Summary: Mr B complained about the way the Council handled an incident involving his son, Mr C, during transport to college and the subsequent safeguarding investigation. We found the Council’s initial decision-making process was flawed and it delayed excessively on several occasions causing distress to Mr B and Mr C. The Council has agreed to apologise to Mr B and Mr C, make a symbolic payment, provide services to him and improve its procedures for the future.

The complaint

1. Mr B complained on behalf of his son Mr C, that:
• the transport staff commissioned by the Council, supporting Mr C in September 2024 failed to effectively manage his needs or communicate properly with him or the police, leading to Mr C being restrained and handcuffed by the police and threatened with being sectioned.
• the Council failed to carry out a proper safeguarding investigation following the incident including:
1. failing to carry out a transparent and thorough initial investigation leading to the case being reopened after several months;
2. delayed without reason in sending the minutes of the meeting in January 2025;
3. failed to communicate properly with Mr B throughout this period;
4. delayed excessively in sending Mr B the final safeguarding enquiry report; and
5. failed to respond to his complaint properly.
2. Mr B said this incident caused Mr C significant avoidable distress and the subsequent handling of the safeguarding enquiry and complaint caused Mr B significant distress.

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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 Mr B and the Council as well as relevant law, policy and guidance.
6. Mr 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

7. 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

8. Mr C is autistic and non-verbal and lacks capacity to make decisions. Mr B is a court-appointed deputy able to make decisions on Mr C’s behalf.

The incident

9. Mr C regularly attends college, and the Council commissioned a transport service (Transport X) to transport him to and from the college. In September 2024 Transport X was taking Mr C to college with two transport assistants. While stuck in traffic on a busy main road, Mr C suddenly became agitated and attempted to assault one of the assistants. The driver stopped the car in the road, the assistants got out of the car and flagged down a passing police car. The police officers handcuffed Mr C as he was distressed and they could not control his behaviour. The police considered taking him to hospital (with a view to sectioning him under the Mental Health Act) but decided not to when a member of staff from the college passing by intervened and calmed Mr C down. The police had also spoken to Mr B by this point who said that taking Mr C to hospital would cause him significantly more stress.
10. The following day the college and the police informed the Council of the incident and said Mr C had sustained bruising. The Council started the safeguarding process and allocated the case to a social worker (SW) who arranged a multi-disciplinary meeting (MDT). SW also spoke to Mr B to gain his views.
11. The Council’s Transport Service carried out its own investigation. The report identified two unsafe behaviours from Transport X staff:
• Leaving the vehicle and not reporting this immediately to college staff or their line manager.
• Not using any de-escalation to calm Mr C down.
12. The report identified a possible recommendation for refresher training for the transport assistants in safeguarding passengers and positive behaviour training to provide different techniques.
13. The MDT took place on 3 October 2024. SW explained she had tried to speak to the travel assistants and the driver, but Transport X would not allow it. It had directed SW to the manager of the Council’s transport team. Mr B said he had not been able to identify triggers for the behaviour on that day and said Mr C now had new transport in a larger vehicle which was working fine. He felt the police involvement using handcuffs had been disproportionate. It was agreed that SW would gather more information, from the family, college, transport team and the police, follow-up with the safeguarding team and feedback to MDT.

Safeguarding decision 1

14. On 9 October SW fed back her initial findings and conclusions to all parties: she was closing the case as the safeguarding threshold had not been reached.
15. On 17 October two senior officers emailed all parties to explain the outcome of the safeguarding enquiry. They were not going to proceed with an investigation because:
• There was no evidence of abuse or neglect; the bruising was attributable to police attempts to manage the immediate risk and not mistreatment.
• The behaviour escalation was sudden, even to staff familiar with Mr C.
• No concerns had been passed from the college to the transport service prior to the journey.
• The travel assistant reported Mr C gave no indication of distress until that point in the journey.
16. For these reasons the Council concluded the safeguarding threshold was not met and recommended future risk preventions instead, to consider how Mr C could best be supported during transport and what could be learnt from the incident in the taxi.
17. The report did include the fact that the police were not informed by the travel assistants of Mr C’s health conditions, but the report concluded that given Mr C’s presentation it is unlikely to have changed the Police actions. Mr B disagreed with this conclusion.
18. Following disagreement from the college and Mr B with the conclusion, the Council held an internal meeting with senior staff to review the case. It upheld the decision that the threshold was not met and the risk mitigation plan was a proportionate response.

