Summary: Mrs X complained the Council did not ensure her child, C, received the short breaks provision in their Education, Health and Care plan and wrongly refused her request for direct payments to arrange this herself. She also said the Council failed to assess her needs as a parent carer. There was fault by the Council which meant C missed short breaks provision, Mrs X did not receive a parent carer’s assessment and was caused avoidable distress, time, and trouble. The Council agreed to apologise, pay a financial remedy, offer Mrs X a parent carer’s assessment, write to other families who may have been affected, and improve its practice.

The complaint

1. Mrs X complains the Council did not:
• ensure her child, C, received the provision set out in their Education Health and Care Plan (EHC plan) from early 2020 to mid-2022, and did not meet their needs as a disabled child;
• properly consider Mrs X’s request in 2021 for a direct payment to arrange C’s provision herself because its policy about this is unlawful;
• tell Mrs X the outcome of its assessment of C’s needs as a disabled child at the end of 2021; and
• consider Mrs X’s requests during this time for a parent carer’s assessment.
2. Because of this Mrs X says C did not receive provision named in their EHC plan for two years and became isolated and withdrawn. Mrs X also says this meant she did not get a break from caring during this time and spent her own money to replace the provision. She wants the Council to:
• apologise;
• consider her request for direct payments;
• ensure provision is in place which meets C’s needs, either arranged by the Council or by Mrs X using direct payments;
• carry out a carer’s assessment for Mrs X and ensure she gets breaks from her caring responsibilities; and
• change its policy about direct payments for disabled children.

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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 an injustice, we may suggest a remedy. (Local Government Act 1974, sections 26(1) and 26A(1), as amended)
4. The Local Government Act 1974 sets out our powers but also imposes restrictions on what we can investigate. 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)
5. When considering complaints, if there is a conflict of evidence, we make findings based on the balance of probabilities. This means we will weigh up the available relevant evidence and base our findings on what we think was more likely to have happened.
6. This complaint involves events that occurred during the COVID-19 pandemic. The Government introduced a range of new and frequently updated rules and guidance during this time. We can consider whether the council followed the relevant legislation, guidance and our published “Good Administrative Practice during the response to COVID-19”.
7. We may investigate matters coming to our attention during an investigation, if we consider that a member of the public who has not complained may have suffered an injustice as a result. (Local Government Act 1974, section 26D and 34E, as amended)
8. 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(i), as amended)

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How I considered this complaint

9. I considered:
• information provided by Mrs X and discussed the complaint with her;
• documentation and comments from the Council;
• relevant law and guidance;
• legal advice about the Council’s policies; and
• the Ombudsman’s Guidance on Jurisdiction and Guidance on Remedies.
10. Mrs X and the Council had an opportunity to comment on my draft decision. I considered any comments received before making a final decision.
11. Under our information sharing agreement, we will share this decision with the Office for Standards in Education, Children’s Services and Skills (Ofsted).

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What I found

The Council’s duties to children in need

12. The Children Act 1989, section 17, requires councils to safeguard and promote the welfare of ‘children in need’ in their area, including disabled children, by providing appropriate services for them. All disabled children are regarded as ‘children in need’ and entitled to an assessment under section 17. When a council is assessing a child under section 17 it is required to consider whether it is necessary to provide various services including “short breaks”, which allow the child to participate in activities and their parent(s)/ guardian(s) a break from caring.
13. The statutory guidance on child safeguarding, ‘Working together to safeguard children 2018’, says where a Council accepts a referral under section 17, it must lead a multi-agency assessment, compete it within 45 working days, and inform the family of its decisions in writing.

