Summary: Mr X complained about the Council’s handling of his father, Mr Y’s, care and support needs during his hospital admission in February 2024, in particular its decision to make a referral to the Court of Protection. I have not investigated whether the Council wrongly applied to the Court of Protection in April 2024 or whether it should have investigated the unexplained bruises on Mr Y’s body further before deciding to carry out a safeguarding investigation as these matters are late. I have found no fault in the Council’s actions or in the length of time Mr Y remained in hospital between November 2024 and February 2025.

The complaint

1. Mr X complained about how the Council handled his father, Mr Y’s care and support needs when he was admitted to hospital. He said the Council wrongly applied to the Court of Protection (CoP), leading to Mr Y being admitted to several care settings between February 2024 and April 2025 against his wishes delaying his return home.
2. Mr X said these actions caused Mr Y avoidable distress over a 14-month period ultimately leading to his premature death. He wants the Council to be held accountable, make changes to its policies to prevent the same happening to other families and reimburse the family’s legal costs.

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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’.
4. 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)
5. As a publicly funded body we must be careful how we use our resources. We conduct proportionate investigations; completing them when we consider we have enough evidence to make a sound decision. This means we do not try to answer every single question a complainant may have about what the organisation did.
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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What I have and have not investigated

7. I have investigated Mr X’s complaint between October 2024 and October 2025.
8. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate.
9. We cannot investigate late complaints unless we decide there are good reasons. Late complaints are when someone takes more than 12 months to complain to us about something a council has done. (Local Government Act 1974, sections 26B and 34D, as amended)
10. We cannot investigate a complaint about the start of court action or what happened in court. (Local Government Act 1974, Schedule 5/5A, paragraph 1/3, as amended)
11. We cannot investigate a complaint if it is about action taken by or on behalf of any local policing body in connection with the investigation or prevention of crime. (Local Government Act 1974, Schedule 5, Section 26, paragraph 2 as amended)
12. I have not investigated events prior to October 2024 as these are late and there is no good reason to consider these now. In line with paragraph nine, this period falls outside of our jurisdiction.
13. I have not investigated the parts of Mr X’s complaint that relate to the actions of the police. In line with paragraph eleven these matters fall outside of our jurisdiction.
14. I have not investigated the parts of Mr X’s complaint that relate to the actions of the NHS. These matters were considered as part of a previous complaint from Mr X. We do not reinvestigate matters that have already been considered.

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How I considered this complaint

15. I considered evidence provided by Mr X and the Council as well as relevant law, policy and guidance.
16. 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

17. 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)

Mental capacity

18. A person aged 16 or over must be presumed to have capacity to make a decision unless it is established they lack capacity. A person should not be treated as unable to make a decision:

• because they make an unwise decision;
• based simply on: their age; their appearance; assumptions about their condition, or any aspect of their behaviour; or
• before all practicable steps to help the person to do so have been taken without success.

19. The council must assess someone’s ability to make a decision when that person’s capacity is in doubt. How it assesses capacity may vary depending on the complexity of the decision.
20. An assessment of someone’s capacity is specific to the decision to be made at a particular time.
21. If there is a conflict about whether a person has capacity to make a decision, and all efforts to resolve this have failed, the Court of Protection might need to decide if a person has capacity to make the decision.

Best interest decision making

22. A key principle of the Mental Capacity Act 2005 is that any act done for, or any decision made on behalf of a person who lacks capacity must be in that person’s best interests. The decision-maker also has to consider if there is a less restrictive choice available that can achieve the same outcome. Section 4 of the Act provides a checklist of steps decision-makers must follow to determine what is in a person’s best interests.
23. If there is a conflict about what is in a person’s best interests, and all efforts to resolve the dispute have failed, the Court of Protection might need to decide what is in the person’s best interests.

Court of Protection

24. The Court of Protection deals with decision-making for adults who may lack capacity to make specific decisions for themselves.
25. The Court of Protection may need to become involved in difficult cases or cases where there is disagreement which cannot be resolved in any other way. The Court of Protection:

• decides whether a person has capacity to make a particular decision for themselves;
• makes declarations, decisions or orders on financial or welfare matters affecting people who lack capacity to make such decisions;
• appoints deputies to make decisions for people lacking capacity to make those decisions;
• decides whether a Lasting Power of Attorney or Enduring Power of Attorney is valid; and
• removes deputies or attorneys who fail to carry out their duties.

Accredited Legal Representative (ALR)

26. An ALR - appointed by the CoP – is a specially qualified lawyer who can present a person who lacks mental capacity to conduct the proceedings themselves, usually in cases concerning welfare, care, residence and deprivation of liberty.

What happened

Background

27. Mr Y was admitted to hospital in February 2024 after becoming unwell. Unexplained bruises on his body, resulted in the hospital raising safeguarding concerns. An investigation by the police, led to the arrest of Mr Y’s wife, Mrs Y. The police put restrictions in place which meant Mrs Y was not to have unsupervised contact with Mr Y. As a result, Mr Y could not return home to live with Mrs Y when he was well enough to be discharged from hospital.
28. The Council planned to discharge Mr Y to a care home instead. Mr Y and his family wanted him to return home but as the Council assessed Mr Y as lacking capacity to make this decision, it referred the matter to the CoP. The CoP ordered Mr Y’s discharge to a care home in June 2024. In July Mr Y became unwell again and returned to hospital. While there, Mr Y expressed the wish to stay with his son, Mr X, as he still could not return home to Mrs Y. The CoP ordered Mr Y’s discharge to Mr X’s home, with carers providing support four times a day and the Council reviewing the arrangement weekly.