Safeguarding decision 2

19. But in December 2024 the Council considered that more discussion was needed as it had received further information from the college and a neighbouring council. So, another MDT was held on 10 January 2025, which Mr B attended. The meeting agreed the threshold was met so SW would reopen the case and carry out a full safeguarding enquiry. The Chair said the report would be sent out within four weeks. The Chair also apologised for the incident and expressed regret for the frustration caused and emphasised the need for transparency and accountability.
20. On 14 February the Chair of the meeting said they were not happy with the transcript of the meeting, and the minutes needed further work so would be sent out in a week. Mr B chased the Council, and it agreed to send them out by the end of February. SW sent out the minutes to all parties on 7 April and apologised for the delay but did not provide any reasons. The minutes were short, only a page and a half long.

Formal complaint

21. On 4 April Mr B complained about the delay and lack of progress with the safeguarding investigation. The Council responded on 13 June, saying it had carried out a full enquiry, and the report would be sent to him by 24 June. It summarised the key findings:
• The police had not been informed of Mr C’s health conditions, and they had apologised for the distress caused.
• The police had committed to reviewing the incident through its learning and development team.
• The importance of sharing vital information about service users had been reinforced with the transport team.
22. The Council noted Mr C had been referred for art therapy to help with the impact of the incident, he had a new driver and escort with relevant training, a new risk assessment had been completed for him and refresher training on safeguarding and positive behaviour support, had been provided to the travel assistants involved in the incident. It had also implemented some new measures to its procedure for transport service-users to ensure consistent and informed support.
23. The next day Mr B requested a review of the complaint at stage two of the Council’s complaints procedure. On 23 June the Council replied apologising for not including the paragraph explaining that as the complaint was about Adult Social Care provision, it was a one stage process, and he should now complain to our service.
24. By 8 July Mr B had not received the report, so he complained to us.
25. The Council sent Mr B the report on 5 December with a letter of apology, but no explanation for the delay. Mr B replied on 14 December asking for the reasons for the delay and pointing out various discrepancies and inaccuracies in the report, including, the transparency, thoroughness and competency of the initial investigation report, the initial conclusion that the safeguarding threshold was not met and the inexplicable delay in sending out the minutes of the MDT in January.
26. In response to my enquiries the Council has explained the following:
• The AI system used to transcribe the January meeting failed, capturing almost none of the discussion. This required reconstruction of the minutes and sign-off causing delays.
• The manager involved with the final safeguarding report was absent from work, hence the delay in sending it out.

Findings

Incident – September 2024

27. All parties agree that Mr C’s behaviour escalated suddenly and unexpectedly in a situation that had taken place many times before. It appears it could not have been predicted as the travel assistants knew him well. However, the manner in which the incident unfolded raised significant concerns for Mr B and meant he questioned whether his son was safe in the care of the transport service. He considered stopping the car in a busy street exacerbated Mr C’s distress, the involvement of the police was disproportionate and the handcuffs led to bruising, and the assistants did not tell the police about Mr C’s health conditions.
28. I understand the situation was difficult to handle and the travel assistants felt their safety was at risk which accounted for the sudden decision to stop the car in an inappropriate location. It is unclear what the aim of the stop was beyond the travel assistants being able to get away from Mr C. But then Mr C was left alone and very distressed, which would suggest he was at risk. It was fortunate that the police were passing and more so the member of college staff who was able to calm him down. Without this intervention it appears likely he may have been taken to hospital and possibly sectioned, which would have greatly exacerbated Mr C’s distress.
29. Given these circumstances I am unable to say the incident happened due to fault by any party but the way it was handled was open to question. The assistants did not try any de-escalation techniques and did not inform the police of Mr C’s health conditions which meant they could not respond to the situation in a fully informed way and Mr C was potentially at risk of even further distress.