Education Health and Care (EHC) plans

14. A child with special educational needs (SEN) may have an Education Health and Care (EHC) plan. This sets out the child’s needs and the arrangements that should be made to meet them.
15. An EHC plan is set out in sections, including:
• section B – the child’s special educational needs;
• section D – the child’s social care needs which are related to their SEN or to a disability;
• section F – the SEN provision required by the child; and
• sections H1 and H2 – any social care provision which must be made or is reasonably required for the child. Support provided by Early Help or under section 17 of the Children Act should be included in section H2.
16. Section 36(2) of the Children and Families Act 2014 defines an EHC assessment as including an assessment of the child’s social care needs. Where a child is not previously known to social care this will require a new assessment to identify if there are social care needs which need to be included in the EHC plan.
17. The Council is responsible for ensuring arrangements specified in the EHC plan are put in place. We can look at complaints about this, such as where support set out in the EHC plan has not been provided, or where there have been delays in the process.
18. Statutory guidance ‘Special educational needs and disability Code of Practice: 0 to 25 years’ (‘the Code’) sets out the process for producing and reviewing EHC plans. The guidance is based on the Children and Families Act 2014 and the Special Educational Needs and Disability (SEND) Regulations 2014. The Code says:
• councils must review EHC plans as a minimum every 12 months. The review process enables changes to be made to the plan, so it remains relevant to the child’s needs and desired outcomes. A council can require a school to convene and hold an annual review meeting on its behalf;
• within four weeks of a review meeting, a council must notify the child’s parent(s)/ guardian(s) of its decision to maintain, amend or discontinue the EHC plan; and
• if a council decides to amend the plan, it should start the process of amendment “without delay”. Following comments from the child’s parent(s)/guardian(s), if a council decides to continue to make amendments, it must issue the amended EHC plan as soon as practicable and within eight weeks of the date it sent the proposed amendments to the parent(s)/guardian(s).

Direct Payments and personal budgets

19. Councils must ensure a child receives the provision set out in their EHC plan. They usually do this by funding an appropriate setting, such as the child’s school, to provide the necessary support. Alternatively, a council may make a direct payment to the child’s parent(s)/guardian(s) so they can organise the provision themselves.
20. Under section 17(A) of the Children Act 1989, where a council has assessed a disabled child as having needs which are eligible for support, they are entitled to a service, or a direct payment, that is sufficient to meet their needs. Section 17(11) states a child is disabled if they suffer from “mental disorder of any kind”. The SEN Code states councils have a duty to offer direct payments for services they may provide to children with disabilities, or their families, under section 17 of the Children Act.
21. For a parent or guardian to request a direct payment, a council must first identify a personal budget. This is the notional amount of money needed to pay for the child’s provision. It can include funding from education, health, and social care. Section 49 of the Children and Families Act 2014 says a council that maintains an EHC plan must prepare a personal budget if asked to do so by the child’s parent(s)/guardian(s). The SEN Code and the SEN (Personal Budgets) Regulations 2014 say a parent or guardian can request a personal budget and direct payments at any time while an EHC plan is being drafted or reviewed.

The Council’s position on direct payments

22. The Council’s policy on direct payments for disabled children says:
• children who have an EHC plan, and their parent(s)/guardian(s), have the right to request a personal budget. This may contain elements of education, social care, and health funding, which may be delivered by direct payments;
• direct payments are available for social care provision without having an EHC plan. However, it only provides this to children who satisfy the eligibility criteria for its Disabled Children’s Team and it has assessed as having a “qualifying social care need over and above what universal and targeted services can provide”;
• direct payments can be used for things like SEN provision specified in an EHC plan, or an alternative short breaks service offer where this is agreed by the Council’s “Short Breaks Panel”; and
• where the Council decides not to make direct payments it must inform the child’s parent(s)/guardian(s) in writing of its decision and reasons, and their right to request a review of the decision.
23. The Council publishes details of its short breaks offer. This sets out a graduated approach to short break services with different eligibility criteria as follows:
• Universal Provision (Level 1) – services available to all children and young people and their families including after-school clubs, children’s centres, and sport clubs.
• Targeted Provision (Level 2/3) – additional or short-term support, from services targeted for children with a disability. These services can be accessed directly by self-referral or via an assessment by the Council’s “Early Help” service.
• Specialist Provision (Level 4) – specialised and longer-term support from specialist services for children with complex needs. Access to these specialist services requires a social care assessment via the Council’s Disabled Children’s Team. Only children at level 4 are eligible for direct payments.
24. In response to our enquiries, the Council said to meet the eligibility criteria for its Disabled Children’s Team, a child must have “a permanent and substantial impairment resulting in a functional disability, which affects their daily living”. It also said the criteria does not include children diagnosed with Attention Deficit Hyperactivity Disorder, HIV, or a psychiatric illness, unless they have other disabilities which meet the eligibility criteria.

