Summary: The Council was at fault for not consulting with Mrs X about the outcome of a safeguarding enquiry regarding the care her mother, the late Mrs Y, received in a care home. The Council has apologised to Mrs X and said it will make service improvements. This is an appropriate remedy for the distress caused. The Council also failed to consult with the Ambulance Service during the safeguarding enquiry, but this did not cause an injustice to Mrs X.

The complaint

1. Mrs X complained the Council failed to properly investigate safeguarding concerns she raised about the care her mother, Mrs Y, received in a care home, causing distress to her and her family.

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The Ombudsman’s role and powers

2. 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)
3. We normally name care homes and other care providers in our decision statements. However, we will not do so if we think someone could be identified from the name of the care home or care provider. (Local Government Act 1974, section 34H(8), as amended)
4. We investigate complaints about councils and certain other bodies. Where an individual, organisation or private company is providing services on behalf of a council, we can investigate complaints about the actions of these providers. (Local Government Act 1974, sections 24A(1)(A) and 25(7), as amended). In this case the Council commissioned the care home so we consider the care home was acting on the Council’s behalf.
5. 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.
6. 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.
7. 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

8. I considered evidence provided by Mrs X and the Council as well as relevant law, policy and guidance.
9. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.

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What I found

Law and Statutory Guidance

Safeguarding

10. 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)
11. The purpose of the enquiry is to decide whether or not the local authority or another organisation, or person, should do something to help and protect the adult. If the local authority decides that another organisation should make the enquiry, for example a care provider, then the local authority should be clear about timescales, the need to know the outcomes of the enquiry and what action will follow if this is not done. (para 14.78, Care Act Statutory Guidance)
12. What happens as a result of an enquiry should reflect the adult’s wishes wherever possible, as stated by them or by their representative or advocate. If they lack capacity it should be in their best interests if they are not able to make the decision, and be proportionate to the level of concern. (para 14.79, Care Act Statutory Guidance)
13. Once enquiries are completed, the outcome should be notified to the local authority which should then determine with the adult what, if any, further action is necessary and acceptable. It is for the local authority to determine the appropriateness of the outcome of the enquiry. (para 14.110, Care Act Statutory Guidance)
14. Cambridgeshire County Council carries out Safeguarding Enquiries in line with the policy of the Cambridgeshire Safeguarding Adults Board.

Council Complaints Policy

15. The Council has a complaints policy for Adult Social Care. The policy gives two stages to investigation. The first stage is an Independent Investigation and the second stage is a Senior Manager Review.

What happened

16. Mrs Y had a number of health conditions. At the end of November 2024 she went to stay in a care home for respite.
17. On 10 December 2024 Mrs Y’s family called the Care Home, as they felt Mrs Y seemed low in mood in their phone call with her. The Care Home advised them Mrs Y seemed fine.
18. On 13 December Mrs Y had a social care review with Social Worker A. Mrs Y’s family were not present at the review. The review concluded Mrs Y was happy at the Care Home. The outcomes from the review were for Mrs Y to have increased support with her continence care and a referral to an Occupational Therapist for a wheelchair assessment.
19. On 14 December the Care Home called paramedics as Mrs Y had slurred speech and appeared to be leaning to one side. Mrs Y’s granddaughter, Ms Z, also went to the Care Home. After assessing her, the paramedics did not take Mrs Y to hospital.
20. On 15 December the Care Home called paramedics as Mrs Y appeared unwell. Initially the Care Home were asked to continue to monitor Mrs Y and to wait for a doctor to contact them. But the Care Home called them again as Mrs Y continued to be unwell. After assessment and consultation with Mrs Y’s family the paramedics took her to hospital. Later that day Mrs Y’s family were told she had had a stroke.
21. After Mrs Y had gone to hospital Ms Z spoke with the Council. She said the care Mrs Y had received was inadequate. The concerns she raised included:
• Mrs Y’s medication had not been correctly administered as carers told the paramedics they left her medication with her to take.
• Mrs Y had bruising to her arm and leg and redness to her buttocks.
• £20 had gone missing from her purse as well as some of her clothing.
• Staff used a hoist with Mrs Y without completing the relevant risk assessments.
• The Care Home did not properly respond to concerns Mrs Y’s family raised about her health.
22. In December 2024 Social Worker A raised a Safeguarding Concern which was triaged by Senior Social Worker B. After this Social Worker C started an Adult Safeguarding Information Gathering Form. The outcome of this was to complete a Section 42 safeguarding enquiry with recommended actions including:
• A Making Safeguarding Personal conversation to gather wishes and outcomes.
• To liaise with next of kin for their views and outcomes
• Send a Section 42 provider form to the Care Home and ambulance service.
23. Mrs Y died in hospital in January 2025.
24. Social Worker D completed the Section 42 enquiry in January 2025. The enquiry recorded that, at the beginning of January 2025, Mrs Y was too unwell to take part in a conversation about the safeguarding enquiry. The enquiry recorded the previous conversation with Ms Z, and the Social Worker spoke with Mrs X, the Care Home Manager and the hospital. The desired outcome from the enquiry was to safeguard others in the Care Home.
25. The Council sent the Care Home a Provider Enquiry Supporting Information Form for it to complete. In response the Care Home said:
• Mrs Y’s medication had been given to her correctly. On admission Mrs Y had been assessed as not able to safely manage her medication. Care staff may have told paramedics her medication was dispensed and Mrs Y then takes it independently, but this would be whilst care staff observed her.
• Body maps completed when Mrs Y went to stay at the care home indicated she had bruising on her arm and leg. Mrs Y was at risk from bruising due to taking blood thinning medication. Her skin was monitored during her stay and there were no further concerns.
• Mrs Y experienced some incontinence at the care home and initially declined support, but after the Social Care Review on 13 December agreed to support. Redness on her buttocks was monitored, with the last record being from 11 December when the redness was no worse than when she had gone to the Care Home.
• The Care Home used a hoist to transfer Mrs Y out of bed when she was unwell and needed to use the toilet. There had been no assessment made beforehand as Mrs Y had been able to walk to the toilet before becoming unwell on 14 December.
• There was no money on the inventory of items completed when Mrs Y went to the Care Home. The Manager was unable to respond to concerns about Mrs Y’s missing clothes as she did not have details of what was missing.
• It had responded to the concerns Mrs Y’s family raised about her well-being and took appropriate action when she appeared unwell.
26. In January 2025 Social Worker D concluded the Section 42 investigation could end and relevant parties would receive feedback. There was a recommendation for staff at the Care Home to be trained in recognising the symptoms leading up to a stroke and to take immediate action when concerns were raised by family or others.
27. In January, February and March 2025 Mrs X contacted the Council to request updates about the Safeguarding Enquiry.
28. In March 2025 the Council sent a copy of the Section 42 enquiry to the Care Quality Commission (CQC – the statutory regulator of care homes). It emailed a copy to Mrs X six days later. The report was sent to Mrs X by Senior Social Worker E. Mrs X called the Council the following day to say she was unhappy with the report.
29. In April 2025 Mrs X made a complaint to the Council in response to the Section 42 enquiry. In addition to the initial concerns she raised, Mrs X said:
• Mrs Y’s slippers had a strong smell or urine when she went to hospital.
• The Section 42 enquiry report gave the wrong cause of death for Mrs Y.
• The Section 42 enquiry report contained discrepancies and used the Care Home’s version of events.
• It was confusing to understand who had completed the Section 42 enquiry.
30. The Council provided a complaint response in June 2025 and said:
• The investigating Social Worker had obtained the relevant records from the Care Home.
• There was no evidence the Council consulted Mrs Y’s family about the outcome of the Section 42 enquiry. It offered an apology for this and for how it shared the report.
• It said it would raise the importance of including families in safeguarding enquiries with the Team Manager, to be disseminated to all relevant staff.
• It apologised for any distress caused to Mrs X by the Council’s use of the term ‘natural causes’ as Mrs Y’s cause of death within the safeguarding enquiry.
31. Mrs X was unhappy with the complaint response but declined a Senior Manager review of her complaint.