Safeguarding decision 1

30. The initial investigation by the transport team manager concluded that these two issues were possible faults which should be addressed with training. So, the subsequent decision made by senior officers in October 2024, that it was not a safeguarding matter, does not appear to flow from the evidence. I understand Mr C was no longer at risk because he had new transport arrangements, the reasoning for the decision focussed entirely on the sudden and unexpected nature of Mr C’s behaviour. It failed to mention the possible fault by the travel assistants or the potential risks of the situation Mr C was left in that could potentially recur. So, it did not properly address Mr B’s concerns.
31. I also consider the conclusion that the failure to tell the police about Mr C’s conditions, did not affect the outcome, was speculation, not supported by the evidence. This was fault which caused uncertainty to Mr B as to whether the incident had been properly considered.
32. At this stage I do not consider there had been any significant avoidable delay: Mr B was aware of the decision by telephone on 10 October and in writing a week later, five weeks after the incident.

Safeguarding decision 2

33. The Council changed its mind just over six weeks later, due to input from the college, Mr B and other third parties. This led to a further meeting and a decision that the threshold was met, so an investigation would be carried out by the original social worker who dealt with the enquiry in September 2024. The meeting also generated an apology for the incident and the investigation to date. This appears to have corrected the initial flawed decision and shows the process working correctly.
34. The final report included a finding of fault by the travel assistants: a failure to inform the police of Mr C’s conditions and the lack of de-escalation techniques and indicated training and other procedural changes had taken place which showed that the second investigation was more through and addressed Mr B’s concerns. So, I have not found fault with the second decision-making process, beyond the significant delay described below.

Delay

35. The Council significantly delayed in producing both the minutes of the meeting in January 2025 and completing the investigation. The former should have been sent out within a week of the meeting (by 17 January) but were actually sent out on 7 April, nearly three months later. Given that the minutes were less than a page and a half long, this delay was fault, exacerbated by the complete lack of explanation for the length of the delay. It was only in response to my enquiries more than a year after the meeting, that the Council explained a failure of the minutes transcription had caused the problem. The delay would still be fault, but a proper transparent explanation would have helped Mr B understand the situation much more clearly.
36. The proposed timescale for the investigation was four weeks, so it should have been completed by 8 February 2025. It was not completed until June 2025 mainly due to the delay with the minute production. This avoidable delay of four months was fault which caused further distress to Mr B. The failure to include the correct information about the complaint process caused Mr B some time and trouble as he was not aware he could complain to us.
37. At this point Mr B had an overview of the report through the complaint response. But a third delay of almost six months in sending Mr B a copy of the investigation report was inexcusable and greatly exacerbated Mr B’s injustice leading to a loss of faith in the process. Again, the Council failed to provide any explanation for this until responding to my enquiries and the explanation itself was weak, doing little to justify the length of the delay.
38. It also highlights a weakness in both the complaint and safeguarding processes: I would expect them to have some checks and balances to pick up work due to staff absence and prevent such excessive delays occurring.

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Action

39. In recognition of the injustice caused to Mr B and Mr C, I recommend the Council within one month of the date of my final decision:
• apologises to Mr B and makes a symbolic payment of £800 (£300 for the impact on Mr C for the handling of the incident and £500 for Mr B’s uncertainty and frustration from the repeated and cumulative delays in completing the safeguarding investigation);
• reviews Mr C’s risk assessment to ensure it fully recognises the risks associated with Mr C’s conditions; and
• ensures the art therapy agreed in January 2025 is provided.
40. I also recommend within two months, the Council reviews:
• its complaints process to ensure there is a check that actions agreed in a complaint response are implemented within the specified timescale; and
• its safeguarding process to ensure investigations are completed within a reasonable timeframe and that checks are in place to identify and resolve delays promptly when they occur.
41. The Council has agreed to my recommendations and should provide us with evidence it has complied with the above actions.

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Decision

42. I find fault causing injustice. The Council has agreed actions to remedy injustice.

Investigator’s decision on behalf of the Ombudsman

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Investigator's decision on behalf of the Ombudsman