Parent carers

25. Assessments under section 17 of The Children Act 1989 should take account of the needs of the whole family. While some services may be offered directly to the disabled child, services may also be offered under section 17 to parents or siblings.
26. Councils are required to provide short breaks services to help family carers of disabled children to continue to provide care, or to do so more effectively, by giving them breaks from caring. The services offered must be set out in a ‘short breaks statement’ and include details of any eligibility criteria. (Children Act 1989, Schedule 2 paragraph (6)(1)(c), Breaks for Carers of Disabled Children Regulations 2011)
27. Section 97 of the Children and Families Act 2014 places specific duties on councils to assess the needs of carers with parental responsibility for disabled children. Councils have an obligation to assess parent carers on the “appearance of need”, or if an assessment is requested by the parent, and to provide a written copy of the assessment to the parent carer.

Complaints about children’s social care

28. The Children Act 1989 Representations Procedure (England) Regulations 2006 set out a three-stage procedure for councils to follow when looking at complaints about children’s social care services. The accompanying statutory guidance, ‘Getting the Best from Complaints’, explains councils’ responsibilities in more detail.

What happened

29. Mrs X’s child, C, has special educational needs and an EHC plan. They also receive social care support from the Council. C has received short breaks for several years. The short breaks are provided by Service A, which is a Council-run service, so from this point forwards I will refer to this as the Council’s short breaks service. The Council includes its short breaks service as an example of “Targeted Provision” in its published short breaks offer, referred to at paragraph 23. At the start of 2020, C was nine years old and the Council had last issued them with a final EHC plan in 2016. The 2016 EHC plan referred to the Council’s short breaks service under C’s social care needs, in section D of the plan.
30. In March 2020, the Council suspended the short breaks service C had been attending, because it involved activities within the community which were no longer possible due to COVID-19 restrictions. C’s school also closed. The Council offered a short breaks service of a different format as an alternative and Mrs X accepted this offer.
31. The Council said:
• C attended the alternative-format short breaks service until September 2020, when Mrs X said they no longer needed a place as their school was re-opening;
• in January 2021 C’s school closed again so C attended some alternative-format short breaks at Mrs X’s request;
• C returned to school full time in February 2021 and stopped attending the alternative-format short breaks; and
• C attended the alternative-format short breaks again from May to August 2021 after Mrs X requested support.
32. During the summer of 2021, Mrs X asked the Council for a direct payment so she could arrange short breaks for C herself, not provided by the Council. The Council said the family were not eligible for direct payments because C was not eligible for statutory support from the Council’s Disabled Children’s Team. It said C was instead receiving short breaks via the Council’s Early Help service.
33. At the end of August 2021, C stopped attending the alternative-format short breaks following an incident during one of the short breaks. Mrs X said the Council told her C could no longer attend because it could not meet their needs. The Council said this was not the case and C could have continued accessing its short breaks service.
34. Mrs X said she complained several times to the Council’s special educational needs (SEN) team that C was not receiving short breaks specified in their EHC plan but did not receive a response. She therefore complained directly to a senior member of staff in late September 2021. The Council told Mrs X it had logged her complaint under the statutory children’s complaints procedure, as described at paragraph 28.
35. A month later, because of Mrs X’s complaint, the Council began an assessment of C under section 17 of the Children Act 1989, as described at paragraphs 12 and 13. In response to our enquiries, the Council said this was to decide if C met its criteria to receive support from its Disabled Children’s Team. During the assessment the Council visited Mrs X and C in early November 2021 to seek their views. It completed the assessment 57 working days after it accepted it should carry one out.
36. After the Council’s assessment visit to Mrs X, over the next five months Mrs X chased the Council several times about the outcome of the assessment and her associated complaint. The Council’s complaints team responded once to say it would look into the issues and update her further but did not follow up on this.
37. Mrs X came to the Ombudsman in April 2022. The Council told us it was still considering Mrs X’s complaint, so we told Mrs X the Council would need to respond before we considered it.
38. Two months later the Council responded to Mrs X’s complaint and arranged for C to start attending short breaks again. The Ombudsman then began our investigation. In late June 2022, C started attending the Council’s short breaks service. In late July 2022, they also began attending the community-based short breaks format which the Council had originally suspended due to COVID-19.
39. In late August 2022, we sent enquiries to the Council as part of our investigation. Shortly after this, the Council offered Mrs X direct payments to arrange short breaks for C herself, which Mrs X declined because the original community-based short breaks she wanted for C were now running again.
40. At the end of September 2022, the Council issued a final EHC plan for C. This named the Council’s short breaks service as special educational provision required by C under section F of the plan. In response to our enquiries, the Council said this was an error and it planned to review C’s EHC plan to remove this reference to its short breaks service in section F.

