Summary: Mrs X complained about failings and delays in the Council’s safeguarding investigation of her mother, Mrs Y’s unwitnessed fall at a care home. We found the delays in the safeguarding investigation and failure to keep Mrs X informed or updated are fault. These faults have caused Mrs X distress and uncertainty.

The complaint

1. Mrs X complains about failings and delays in the Council’s safeguarding investigation of her mother, Mrs Y’s unwitnessed fall at a care home. Mrs X found this deeply upsetting and distressing and felt she had no choice but to move Mrs Y to another care home.
2. Mr Z is assisting Mrs X in making this complaint.

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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)
5. Under our information sharing agreement, we will share this decision with the Care Quality Commission (CQC).

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How I considered this complaint

6. I considered evidence provided by Mr Z and the Council as well as relevant law, policy and guidance.
7. Mrs 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

Safeguarding

8. 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 here

9. The following is a summary of the key events relevant to our consideration of the complaint. It does not include everything that happened.
10. Mrs Y was a resident at a care home. She has a number of medical conditions, including a diagnosis of dementia. As Mrs Y is at high risk of falls due to reduced mobility she had bed rails and a sensor mat in place to minimise her risk of falls while in her bedroom. And two carers hoisted Mrs Y from her bed to her chair.
11. Mrs X says Mrs Y had an unwitnessed fall at the care home in June 2024.
12. In the early hours of 15 June 2024 the care home called an ambulance as Mrs Y was vomiting and complaining of hip pain. The care home also informed Mrs X. Mrs Y was taken to hospital where she had surgery to repair a fractured femur.
13. On 17 June 2024 the hospital and ambulance service both raised safeguarding concerns with the Council. When the ambulance crew arrived they found Mrs Y’s leg was very deformed and she had a mid-femur fracture which they noted the care home’s nurse was not aware of. There was no explanation for how this had happened and the crew felt it was likely to be from an injury. Mrs Y was a hoisted patient and unable to mobilise at all. The referral notes Mrs X told the crew Mrs Y had been fine when she saw her on 13 June 2024. The ambulance crew said a doctor at the hospital had said it was unlikely to have just happened over night.
14. A safeguarding social worker, Officer 1 contacted Mrs X on 28 June 2024 to discuss the concerns. The records show Mrs X told Officer 1 that Mrs Y had not mobilised for approximately six months. She suspected the carers may have dropped Mrs Y when hoisting her, causing the injury to her femur. Miss X did not want Mrs Y to return to the Care Home when she was discharged from hospital.
15. Officer 1 also asked the care home to complete an internal investigation.
16. When Mrs Y was discharged from hospital Officer 1 visited her at the new care home with Mrs X to ascertain whether Mrs Y had any insight as to what happened prior to her hospital admission. As Mrs Y was unable to engage with the process Mrs X provided further details of her safeguarding concerns.
17. Officer 1 then visited the Care Home to discuss the safeguarding concerns with the home manager. They also read Mrs Y’s support plan and her care intervention notes for the period 10 to 15 June 2024 to try and establish whether Mrs Y’s fracture was sustained prior to 15 June 2024 as indicated by the ambulance crew.
18. In August 2022 Officer 1 contacted the hospital who confirmed Mrs Y’s discharge notes confirmed a fracture of the femur. Officer 1 then contacted Mrs X to provide an update. They set out the action taken and information obtained and explained they were no further forward in establishing how Mrs Y’s fracture had happened. The records show Mrs X did not want the officer to say the outcome was inconclusive and felt they were siding with the care home.
19. Officer 1 visited the Care Home again in late August 2024 to review the care notes for a wider period. They also spoke with the Care Home manager again who maintained Mrs Y was nursed in bed from 10 to 15 June 2024. And that if carers had dropped Mrs Y when transferring her, as Mrs X suggests, they would have informed the manager and completed an incident form. The most recent form was from January 2024 when Mrs Y was found on the crash mat.
20. Officer 1 could not find any case recordings to indicate how Mrs Y could have sustained a femur fracture. They contacted the hospital to try an establish how Mrs Y may have sustained a fracture. There is no record the hospital responded.
21. Mrs X was unhappy with the outcome of the investigation and asked for it to be reviewed. As Officer 1 had left the Council, the investigation was reallocated to Officer 2 who contacted Mrs X in late September 2024. Officer 2 agreed to review all of the information obtained, follow up with the hospital and make an unannounced visit to the Care Home.
22. Officer 2 visited the Care Home on 1 October 2024 and followed up with the hospital on 4 October 2024.
23. The Council’s records show that in November 2024 Officer 2 recommended the safeguarding concern be partially substantiated based on the following:
• There was no root cause analysis to reflect how Mrs Y sustained her injuries;
• While the Care Home produced an internal report, there was a lack of communication with Mrs X about Mrs Y’s wellbeing;
• Daily notes do not provide a lot of information about the care and support Mrs Y received.
24. Officer 2 noted the risk had been removed as Mrs Y no longer resided at the care home so was no longer at risk. They considered the safeguarding enquiry concluded and recommended closure.
25. Officer 2 did not communicate their findings with Mrs X and subsequently left the Council. The investigation was reallocated to Officer 3 in January 2025.
26. In February 2025 Mr Z made a formal complaint to the Council on Mrs X’s behalf. He complained about delays, a failure to collect sufficient information, Officer 1’s refusal to consider a photograph of Mrs Y’s injury and the failure to contact Mrs X or provide an update.
27. Officer 3 contacted the Care Home in March 2025 to identify what measures had been put in place to reduce further risk to other residents at the home, and the actions and learning from the case. They then wrote to Mrs X in April 2025 confirming the outcome of the safeguarding enquiry. In this letter Officer 3 apologised that the Council had not sent Mrs X a written outcome of the safeguarding enquiry started by Officer 1 and completed by Officer 2.
28. Officer 3 confirmed the Care Home had completed an internal investigation which largely focussed on the week leading up to the 14 and 15 June 2024. As part of the investigation the Care Home manager had checked accident reports and daily logs and had contacted a senior nurse who regularly visited the home for advice. Officer 3 said the Home’s internal report stated the fracture was most likely pathological and due to an injury or trauma.
29. In addition Officer 3 confirmed Officers 1 and 2 had visited the Care Home and read the care notes. Officer 2 in completing the investigation noted the care home acknowledged:
• their care and practices in supporting vulnerable adults with osteoporosis needed to improve;
• that staff needed to complete more robust recording;
• all unexplained bruising were to be raised as safeguarding concerns
• risk assessments and care plans needed to be updated and more detailed recording was required.
30. To achieve this staff would receive additional training and through team meetings staff were made more aware of the dangers of adults with osteoporosis being more susceptible to getting fractures.
31. Officer 3 confirmed the safeguarding team recognised that Mrs Y may well have had the fracture before the morning of 15 June 2024. They also confirmed the outcome of the safeguarding enquiry was partially substantiated.
32. As Mrs X remains dissatisfied, Mr Z has asked the Ombudsman to investigate her concerns. Mr Z complained the Council had not carried out a re-investigation but had instead relied on the findings of the Care Home’s internal investigation. He also complained the Council had not responded to their concern that it had failed to review the photograph of Mrs Y’s injury. In addition Mr Z complained the Council had not sent Mrs X a copy of the safeguarding enquiry report. Nor had it explained the basis of its view that Mrs Y may well have had the fracture before 15 June 2024.
33. In response to our enquiries the Council acknowledges there was a delay in Officer 1’s initial contact with Mrs X in June 2024. It says it would ordinarily expect contact to be made within a few days.
34. The Council disputes that officers failed to collect sufficient evidence to come to a view. It says key information was gathered. It received the internal report from the Care Home on 15 July 2024 and Officers 1 and 2 visited the home to discuss the concerns and view the care records. The Council also asked the hospital safeguarding team if a medic would be able to state the cause of the fracture Mrs Y sustained. No doctor provided any account. The Council states the photograph of the injury would not have added to the key focus of the safeguarding enquiry, which was - had there been neglect by the care home?
35. Given Mrs X’s view that there was an act of negligence at the care home, the Council reallocated the safeguarding enquiry to be looked at again. It says no new significant information was uncovered by these reviews as all key information available had been gathered.
36. The Council says its Safeguarding Team recognises the importance of completing safeguarding enquiries in as timely a manner as possible. It acknowledges this enquiry had delays which have added to the time taken and apologises.