Findings

32. When Mrs Y went to hospital Mrs X and Ms Z raised concerns to the Council about the quality of care Mrs Y received in the Care Home. There was no evidence of fault in how the care home provided care to Mrs Y or in the steps it took when she was unwell.
33. The Council began the section 42 enquiry when Mrs Y was in hospital, it was completed after she had died. In line with statutory guidance and policy, as part of the Section 42 enquiry the Social Worker:
• Consulted with Mrs Y’s family to determine their desired outcome and to discuss what had happened.
• Spoke with the Care Home and sent a Provider Enquiry Supporting Information Form for them to complete.
• Considered Making Safeguarding Personal and the six principles of safeguarding.
• Identified an enquiry outcome.
34. The recommended actions from the Information Gathering included sending a safeguarding form to the Ambulance Service. There is no evidence to suggest the Council did this. This is fault. Having information from the Ambulance Service would have been helpful as it would have been able to offer its perspective on any concerns about Mrs Y’s care at the Care Home. However, on the balance of probabilities I do not consider this caused injustice to Mrs Y or her family as the Ambulance Service should have raised its own safeguarding concern if it had concerns about risk to Mrs Y. The Council did consult with the Safeguarding Lead from the hospital who raised no concerns and I have not identified other concerns from the available evidence from the Council or Care Home.
35. The recommendation of the Section 42 enquiry was for care staff to be trained in recognising the symptoms leading up to a stroke and to take immediate action when concerns were raised by a resident’s family. These were appropriate and proportionate recommendations to the safeguarding concerns.
36. There were five Social Workers involved in the Section 42 enquiry process, three Social Workers and two Senior Social Workers. Whilst this is not fault, the number of people involved created confusion and frustration for Mrs X and there was also a risk to the Council from the lack of continuity and oversight. This is something the Council may want to consider in other similar circumstances.
37. The Section 42 report was completed in January 2025. Mrs X asked the Council for updates between January and March 2025 but dd not receive any information. The report was reviewed by a manager and sent out in March 2025. This was over two months after the Social Worker completed the Section 42 enquiry. This delay is fault and caused frustration to Mrs X. There is also no evidence Mrs Y’s family were consulted about the outcome of enquiry. The Care Act Statutory Guidance says a council should determine any actions from a safeguarding enquiry with the adult. As Mrs Y had died, Mrs X should have been consulted as her representative. This is fault and caused distress to Mrs X.
38. The Council acknowledged the faults in its complaint response and apologised to Mrs X. It also said the Team Manager would promote the role of family in safeguarding enquiries to the relevant staff. The apology, combined with the service improvement it said it would make is an appropriate remedy for the distress caused to Mrs X.

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Decision

39. From the available evidence I find fault causing injustice for which the Council has already taken appropriate action.

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Investigator's decision on behalf of the Ombudsman