My findings

The Ombudsman’s jurisdiction

41. As described at paragraph 4, we cannot investigate late complaints unless we decide there are good reasons. In this case, Mrs X came to the Ombudsman in April 2022, so we would usually only look at what happened after April 2021. However, I decided to look at what happened from the point the Council suspended its original short breaks format in March 2020, because of the significant delays in the Council responding to Mrs X’s complaint.

C’s Education Health and Care (EHC) plan

42. The Council did not issue any final EHC plans for C from 2016 until September 2022, after Mrs X came to the Ombudsman. During the period I investigated, C’s school provided EHC plan annual review paperwork to the Council in both 2020 and 2021. On both occasions the Council decided it should issue an amended plan but failed to do so. This was fault. However, I do not consider this caused the family an injustice. Mrs X told me she had no concerns about C’s EHC plan or SEN provision other than that he had missed short breaks, which I will address later in this decision statement.
43. As described at paragraph 15, councils should include any support provided to a child by Early Help, or under section 17 of the Children Act, in section H2 of their EHC plan. The Council provided conflicting information to Mrs X about whether the short breaks it provided to C was part of their EHC plan provision. This was fault which caused Mrs X confusion, for which the Council should provide a remedy.

January 2022 single assessment

44. The Council took 57 working days to complete its single assessment, which was longer than the 45 working days required by statutory guidance. This was fault. However, based on the evidence my view is if the Council had completed the assessment on time this would not have resulted in a different outcome.
45. The Council’s records of its November 2021 assessment visit to the family show it explained the outcome of the assessment to Mrs X verbally. However, the Council did not properly follow up on the assessment by sharing its report to confirm the outcomes in writing and seek Mrs X’s agreement. This was fault. Because of this Mrs X said she was not clear on the outcome or what the next steps should be. She chased the Council about this in February 2022, but it did not respond, which was also fault. The Council should act to remedy the confusion it caused.

Short breaks provided to C

46. Regardless of whether C should have been receiving the short breaks via their EHC plan provision, or via children’s social care services, the Council accepts it assessed C as needing short breaks. Therefore, the family was entitled to this support throughout the period I investigated.
47. We recognise councils had to offer alternative services in some areas due to COVID-19 restrictions. The Council is not at fault for temporarily changing the format of its short breaks service. I am satisfied evidence shows the alternative-format service was suitable for C’s needs and aligned with the outcomes that short breaks provision was intended to achieve for them. I am also satisfied there were times when C did not attend the alternative-format service because Mrs X decided not to send them. Therefore, my view is the only period where C missed short breaks due to fault by the Council, was from the start of September 2021 until the end of June 2022. This is because:
• C stopped attending the alternative-format short breaks following an incident in late-August 2021. Mrs X told us at this point the Council told her its short breaks service could not meet C’s needs. There was no evidence it said this. However, correspondence from the time shows Mrs X thought staff had told C they could not attend anymore due to their behaviour. When Mrs X queried this, the Council clarified C could continue to attend, and offered to re-assess C via its Early Help service. Mrs X’s response indicated she accepted the offer of an assessment and sought to further clarify the Council’s position on whether C could continue to attend its short breaks service. The Council failed to respond to Mrs X’s latest email about this and did not take any steps to arrange the assessment it had offered. This was fault which I consider contributed to C missing short breaks from this point;
• Mrs X complained a month later that C was still not receiving short breaks. The Council took a further month to accept it should arrange a single assessment. As described above, the Council then took longer than it should have to complete the assessment, failed to properly communicate the outcome to Mrs X, and failed to respond when she repeatedly chased this. Throughout this time the Council knew C was not receiving short breaks and took no steps to address this until after Mrs X came to the Ombudsman.
48. The Council should remedy the distress caused to Mrs X and C by the fact C did not receive short breaks from the start of September 2021 until the end of June 2022.

