admitted to hospital, before being discharged back to placement M in early August 2024.
14. On the day of Y’s discharge from hospital Mr X contacted the Council’s out-of-hours service to raise safeguarding concerns. He said the MDT had failed to manage the risks over the past week and its actions were ineffective and inadequate. He requested a call back to discuss his concerns.
15. Following Mr X’s call to the Council’s out of hours team, the Council contacted placement M the same day to discuss safety plans for Y’s hospital discharge. The Council acknowledged Mr X’s safeguarding concerns by email
16. After returning to placement M, Y again became dysregulated. This resulted in police involvement, a night in custody, and Y being taken back to hospital. This time, Y was not admitted and instead remained in the emergency department before being told to return to placement M.
17. The day after Mr X first contacted the Council, an urgent MDT meeting was held which Mr X attended to review the circumstances of Y’s discharge. An urgent MARM meeting (06/08/24) was held with placement M, hospital, and ICB the next day to consider the risks associated with Y’s recent discharge and care options moving forward. The hospital stated it could not admit Y again, and the meeting ended without any solutions to Y’s care moving forward. The ICB advised it would provide an update on Y’s hospital situation the following day.
18. At a later meeting the same day, attended by the ICB, placement M, and the Council, the ICB advised that none of the alternative care options it had considered were suitable for meeting Y’s needs. As a result, placement M agreed to Y returning on the condition that a new, fully trained agency care team would take over Y’s support.

Y’s second return from hospital to placement M

19. Later that day, the hospital decided, in agreement with Y, for Y to return to placement M, where the new care team would provide their care.
20. On the way there, Y informed Mr X they were returning to placement M. Mr X contacted the Council’s out-of-hours team to raise safeguarding concerns about the sudden decision to send Y back to placement M. He said the Council had not put adequate measures in place to ensure Y’s safety at placement M. He requested a call back from the area team to discuss his concerns.
21. The following day, Mr X contacted the Council and the ICB to ask why he had not been informed of the decision to return Y to placement M. He referred to an established communication plan, which required updates on Y’s care to be shared with all relevant parties, and noted that this had not been followed when Y was sent back to placement M.
22. The ICB responded that Y’s out of hours discharge from hospital was an exceptional circumstance and as a result the hospital would be responsible for explaining any discharge plans to Y and family.
23. Two days later Mr X complained to the Council that he had not received a call back as requested following his initial safeguarding concerns.
24. In its complaint response the Council apologised to Mr X. It said the notes taken from the out of hours officer were not clear and as a result the team on duty the next day failed to call him back. The Council further said it had instructed its staff to improve clarity of their notes and actions as part of ongoing service improvements.
25. Mr X unhappy about the Council response escalated his complaint to the next stage.
26. In its stage two complaint response from October 2024, the Council told Mr X that following his call on the day of Y’s discharge from hospital, the Council’s out of hours team contacted Y’s care home to discuss safety plans in preparation for their return from hospital.
27. Following our enquiries the Council told us it was the hospital’s decision to send Y back to placement M when it decided Y was clinically fit to return. The hospital had agreed details of Y’s care with placement M. As a result, the Council said the situation was handled as a hospital discharge process. The hospital did not inform the Council or the ICB of its plans which it agreed with placement M following the MARM meeting earlier that day. Instead, the hospital communicated its plans with Y directly which the ICB said was typical during out of hours decisions.

Risk assessments

28. In July 2024, prior to Y’s admission to hospital, the Council reviewed Y’s original risk assessment dated April 2024. Following Mr X’s complaint about safeguarding concerns related to Y’s discharge from hospital in early August, the Council discussed these concerns within its MDT meetings which it increased in their frequency from fortnightly to weekly. It used these meetings to discuss risks and kept Mr X informed by sharing meeting notes.
29. In October 2024, the Council advised that it had requested updated risk assessments and crisis plans from all agencies involved in Y’s care, with the aim of consolidating documentation into a single aligned version. A face-to-face meeting was held in November 2024 involving the ICB, the care home, the Council, and Mr X to review the risk assessment; while amendments were discussed and made, there is no evidence that a final revised version was produced immediately afterwards.
30. Mr X told us that the severity and frequency of Y’s incidents decreased since October 2024 and Y is now being looked after by a new team at the Council since April 2025 when Y’s situation improved further. Mr X said since then the Council issued a care plan and risk assessments are now in place.

My findings

31. The hospital where Y was treated in the Emergency Department arranged for Y to return to placement M out of hours. The Council had held multiple meetings on the previous day and the same day to manage the risks associated with Y’s care at placement M going forward and expected Y to remain in hospital overnight, with the ICB providing an update on next steps the following day. However, the hospital made the decision to discharge Y back to placement M after satisfying itself that appropriate care arrangements were in place. This decision was not communicated through the agreed communication plan, and Mr X was informed by Y while they were travelling back to placement M, causing uncertainty and avoidable distress. The Council was also not informed of the hospital’s decision, and therefore the distress caused to Mr X was not the result of fault by the Council.
32. Following Y’s discharge, Mr X contacted the Council’s out-of-hours service and requested a call back the next day. Although the call was recorded and a note left for colleagues to return the call, the Council failed to do so, which it attributed to unclear case notes. The Council apologised and introduced additional training for out-of-hours staff to improve record-keeping. However, Mr X contacted both the Council and the ICB the following morning and received several updates about Y’s care and the safety measures in place. As a result, the failure to return the call did not cause Mr X a significant injustice.
33. There is no evidence the Council reviewed Y’s risk assessment following the near-fatal suicide attempt until October 2024, when Mr X requested a consolidated risk assessment from all agencies, and this delay was fault. Instead, the Council told us it increased MDT meetings from fortnightly to weekly to discuss risks and shared meeting notes with Mr X, keeping him informed of the actions taken to safeguard Y. As a result, the delay in reviewing the risk assessment did not cause Mr X or Y a significant injustice.

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Decision

34. I find no fault by the Council in the way it dealt with Mr X’s safeguarding concern.

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Investigator's decision on behalf of the Ombudsman