Matters subject to investigation

29. In early September Mr Y was discharged from hospital to Mr X’s home.
30. A short while later, the police lifted the restrictions, allowing Mr Y to have unsupervised contact with Mrs Y. However, unless and until the CoP revised its order that Mr Y had to be discharged from hospital to Mr X’s home, he therefore remained unable to return to his own home.
31. In early October during a care needs review, the Council noted Mr Y’s family asked for the care visits to be reduced to twice a day instead of four times a day to give Mr Y the flexibility to access the community. While the police investigation into Mrs Y was closed, the Council’s safeguarding investigation remained ongoing. The Council further informed Mr X it could not reduce the care visits as they were part of the court order.
32. The Council decided to hold a best interest decision meeting. The same day Mr X asked about the possibility of Mr Y returning home to Mrs Y. The Council said it had to wait for the view of an Accredited Legal Representative (ALR) before it was able to consider this further.
33. The Council said it needed to hold a strategy meeting with the police and to review the case notes about why the police investigation ended so it could decide next steps in the safeguarding enquiry.
34. A week later in October the strategy meeting took place.
35. In November 2024 Mr Y was admitted to hospital as he had an unsupervised fall.
36. In December, the Council completed its safeguarding report, which stated that, subject to the agreement of the CoP, it would recommend that Mr Y return to his own home, provided that a robust care package was put in place. Electronic sensors, designed to detect situations that may indicate Mr Y requires assistance, would also be installed, and a contract of expectations would be completed setting out the conditions of Mr Y’s return to Mrs Y.
37. The next day the hospital informed the Council that Mr Y was fit to leave the hospital.
38. In mid-December the CoP made an order that Mr Y could be discharged home, subject to the Council putting in place the safeguards and care arrangements it had recommended.
39. The care agency the Council previously instructed to deliver Mr Y’s package of care at Mr X’s home, was unable to provide the required care over the Christmas period. Instead, the Council considered discharging Mr Y into a care home.
40. It carried out another mental capacity assessment and decided Mr Y lacked capacity to decide his discharge location.
41. At the end of December the Council contacted Mrs Y to ask her opinion of discharging Mr Y into a care home instead. Mrs Y responded that Mr Y was well again and the family would only allow him to be discharged to his own home.
42. The next day the Council informed Mrs Y it had to hold a best interest meeting to make the decision.
43. In January the Council carried out a Care Act assessment and held a best interest meeting to consider Mr Y’s discharge location from hospital. It decided Mr Y could return to his own home.
44. Following the best interest decision Mrs Y agreed to the installation of an electronic sensor service as part of the recommendations stipulated in court order. Mrs Y initially refused to have this installed as they could not afford the service, but later agreed to its installation.
45. At the end of January, the Council completed Mr Y’s support plan. It stated Mr Y remained medically fit to be discharged while he was awaiting measures to be implemented at his home.
46. The Council arranged a package of care with the care agency and a few days later Mrs Y signed the contract of expectations.
47. In February 2025 Mr Y returned to his own home with a package of care. This included two care workers visiting him four times a day to meet his personal care needs, preparing meals and administering his medication.
48. In early April Mr Y was re-admitted to hospital where he passed away the next day.
49. In May 2025 Mr X complained to the Council. He said Mr Y’s bruises were found on his hospital admission in February 2024 and are a common sight linked to medication which he has taken since 2007. He said the bruises were not potentially linked to physical abuse and hence should not have been a safeguarding concern. He said the Council should have made enquiries into where these bruises stemmed from and not escalated the case to a safeguarding enquiry or made a referral to the CoP. He said this led to Mrs Y being wrongly arrested in May 2024 and Mr Y being kept away from home between February and May 2024.
50. In August 2025 the Council responded to Mr X’s complaint. It said:
• as there was a dispute following a best-interest meeting in April 2024 about Mr Y’s discharge location and whether Mr Y had capacity to make this decision, the Council had to make a referral to the CoP to make this decision;
• it did make enquiries in line with the Mental Capacity Act and it requested medical evidence to confirm the cause of the bruises; and
• It completed the necessary safeguarding investigations, enquiries, assessments, and applications to the CoP to maintain Mr Y’s safety.
51. Unhappy about the Council’s response to his complaint at stage one, Mr X escalated the complaint to the Council’s stage two.
52. In October the Council contacted Mr X and informed him it had allocated an investigator to look into his complaint at stage two. The letter also signposted him to us if he remained dissatisfied with the outcome of its investigation.
53. At this stage Mr X complained to us.

My findings

54. The matters raised by Mr X whether the Council should have made a referral to the CoP in April 2024 or whether it should have made further enquiries into the unexplained bruises on Mr Y’s body before it decided to carry out a safeguarding enquiry fall outside the scope of my investigation. In line with paragraphs 9, 12 and 14, these matters are late, or have already been considered as part of Mr X’s previous complaint.
55. The CoP ordered in mid-December 2024 that Mr Y could return to his own home, subject to specified conditions. While the Council put the court-ordered conditions in place, it considered an interim care-home placement and assessed that Mr Y lacked capacity to make the decision about this arrangement. His family did not agree to the proposed placement, and Mr Y therefore remained in hospital until his discharge in February 2025. The Council took the necessary steps to implement the conditions required by the CoP, and I have not identified any avoidable delay on its part in doing so. As a result, the Council was not at fault, it did not cause an unreasonable delay in Mr Y’s return home between mid-December 2024 and February 2025. Instead, the delay resulted from the restrictions imposed by the CoP, which the Council was required to comply with.

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Decision

56. I have not found fault.

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Investigator's decision on behalf of the Ombudsman