Request for direct payments

49. The Council accepted C was eligible for “targeted” short breaks provision, which by the Council’s definition is for children with a disability. However, although the Council accepts C is disabled, it decided they were not eligible for a direct payment because they did not meet the criteria for assessment by its Disabled Children’s Team. The Council was at fault in its refusal to consider Mrs X’s direct payment request because:
• C’s school carried out an annual review of their EHC plan in July 2021, around the same time Mrs X first asked for a direct payment. As I have already explained, the Council failed to have proper oversight of the EHC plan review process and did not issue an amended final plan in 2021 as it should have. It therefore did not consider the direct payment request as part of the review, as it should have;
• C is entitled to direct payments under the Children Act 1989 because they are disabled according to the Act’s definition under section 17, so the Council was wrong to refuse to consider the request; and
• the Council’s policy on direct payments for disabled children applied in this case is a matter the Ombudsman has previously considered in case ref 20012558. In that case we decided the Council’s policy did not comply with the Children Act 1989 or the Children and Families Act 2014, and the Council agreed to review its policy. In Mrs X’s case, the Council’s policy wrongly restricted her entitlement to direct payments because C was only receiving support from its Early Help service, not its Disabled Children’s Team.
50. The Council accepted our previous recommendation that its policy was wrong in December 2021, before it completed its assessment of C in January 2022. However, it still decided to restrict access to direct payments in line with a policy we had told it was not compliant with relevant legislation. It then did not review its position on this until August 2022, after Mrs X came to the Ombudsman. There were several opportunities where it could have done this while Mrs X continued to chase up her complaint. This was fault.
51. The Council eventually reviewed its January 2022 assessment decision and offered Mrs X direct payments for short breaks in late-August 2022. She refused this offer, but only because the Council was running its original short breaks service again by this point. Had the Council acted without fault and offered direct payments in January 2022, my view is it is likely Mrs X would have accepted this offer. This would have meant C would not have missed short breaks for such a significant period. As outlined previously, the Council should remedy the injustice caused to Mrs X and C for the short breaks missed in 2022. The Council should also remedy the unnecessary frustration and inconvenience caused to Mrs X because of the time she had to spend pursuing these issues in 2022. The Council failed to offer direct payments in January 2022, a decision it now accepts was wrong following the recommendations it agreed to in December 2021 after the Ombudsman’s previous consideration of this issue.

Parent carer’s assessment

52. The Council said the last time it carried out a parent carer’s assessment of Mrs X was in 2018. Mrs X said she asked for another parent carer’s assessment at some point around the time she complained to the Council, but there was no evidence she did so. Similarly, the Council said it offered Mrs X a new parent carer’s assessment in August 2021 when C stopped attending its short breaks service, but she declined this. However, there was no evidence of this either. Based on the lack of evidence about this, I was unable to make a finding about whether the Council should have carried out a parent carer’s assessment between March 2020 and December 2021 and failed to do so.
53. The Council’s records of its January 2022 single assessment of C showed it considered Mrs X’s circumstances in the context of C’s home environment. In doing so it identified Mrs X had her own health needs and the family lacked a support network. I consider this should have triggered consideration of whether it should carry out a full parent carer’s assessment of Mrs X based on the “appearance of need”, as described at paragraph 27. There is no evidence the Council considered this. Instead, it decided no further action was needed because “[C] would have [their] care needs met” by the continuation of support from its short breaks service. This was fault. My view is the Council should now offer Mrs X a parent carer’s assessment as a remedy.

Record keeping

54. I am not satisfied the Council kept accurate or properly organised records about its interactions with C and their family because:
• the information the Council provided in response to my enquiries fell significantly short of the records we would expect it to hold for a child accessing support from various teams across children’s services;
• there has clearly been confusion as to whether the short breaks provided to C were part of their EHC plan provision, or otherwise, because this was not properly and consistently recorded;
• Mrs X told me she first complained to the Council’s SEN team that C was not receiving short breaks before she directly contacted a senior member of staff. She said she never received a response from the SEN team and in general it never responds to queries. Based on the lack of information the Council provided in response to my enquiries, my view is it did not properly keep track of communications it received from Mrs X; and
• the Council’s failure to issue final amended EHC plans for C during the period I investigated is a further indication of a lack of organisation in how it managed the EHC plan review process.
55. The Council’s failure to keep proper records was fault, which caused Mrs X confusion and unnecessary time and trouble in pursuing these issues. The Council should act to remedy this injustice.

