Summary: Miss B complained the Council did not consider all evidence in reaching its safeguarding outcome. There was fault by the Council. It failed to communicate with Miss B about its consideration of the information she raised with it and explain why this did not change the safeguarding outcome. Miss B suffered distress and frustration. The Council has agreed to apologise to Miss B, make a symbolic payment and issue a staff briefing.

The complaint

1. Miss B complains about the outcome of the Council’s safeguarding investigation regarding the care of her late father, Mr C. She says the Council has not considered all evidence and has wrongly concluded there is no evidence of negligence during the time Mr C received care between September and November 2023.
2. Miss B says her father received inadequate care and his suffering caused distress to her and the family. She would like the Council and the care provider to be held accountable for the deterioration of her father’s health between September and November 2023. She says there is evidence he was not properly cared for during this time. She would also like the care fees to be refunded for this period and care staff to be trained.

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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 may investigate a complaint on behalf of someone who has died or who cannot authorise someone to act for them. The complaint may be made by someone we consider to be suitable. (Local Government Act 1974, section 26A(2), as amended)
5. 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

6. I read Miss B’s complaint and spoke to her about it on the phone.
7. I considered evidence provided by Miss B and the Council as well as relevant law, policy and guidance.
8. Miss B 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

9. 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)

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What happened

10. This is a summary of events outlining key facts and it does not include everything that has happened in this case.
11. The Council carried out safeguarding enquiries after concerns were raised about Mr C’s care. The Council sent the outcome of its concluded enquiries to Miss B in November 2024. It told her it had concluded there was no evidence of neglect from the care provider during the time Mr C received care between September and November 2023.
12. Miss B told the Council she had reviewed the information provided by the relevant professionals and bodies, as well as the care providers care notes. As a result, she told the Council she disagreed with its conclusion. She asked the Council to further consider the care records from the time, where district nurses had left the following notes for the carers:
• Multiple observations of missing hygiene pads.
• Inadequate personal hygiene care twice.
• The absence of a catheter strap on one occasion, resulting in a pressure sore.
13. Miss B also raised a complaint with the Council about the safeguarding outcome, as she felt it was inadequate.
14. I asked the Council if it followed up with Miss B or the district nurses about the source of the information Miss B had told it about. In response, the Council told me it enquired with the district nursing team about the records, and it received confirmation there were notes from November 2023 which observed an ulcer to the leg caused by a missing catheter strap, and poor personal hygiene care.
15. However, the Council told me it failed to follow-up with Miss B and share these emails with her, and explain why this did not change the safeguarding outcome. The Council told me it recognises its communication should have been better and it apologises for this.

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Analysis

16. There was a discrepancy between the evidence Miss B referred the Council to, and the records the Council considered in helping it to reach its safeguarding conclusion. So, when Miss B told the Council about the evidence she had, the Council should have followed up with Miss B to query the source of this information and consider whether it was relevant to the safeguarding enquiry. In response to my enquiries, the Council acknowledged it did not follow up with Miss B. This was fault.
17. However, the Council did query the records with the district nursing team, which confirmed the information Miss B raised with the Council after she received the safeguarding outcome. The Council should have then further considered whether this information was relevant and decided if this impacted the safeguarding findings and outcome. The Council has told me it considered the information from the district nursing team, but this did not change the Council’s view of the safeguarding outcome. It explained the safeguarding enquiry had already been concluded based on a comprehensive review of information from multiple professionals and the evidence did not change the safeguarding outcome.
18. However, the Council was at fault for not communicating with Miss B about this. It should have informed her it had considered the information and explained why it did not change the safeguarding outcome. The Council’s failure to do so was fault. It told me it recognises it should have contacted Miss B to discuss this further, and it apologises for the oversight.
19. The identified fault caused avoidable distress and frustration to Miss B. I have made recommendations below to reflect this.
20. We have published guidance to explain how we calculate remedies for people who have suffered injustice because of fault by a council. Our primary aim is to put people back in the position they would have been in if the fault by the Council had not occurred.
21. Sometimes we will recommend a financial payment to the person who brought their complaint to us. This might be to reimburse a person who has suffered a quantifiable financial loss, or it might be more of a symbolic payment which serves as an acknowledgement of the distress or difficulties they have been put through. But our remedies are not intended to be punitive and we do not award compensation in the way a court might. Nor do we calculate a financial remedy based on what the cost of the service would have been to the provider.

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Action

22. To remedy the outstanding injustice caused to Miss B by the fault I have identified, the Council will take the following action within four weeks of my final decision:
• Apologise to Miss B for the distress and frustration caused by the Council’s failure to communicate with her about its consideration of the information she raised with it and explain why this did not change the safeguarding outcome. This apology should be made in line with our guidance Making an effective apology.
• Pay Miss B £500 to acknowledge the same as above.
23. Within three months, the Council will also remind relevant staff that when further information is presented to the Council after a safeguarding outcome is reached, that it should communicate with the family whether it has changed the outcome and why. This will provide assurance in future cases that all available evidence has been considered and prevent avoidable distress.
24. The Council should provide us with evidence it has complied with the above actions.

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Decision

25. I uphold Miss B’s complaint and find fault causing injustice. The Council has agreed actions to remedy injustice.

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Investigator's decision on behalf of the Ombudsman