Analysis

37. The Ombudsman does not act as an appeal body. It is not the Ombudsman’s role to decide whether or not safeguarding enquires are substantiated; that is the Council’s job. Our role is to review the process by which decisions are made, and where we find fault, to determine whether a significant injustice was caused to the individual complainant.
38. It is clear that there were delays in the process which amount to fault. There were also failings in communication and Mrs X was not always kept informed of the progress of the enquiries. The records show Officer 2 completed the enquiries in November 2024 but did not inform Mrs X of the outcome. Then, although investigation was reallocated in January 2025, Officer 3 did not contact Mrs X to confirm the outcome for a further three months. These failing in communication are fault.
39. I consider the Council should make a symbolic payment to Mrs X to recognise the distress and uncertainty she experienced as a result of the delays and poor communication.
40. Mrs X complains the safeguarding investigation was inadequate and that officers failed to collect sufficient evidence to reach a sound view. However I am satisfied the Council took account of all relevant evidence and followed a proper decision making process.
41. The documentation does not support Mr Z’s view that the Council did not carry out its own investigation but rather relied on the findings of the Care Home’s internal investigation. Officers discussed the concerns with both Mrs X and the care home manager. They visited the care home several times and reviewed Mrs Y’s support plans and care records for the weeks leading up to her hospital admission. Officers also attempted to obtain a medical view on how Mrs X could have sustained a fractured femur.
42. There is no dispute Mrs Y sustained a fractured femur and whether or not officers viewed a photograph of the injury would not change or add to this.
43. I recognise Mrs X will be disappointed the Council has not been able to establish how Mrs Y sustained a fractured femur, but I do not consider this to be fault by the Council.

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Action

44. The Council has agreed to apologise to Mrs X and pay her £250 to recognise the distress and uncertainty the delays and poor communication caused her.
45. We publish guidance on remedies which sets out our expectations for how organisations should apologise effectively to remedy injustice. The organisation should consider this guidance in making the apology I have recommended in my findings.
46. The Council should take this action within one month of the final decision and provide us with evidence it has complied with the above actions.

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Decision

47. 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