Complaint handling

56. The Council at first correctly accepted Mrs X’s complaint via the statutory children’s complaints procedure. However, it was then at fault in how it handled and responded to the complaint because:
• it decided its January 2022 single assessment of C resolved the complaint. However, it failed to properly explain this to Mrs X because it did not issue a complaint outcome. It also did not explain how she could escalate the complaint via the statutory process if she wished to do so;
• it then failed to respond when Mrs X chased a complaint outcome several times; and
• it only responded to the complaint after Mrs X came to the Ombudsman. When it eventually responded to the complaint it wrongly did so via its corporate complaints procedure rather than the statutory procedure it had at first accepted the complaint through. The response it provided was not a full response to the issues Mrs X had raised and did not recognise or apologise for the delays in responding.
57. The Council should remedy the unnecessary distress, time and trouble caused to Mrs X by its faults in handling her complaint. However, I have not recommended the Council should review its complaints handling processes. This is because, since the time of Mrs X’s complaint, the Council accepted there were issues with its complaints handling and engaged with the Ombudsman to review its complaints function.

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Agreed action

58. Within one month of our final decision, the Council will:
1. apologise to Mrs X and her family for the faults identified;
2. offer Mrs X a parent carer’s assessment; and
3. pay the family a total of £1,000 comprising of:
1. £100 to recognise the impact on C of missing short breaks they were entitled to from the start of September 2021 until the end of June 2022 due to fault by the Council;
2. £300 to recognise the avoidable and cumulative distress caused to Mrs X because she did not get breaks from caring for C from the start of September 2021 until the end of June 2022;
3. £300 to recognise the avoidable distress, frustration and inconvenience caused to Mrs X by the Council’s failure to properly communicate with Mrs X, or recognise it should have reviewed its direct payments decision sooner; and
4. £300 to recognise the unnecessary time and trouble spent by Mrs X in bringing the complaint.
59. Within three months of our final decision, the Council will:
1. share a copy of our final decision with its Mayor’s cabinet members with portfolio responsibility for Education and Skills, and Adult and Children’s Social Care;
2. write to all families with children who are receiving short breaks through its Early Help service, to tell them:
1. about the changes to the Council’s direct payments policy for disabled children, following the review it agreed to carry out after the Ombudsman’s previous investigation;
2. that they can now request a direct payment to arrange their short breaks if they wish to do so and the Council will consider this; and
3. if they have previously requested a direct payment for short breaks and this was refused, they can complain to the Council and ask it to reconsider. We would expect the Council to give due consideration to the findings and recommendations in this decision statement when considering similar complaints.
3. review its procedures for EHC plan reviews and issues reminders to relevant staff to ensure that following review meetings it issues the final amended plan within statutory timescales;
4. remind relevant staff that statutory guidance and Council policy says single assessments under section 17 of the Children Act 1989 should be:
1. completed within 45 working days; and
2. the outcome communicated to the family in writing.
5. remind relevant staff about the Council’s duties under the Children and Families Act 2014 to assess parent carers on the ‘appearance of need’; and
6. review its record keeping procedures and issue reminders to staff across SEN, Children’s Social Care, Early Help, and the Disabled Children’s Team to ensure:
1. it keeps accurate, consistent, and properly organised records for each child; and
2. it clearly and consistently records short breaks provision, so families are clear through what route their child has been assessed as requiring short breaks.
60. The Council will provide us with evidence it has complied with the above actions.

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Final decision

61. I have completed my investigation. There was fault by the Council which meant C missed short breaks provision and Mrs X did not receive a parent carer’s assessment. It also caused avoidable distress, time, and trouble for Mrs X. The Council agreed to our recommendations to remedy this injustice, write to other families who may have been affected, review relevant procedures, and issue reminders to its staff.

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Investigator's decision on behalf of the Ombudsman